Você está na página 1de 36

A Model of HUnlan

ccupation, Part 1.
Conceptual Franlework and Content
(theory, occupation, treatment model, systems)
Gary Kielhofner
This paper, the first of foUT, pre-
sents the structure and content of a
model of occupation. The model
is proposed as the first step in the
development of a paradigm of
occupation for the field of occupa-
tionaltherapy and is designed for
application in practice and
research. It draws upon the theory
of open systems to build a structu-
ral framework. Concepts relevant
to human occupation are inte-
grated into this framework. Sub-
sequent papers will add concepts
to the model and demonstrate its
application in chnical practice.
T
he field of occupational ther-
apy is currently without a
universal conceptual foundation to
shape its identity and guide its prac-
tice (I, 2). Several frames of refer-
ence have been proposed as alterna-
tives for a unifying conceptual core
(2). This competition among pro-
ponents of alternative frames of ref-
erence for dominance in occupa-
tional therapy has been identified as
a crisis period in the developmen t of
the field (3). Crisis is a natural and
critical stage in the ontogenesis of a
discipline. 1't results in the eventual
unification of the discipline under a
single paradigm (3). Paradigms in
Janice Posatery Burke
academic disciplines guide val ues
and commitments to conceptual
ideas and traditions of research. In
applied fields they a Iso determine
the application of concepts to
practlce.
In occupational therapy the reso-
Iution of the present crisis and the
eventual commitment to a single
paradigm are critical for shaping
the future identity of the field and
the nature of its service. Conse-
quently, such a commitment re-
quires acknowledgment and
thoughtful decision making. This
paper and the three that follow are
grounded in the belief that occupa-
tional therapy must select as its
universal conceptual foundation a
paradigm of human occupation. As
pointed out by those who have
advocated such a position, any other
alternative will result in the failure
of the field to thrive or even to sur-
vive as a unique and needed health
profession (4-6).
The series that this paper intro-
duces will present a model of human
occupation. This is an important
first step in.the development of a
more generic paradigm designed to
stimulate further practice, theory,
and research in occupational ther-
apy. The model will integrate theo-
retical concepts into a representa-
tion of occupation that can be
applied to both practice and re-
search. Eventually, a paradigm of
occu pa tion will yield a more clearl y
articulated explanation of human
occupation.
The Nature and Use of Models
A model is a representational tool.
The usefulness of a model as a tool
rests on its capacity to order, catego-
rize, and simplify complex pheno-
mena (4). Models function to de-
scribe the organization among parts
of some empirica I phenomena,
Gary Kielhofner, M.A., D1. P.H.,
OTR, is Assistant Professor at the
Medical College of Virginia, Vir-
ginia Commonwealth University,
Richmond, Virginia.
Janice Posatery Burke. M.A.,
OTR, is Director of Training in
Occupational Therapy, University
Affihated Program, Childrens
Hospital of Los Angeles, Califor-
nia, and Clinical Assistant Profes-
sor, Occupational Therapy
Department, University of South-
ern California, Los Angeles,
California.
572 September 1980, Volume 34, No.9
and to identify abstract charac-
teristics and relationships that appl y
to a whole class of phenomena (4).
Thus a model serves as a type of
analogy that imparts clearer and
more distinct understanding of the
phenomena. Models are tools for
thinking. Thinking is a skill and,
like any skill, is enhanced when the
person using it has the best tools
available for employing the skill
(7). Such skillful thinking is a caveat
in the everyday clinical problem-
solving of the occupational thera-
pist and in the theorizing and
research needed to validate practice.
Models of Human Occupation.
The model presented here is pre-
liminary and explora tory and, th us,
incomplete. It will require substan-
tial empirical validation and con-
ceptual refinement. It is presented
to stimulate, rather than confine,
thinking in occupational therapy.
This model is designed to provide
occupational therapists with mod-
ern conceptuaI tools tha tare practi-
cally organized for theory, research,
and practice. It organizes con-
cepts of occupation into a frame-
work based on general systems the-
ory. By so doing, the model specifies
relationships among conceptual
enti ties and describes and explains a
spectrum of human behavior (oc-
cupa tion) tha tis cri tical to the iden-
tity and practice of occupational
therapy.
The model is generated in two
steps. First, an organizing frame-
work of open systems is described.
Man is conceptualized as the open
system and his occupational behav-
ior is the output of that open sys-
tem. In the second step, specific
concepts that explain and describe
human occupation are integrated
within the framework of the open
system. Thus the model organizes
those aspects of motivation, behav-
ior, cognition, and so on that are
relevant to understanding occupa-
tion. While the physical or biologi-
cal components of occupation are
acknowledged in the model, it
focuses on the psychosocial and cul-
tural aspects of occupation.
According to this model, all of
human occupation arises out of an
inna te, spontaneous tendency of the
human system-the urge to explore
and master the environment. The
model is based on the assumption
tha t occupa tion is a cen tral aspect
of the human experience. It is Man's
innate urge toward exploration and
mastery and his consequent ability
to symbolize that makes him unique
among animals.
Society and cui ture are buil t upon
and require human occupation for
their maintenance:' just as surely as
perpetuation of the species requires
human sexuality. Recent trends in
medicine have focused too narrowly
on the inner workings of the human
organism so that occupation has
become misunderstood and de-
valued. Work and play are not
merely by-products of the human
essence: they are the essence of
human existence.
Occupational therapy embodies
an appreciation of Man's greatest
capacity, the ability to explore and
master his world. Occupational
therapy clinics tap the deepest and
most powerful adaptive response-
the abili ty to find challenge and
meaning in one's daily undertak-
ings, one's occupation. The model
expounded here is an attempt to de-
scribe and explain that central
aspect of, human existence and
adaptation.
Step One: The Organizing
Framework
The organizing framework :.peci-
fies both the relationships between
parts and the dynamics of the sys-
tem as a whole. These specifica-
tions, the laws or rules by which an
open system is organized, describe
how the open system of occupation
will operate. An open system, un-
like mechanical systems, cannot be
reduced to a study of its parts in
isolation. In the open system, char-
acteristics of parts and their rela-
tionships are only a portion of the
explanation of the system. The
in tegration and in terreIa tion of the
system's parts, the dynamic interac-
tion of the system with its environ-
ment, and the integrity of the sys-
tem in the midst of constant change
must also be studied (8). In the end,
the system and its environment are
seen as a dynamic network of insep-
arable relationships.
Integration of the System's Parts.
An open system is an organized
complex of subsystems that are in
dynamic interaction (8). The system
is, in turn, in dynamic interaction
with its environment. All parts exist,
are maintained, and transformed
through this dynamic interaction.
In the present model, the system
represents Man, and the interaction
of the system with the environment
is human occupation. The environ-
ment is the physical, social, and cul-
tural setting in which the system
operates.
The open system interacts with
the environment by way of a process
of input, output, throughput, and
feedback (8). Figure I illustrates the
process. The output consists of
mental, physical, and social aspects
of occupation. To produce its out-
put, the system uses its stock of
available information to organize
action and predict its consequences.
Input is the information that comes
into the system from the environ-
ment. Without this information,
the system cannot function. This
information becomes a basis for the
system's ability to act on the envir-
onment. The concept of feedback
The American Joumal of Occupational Therapy 573
refers to information about the con-
sequences of action. Through feed-
back, the system is informed about
the results of its own output.
Both input and feedback consti-
tute the means by which the system
can organize itself to adapt to the
environment. When this incoming
information is organized into the
system (the subsystems are reorga-
nized to accommodate this informa-
tion), the system is changed and can
produce new output. The output,
of course, produces new feedback
that further modifies the system.
The internal organizational process
in this "flow of information" is
throughput. It is the interaction of
input and feedback with the inter-
nal structures and functions of the
system. Throughput links the other
processes of input, output, and
feedback and completes a cycle.
This cycle makes the system self-
transforming; that is, as the system
produces output or acts, it creates
new information that thus modifies
it. Thus, the system is a collection of
parts and processes in dynamic
interaction. Cause and effect expla-
nation only confuse and fragment
understanding of this property of
the open sys tem. Each of the parts is
integrated into total network con-
di tions that resonate with the others
in a dynamic state (9).
The internal parts of an open sys-
tem (Figure 2) representing human
occupation are conceptualized here
as three hierarchically arranged
subsystems. According to systems
laws, the higher levels govern the
lower levels. The lower levels, in
turn, constrain the degrees of free-
dom of higher levels (10). In this
model, the volition subsystem will
be said to occupy the highest level.
It governs the lower subsystems. Its
structure consists of innate and
acquired urges to act in certain ways
(motivational structures). The
function of this subsystem is to
enact or initiate action.
The habituation subsystem repre-
sents the middle ground. Its struc-
ture includes components that ar-
range behavior into patterns. Its
function is to regulate patterns of
action that are output by the system;
thus, it maintains order in the out-
put. This subsystem is organized
under the volition subsystem and is
accordingly governed by the choices
of that higher level subsystem.
The performance subsystem oc-
cupies the lowest level. Its structure
consists of the basic capacities for
action, namely, skills. It is governed
by both the habituation and the
volition subsystems, which enact
and maintain its store of skills;
thus, its function is to produce
behavior that is called upon by the
higher level systems.
These three subsystems organize
and regulate the output of the sys-
tem. Each contributes to the output
in a different way. The volition sub-
system has the greatest degrees of
freedom; it is the level at which
action is freely and consciously
chosen. The habituation subsystem
represents automatic and routine be-
havior. It regulates the output of the
system into regular and predictable
patterns. The performance subsys-
tem organizes output at the lowest
level, governing small patterns of
ski lied action. The interaction of
these three subsystems and the on-
going input, throughput, output,
and feedback cycles constitute the
basic dynamics of the system. All of
these components intermesh as the
system functions over time.
Characteristzcs of the Envzron-
ment and Dynamic Interaction with
the Environment. Any open system
exists in an environment. A living
system cannot exist without inter-
action with the environment. This
interaction benefits the system with
both information and energy that
are cri tical for its ongoing organiza-
tion. In the model of human occu-
pation, concern is exclusively with
the input of information into the
system. The importation of energy
is a physiological function of the
open system (e.g., eating), which
need not concern a study of human
occupation in any direct way.
Within the model of human
occupation, the environment is
conceptualized as external objects,
people, and events that influence
the system's action. This conceptu-
alization of the environment is
guided by Robinson's specification
th'(t the human system must process
information about objects, people,
and events for competency (II).
Information about these three as-
pects of the environment enter the
system as it is acted upon (input)
and as it acts on the environment
(feedback). This information is
organized in the three subsystems
and makes possible behavior that
can meet the demands of the en-
vironment.
The system both changes and is
changed by the environment; each
shapes the other. Man creates his
physical and symbolic environment
at the time he learns to act compe-
tently in it. As the open system
explores and masters the environ-
ment, it transforms both itself and
the environment (12).
The History of Change in the
System. An open system cannot be
fully understood without an exam-
ination of its past experience. The
system's ongoing existence is an
organized continuation of change
in the subsystem relationships and
the relationship of the system to its
environment. The integrity of the
system is preserved through, and
not in spite of, constant change. To
understand the system, one must
know its pattern of change.
574 September 1980, Volume 34, No.9
Each kind of open system has a
recognizable pattern of change.
While the general patterns of the
living system are represented in
birth, life, and death, each species
has its own pace, sequence of
changes, and pattern of action-the
qualitative aspects of how its lives.
The patterns of change in the
human system are largely patterns
of change in human occupation.
They are culturally determined to
some extent; however, most socie-
ties include a pattern of childhood
play, followed by an apprenticeship
or studen t period tha t prepares the
young member for productive par-
ticipation in adult life. As the sys-
tem changes through the lifespan, it
must be continually reorganized so
as to respond to the changing
expectations and demands of the
social group for occupational be-
havior or performance.
In the foregoing sections, human
occupation was conceptualized
within the framework of an open
system. This framework and the
properties of the open system it
represents comprise a set of organi-
zationallaws of human occupation,
laws that describe the organization
of the model and the interrelation-
ships of its component parts. It is
important to remember that the
graphic or visual illustrations of
this framework have implicit in
them the general la ws tha t govern
the open system, and that they are
merely a shorthand representation
of an entire set of laws that govern
human occupation.
Step Two: The Descriptive Con-
tent of the Model of Human
Occupation
Concepts that describe occupation
will be discussed here as they are
incorporated into the conceptual
framework just presented (see Fig-

The Open System
Input
information
Throughput
Information
Feedback
(organization
an9 reorganiiation
Olltput
information
ofinforma(ion)
Action
Feedback
Figure 1 The open system
ure 3). 'When new concepts are
incorporated, they will be integrated
with concepts already introduced
into the model. Thus, the discus-
sion will be cumulative. As addi-
tional concepts are introduced, the
interrelationships of all concepts
should become apparent.
The Volition Subsystem. This
highest level subsystem exerts a
broad con troll ing infl uence over
the entire system. It is primarily
governed by the innate spontaneous
tendency toward exploration and
mastery. This is the urge that moti-
vates occupation (12). As the system
grows and changes, this global urge
is differentia ted and refined through
experience. Central to this differen-
tiation is the importation of infor-
mation and its internal symbolic
representa tion in the voli tion su b-
system. Human action requires an
inner symbolic model of the self as
an actor in the world (13). The basic
urge toward exploration and mas-
tery of the environment, together
with this growing symbolization of
onself acting in the world, consti-
tutes the volition subsystem.
The differentiation of this sub-
system is conceptualized as yielding
three motivational-symbolic com-
ponents: personal causation, valued
goals, and interests. Personal causa-
tion refers to the image of the self as
a competent or incompetent actor
(14). It determines whether the sys-
tem will expect success or failure
and subsequently whether or not
the system will enact action. Val ued
goals and interests reflect the plea-
sure associated with past experi-
ences and future possibilities for
action. They govern the type of
action the system will "output."
The American Journal of Occupational Therapy 575
Ontogenesis
of
the
System
CHANGE
OVER TIME
THE HUMAN SYSTEM
THROUGHPUT
Volition Subsystem
INPUT
Informatiqn
Habituation SUbsystem
OUTPUT
FEEDBACK
Action
Performance Subsystem
F.eedback
ENVIRONMENT
Figure 2 The system and its environment
Valued goals are commitments to the structural components of the
action, and interests are preferences differentiated volition subsystem
for action. Both exert con trol over making possible that subsystem's
the volition subsystem by setting function, to enact output.
priorities among occupational ac- I. Personal Causation. Personal
tivities and their consequences. causation grows out of the basic
Valued goals reflect the external urge to explore and master the
realities of society and culture. They environment (14). Symbolically, it
link occupation to society's need for represents to the system its changes
individual productive participa- of success and failure when acting
tion. Interests shape the unique on the environment. This symbolic
aspects of occupation and underlie image can enhance, modify, or
the variety of occupations that can thwart the basic urge to explore and
satisfy the urge to explore and mas- master. Feedback is essential to the
ter the environment. The three con- formation of the inner symbolic
cepts of personal causation, valued image allowing the system to moni-
goals, and interests are proposed as tor the cansequences of its action. If
desired outcomes are achieved con-
sistently, a sense of effectance and
successful control over the envir-
onment develops; if not, a sense of
"lack of control" develops.
The continuum from control to
noncon trol is represen ted in two
primary modes sym bolizing the self
as an actor-pawn and origin (14).
Pawns do not believe they are in
control and do not actively seek
environmental challenges that
would allow mastery. They see Ii ttle
opportunity to choose, and believe
that they are controlled by circum-
stances outside themselves. Pawns
do not enact occupation: as a result,
skilled behavior that allows a sense
of control does not develop. The
behavior that does result in success
is thought to be based on luck or
chance, while failures are viewed as
a result of personal incompetence
and ineffectiveness.
Origins, on the other hand, are
individuals who see themselves in
contra!' They strive to explore and
master the environment and seek
out challenges. The origin thus
develops skills to be used in upcom-
ing situations that will increase his
or her chances of success. The ori-
gins see themselves as having con-
trol as they strive toward productive
behavior, gaining mastery over
daily life tasks. The pawn and
origin represen t characterizations
of persons who are either totally
unable or totally able to carry out
their urge toward exploration and
mastery. Most individuals exist
somewhere on a continuum between
these two extremes. Each person's
sense of control is based on particu-
lar actions that are routinely suc-
cessful and become special areas of
competence. Each person's sense of
personal causation, or belief in their
proven efficacy in some sphere of
action, is necessary for the output of
competent occupational behavior.
576 September 1980, Volume 34, No.9
2. Valued Goals. Values are basic
commitments to action; they orga-
nize behavior by establishing and
employing an internal order of
priorities and determining the im-
portance of various occupa tional
behaviors to the individual (\5).
Valued goals are a conceptualiza-
tion of the way in which values
guide productive behavior. Occu-
pation is organized toward produc-
tive ends; it is not oriented to global
diffuse values, but to specific valued
goals. Values are serious attach-
ments to ideas, customs, and insti-
tutions that result in an individu-
al's feeling of being identified with
a social group (\5). Valued goals
represent plans of action that the
individual intends to pursue in
order to attain productive ends.
They are linked to more global
values, but specify what will be
accomplished and how it will occur.
The importance of valued goals
for competent occupational behav-
ior or performance is that they
sustain action that might not be im-
mediately gratifying. Less pleasur-
able aspects of work are made satis-
fying because of the ends they can
accomplish or because they are part
of a larger process tha t is in trinsi-
cally satisfying. Valued goals can
operate in this fashion because they
organize a sense of time. They
involve an image of the self as an
agent placed in time with past
actions and consequences, present
circumstances, and future possibili-
ties. This image of the past, present,
and future is organized into a struc-
ture of priorities yielding plans of
action based on the anticipation of
valued accomplishments.
3. Interests. Interests are personal
dispositions to find pleasure in cer-
tain objects, events, or people (16).
Interests lead to active participation
in satisfying occupational acti vi ties
and also serve to maintain self-
initiated activity. Though less
serious than values, interests attract
and hold attention and determine
how an individual will freely em-
ploy his or her time. Interests evolve
as one acts on new opportunities or
challenges that are tried and later
retained or discarded according to
the amount of pleasure associated
with doing them. Interests place the
unique stamp on people's occupa-
tion as they enact the basic tendency
toward exploration and mastery. In
concert with personal causation and
valued goals, interests organize the
enactment of occupation.
Summary. The volition subsys-
tem consists of three components
that are differentiated out of the
innate global urge toward explora-
tion and mastery of the environ-
ment. They incorporate informa-
tion from experience to form
internal symbolic representations
of the self as an actor in the world.
This symbolization of one's effec-
tiveness (personal ca usation), of the
importance of certain actions (val-
ued goals), and of the pleasure from
engaging in specific occu pa tions
(interests) guides the enactment of
output. Belief in the efficacy, im-
portance, and pleasure of action
guides enactment of occupational
behavior or performance.
The Habituation Subsystem. The
habituation subsystem organizes
occupational behavior or perform-
ance into patterns or routines. This
subsystem consolidates the practiced
choices of the volition subsystem
and integrates them into predicta-
ble patterns. Two con'cepts are used
to describe the content of this sub-
system-habits and internalized
roles. These components of the
habituation subsystem are governed
by the volition subsystem. That is,
the formation of habits and roles
depends on the conscious choices
made on the basis of valued goals,
interests, and personal causation.
This habituation subsystem orga-
nizes patterns of behavior that satisfy
the urge to master and explore that
drives the volition subsystem. At the
same time it organizes these pat-
terns of behavior to respond to the
external demands of the environ-
ment, thus maintaining action that
is satisfying both to the system itself
and to the environment.
I. Habits. When an individual
repeats certain actions, they become
automatic routines or habits (17).
Habits provide an integrated con-
sistency in the action of every day
life. When they organize behavior
according to social norms, habits
allow the person to respond appro-
priately and consistently to social
demands without constant con-
scious a tten tion. Ha bi ts structure
the use of time to achieve more effi-
cacy in daily occupational per-
formance.
Habits operate largely below the
level of consciousness. It is only
when habitual action fails that con-
scious decision making of the voli-
tion subsystem is needed. In the
volition subsystem new courses of
action can be enacted, which even-
tually can become new habits. As
exploration yields new ways of
doing things and mastery refines
them through practice, new habits
are formed. Since habits are auto-
matic behaviors largely governed by
unconscious feedback, they are
somewhat rigid and may become
maladaptive when the environment
changes: for example, when the
housewife's children leave home,
the parent's every day habits must
change. Internal changes in the sys-
tem can also require habit change:
for example, the active person who
becomes hemiplegic after a stroke
must reconstruct daily patterns of
action. Over the life cycle, ha bi ts are
constantly transformed as part of
The American Journal of Occupational Therapy 577
Onlogen,esis' (change.)
, oltl1e ,
System "
Over
Time'
THE-HUMAN SYSTEM
n-lROUGHPUT -
STRUCTURE 'FUNCTION
VOLITION SUBSYSTEM
-'-Personal Causation:'
-Valued Goals,
: -
'INP1JT
Feedbac'!.
"- Maintains
HABITUATION SUBSYSTEM
JnternalizedRoles
and Habits, '
,Action
OUTPUT
Information
PRODUCTION SUBSYSTEM
Skills

-Objects
-People
-Events
ENVIRONMENT
Figure 3 A model of human occupation
normal ontogenesis. Thechild must
learn new habits when becoming a
student, and later when becoming a
worker or a spouse, or when taking
on any new role. For adaptation,
habits must be consistent enough to
organize behavior, but flexible
enough to respond to external and
internal changes in the system.
2. Internalized Roles. The con-
cept of role represents a higher level
of organization of behavior than
habit. The routines of role behavior
are larger than the routines of habit
and require more complex organi-
zation. When role patterns are
internalized into the habituation
subsystem, the individual's values
and interests are merged with the
demands of society for participa-
tion. The behaviors organized under
the internalized role fulfill the
demands of the social environment
amd satisfy the system's urge to
pursue valued goals and interests. A
role includes an entire set of required
behaviors that go along with oc-
cupying a position in a social group
(18). During those times of the day
when a person is acting within a
role, its requirements serve as a
framework to organize behavior.
While it is possible to conceive of
several types of roles (e.g., sexual or
familial roles), this model is con-
cerned with occupational roles such
as preschooler, student, housewife,
worker, and retiree (19). The occu-
pational role refers to the productive
roles that determine the bulk of
daily routines and thus organize
most of the behavior within the
system.
Occupational role behavior de-
mands not only certain routines of
skilled action, bu t also incl udes pre-
scriptions for when they are done,
in what context, with whom, and
how often. The occupational role
serves as a context to organize the
behavior of the actor. This "con-
texting" is a phenomenon people
experience daily as they act within a
series of roles. Competent interac-
tion with the environment is a pro-
cess of effective role performance
(20).
Like habit, a change in roles
represents a critical adaptive pro-
cess, Role change occurs in the nat-
ural context of human ontogenesis
(e.g., the change from the student to
worker roles). Role change may also
be imposed by disability. Changing
from role to role is a complex phe-
nomenon and requires the transfor-
mation of both habits and skills and
their integration into a different
daily life pattern.
Summary. The habituation sub-
system organizes behavior into pat-
terns according to social norms and
prescriptions for role behavior. It
578 September 1980, Volume 34, No.9
also organizes behavior into auto-
matic routines that are consistent
with the volition subsystem urges
toward exploration and mastery.
Habits and roles are automatic rou-
tines of behavior that function to
maintain behavior so that it occurs
consistently and predictably. The
habituation subsystem serves to
integrate the individual with the
environment by linking internal
spontaneous urges with external
environmental demands.
Performance Subsystem. The per-
formance subsystem is most directly
linked with the system's output. It
is structurally composed of skills
and it functions to produce skilled
action. Skilled action requires both
physiological (neurological and
kinesiological) and symbolic func-
tions, with the latter superimposed
organizationally on the former (21).
Skills consist of flexibly organized
and in terrelated componen t actions
that lead to the accomplish men t of
a purpose or goal under variable
environmental conditions (22).
Skilled action requires recognition
of the features of a task and the
proper means to its a tta inment. It
also requires a means of converting
that information into action and of
obtaining feedback concerning the
success of the action (23). Skills
incIude not onIy the movemen t and
perception required to act on the
environment, butalsodecision mak-
ing and problem solving.
Rules that govern skilled action
are organized within this subsys-
tem. These rules contain informa-
tion about how to interact success-
fully with the environment (objects,
events, and people) to achieve cer-
tain ends (II). These rules result in
the organization of flexible strate-
gies for production of action and
the use of feedback to guide their
operation.
Skills and the rules that organize
INPUT
-Demands
-Expectations
-'Supports
"...Consequel1ces
or action
-Constraints
ENVIRONMENT
The Human System
Throughput
Feedback
OUTPUT
Feedlorwatd
-meal)ing
--expectatiQJ:1
ACTION
c.:use of skills 10 act on
the enVifCJOm8(lt
Figure 4 Input, output. feedback, and the environment
them are not innate structures, but
are acquired by both playful explo-
ration and mastery practice (21).
The rules that govern skilled action
are processed largeIy during the
long period of immaturity through
child's play (22). However, through-
out life, by actively engaging the
environment in exploratory play,
an individual can generate new
skills. In adult life, serious mastery
practice also serves as an important
source of new skills. Both play and
practice are energized by the voli-
tion subsystem's urge toward mas-
tery and exploration.
The performance subsystem is
critical to the overall adaptation of
the system. Habits and roles can
only build routines of behavior from
pre-existing skills that are available
to be organized into patterns. The
volition subsystem can only enact
those behaviors that the perform-
ance subsystem can produce. Thus,
the configuration of skills in the
performance subsystem constrains
the higher level subsystems. In turn,
the performance subsystem is or-
ganized by the higher level subsys-
tems. The volition subsystem, by
enacting output, determines which
skills will be learned through ex-
ploration and mastery practice. The
ha bi tua tion su bsystem organizes
skills into routines for everyday life
and for role performance. Those
skills that are not called upon in
these routines eventually become
obsolete. Those which are called
upon routinely become more effec-
tive. The interaction of the three
subsystems is critical for determin-
ing the composition of the system's
output.
Output into the Environment
The system's output (Figure 3)
includes both information and ac-
tion. The system projects informa-
tion on objects, people, and events
that are being or will be encoun-
tered and anticipates the results of
such action. This output of infor-
mation is critical for all the system's
performance. It attributes meaning,
The American Journal of Occupational Therapy 579
importance, relevance, and interest
to the world. Such output is ex-
pressed in long time frames by goals
and objectives and in short time
frames by the purpose with which
the world is acted upon minute by
minute.
he other component of output
is action. Both information and
action are simultaneous outputs of
the system. Action is based on the
information that is being projected
in time. The consequence of action
is returned to and recorded in the
system as new information during
the feedback process. The through-
put reorganizes and uses the infor-
mation for subsequent output.
Thus, the flow of information be-
tween the system and environment
is essential to guide action.
Action and information are com-
bined by the system to achieve
results (in the use of skills) to meet
expectations for performance (as
organized by habits and roles) and
to satisfy the system's own purposes
(as con tained in the voh tion subsys-
tem). The output of information
and action to achieve purposeful
ends is occupational behavior. Pur-
poses may beseriousor playful, but
they always guide occupation.
Input and Feedback from the
Environment
As Man engages his environment,
his occupation generates feedback
to guide future behavior (Figure 4).
This feedback informs the system of
constraints imposed upon behavior
by the physical and social world
and of the consequences of various
actions (24). Information \Nhich en-
ters the system as feedback may
range from that which informs it
about the properties of inanimate
objects to the reactions of others fol-
lowing one's actions. In the feed-
back process actual performance is
compared to expected outcomes.
Ontogenesis
olthe
System
Over
Time
(Trajectory
Jlt Change)
THE HUMA-N SYSTEM
THROUGHPUT
Structure Function
VOLITION SUBSYSTEM
-PerSonal Causation
Goais Enacts
-Interests
INPUT
HABITUATION SUBSYSTEM
OUTPUT
FEED FORWARD
Internalized Roles
and Hanits
Maintai'ls
Action
PRODUCTION SUBSYSTEM
Produces
FEEDBACK
ENVIRONMENT
-Objects
-People
-Events
Figure 5 An occupational behavior model
This process allows the system to back or performance also shapes the
make adjustments in its perform- individual's self-images and thus
ance tha t, in turn, influence the directly affects the personal causa-
organization of the system itself. tion component of the volition sub-
Because feedback is sometimes medi- system. Habits and internalized
ated through the social system, roles operate almost entirely on the
behavior can be compared with basis of feedback and thereby cause
social expectations and thus feed- actions and routines to be adjusted
back serves to socialize the individ- according to information concern-
ual as he or she to the ing how the beha vior pa ttern is
demands of the environment. Feed- working.
580 September 1980, Volume 34, No.9
Input is information coming
directly into the system from the
environment. The demands of the
environment comprise input to the
system. Society makes demands on
the system through input in the
form of norms and role require-
ments (20). This input comes from
parents. peers. and a variety of social
institutions in which occupational
roles are enacted. Like feedback. the
input information serves to reor-
ganize the system.
Conclusion
The first part of a model of human
occupation has been presented
(Figure 5). This part. the structure
and content, was organized into two
steps: I. developing a conceptual
framework from open systems, and
2. specifying conceptual content to
describe the structure and function
of the system. The resulting struc-
ture and content of the model de-
scribes Man as an occupational
creature. The model is proposed as
a tool for practice and research, a
tool that may eventually lead to a
paradigm of human occupation that
will guide occupational therapy
practice.
The concepts borrowed from open
systems describe abstract laws that
govern how any open system is
organized and changed over time.
The throughput of the system is
made up of three subsystems that
have both structure and function.
he highest level governing the
subsystem is the volition subsystem.
Its structural component are per-
sonal causation, interest, and valued
goals. These govern the system's
choices for action. These choices
and their subsequent triggering of
action is referred to as enactment,
the function of the volition subsys-
tem. The habituation subsystem's
structure is composed of habits and
internalzzed roles; they function to
maintain behavior in routine pat-
terns. At the lowest level is the per-
formance subsystem whose structure
consists of skills; its function is to
produce action. As the three subsys-
tems interact, the volition subsys-
tem governs the basic tendencies of
the organism to act; the habituation
subsystem maintains action; and
the performance subsystem organ-
izes actions into skills. These sub-
systems together organize the out-
put of the system. The output is
comprised of both information and
action and is referred to as an occu-
pational behavior or performance.
This occupation or purposeful ac-
tion generates feedback. Feedback
and input are information entering
the system that reorganize the in-
ternal makeup of the system. Thus,
action yields information that
changes the system. This in turn
makes possible new action that
further changes the system. Because
of this ongoing cycle, the open sys-
tem is said to be self-transforming.
This self-transformation is the basic
process of change in the system.
The explanation of change, or
ontogenesis, of human occupation
is a complex one requiring addi-
tional concepts to be added to the
model. Two papers that follow
further de cribe the model and pre-
sent additional concepts.
REFERENCES
Johnson J, et al: Report I: Task force
on target populations. Am J Occup
Ther 28: 158-163,1974
2. Hopkins H: Current basis for theory
and philosophy of occupational ther-
apy in Willard and Spackman's Occu-
pational Therapy, Helen L. Hopkins,
Helen D. Smith, Editors. New York: J.B.
Lippincott Co, 1978
3. Kielhofner G, Burke JP: Occupational
therapy after 60 years: An account of
changing identity and knowledge. Am
J Occup Ther 31: 657-689,1977
4. Reilly M: Occupational therapy can be
one of the great ideas of 20th century
medicine. Am J Occup Ther 16: 1-9,
1962
5. Wiemer R: Traditional and nontradi-
tional practice arenas. In Occupational
Therapy: 2001 A.D. Publication of the
American Occupational Therapy As-
sociation, 1979
6. Shannon P: The derailment of occupa-
tional therapy. Am J Occup Ther 31:
229-234, 1977
7. Bors JS: The Art of Awareness,
Dubuque, IA: Brown Publishers, 1973
8. Von Bertalanffy VL: General Systems
Theory, New York; George Braziller,
1962
9. Moss G: Illness, Immunity and Social
Interaction, New York: John Wiley &
Sons, 1973
10. Fiebleman JK: Theory of integrative
levels. In Psychology and Effective Be-
havior, James Coleman. Editor. Glen-
view, IL: Scott Foresman and Co, 1969
11. Robinson A: Play: the arena for ac-
quisition of rules for competent behav-
ior. Am J Occup Ther 31 :249-253,1977
12. Florey L: Intrinsic motivation: thedynam-
ics of occupational theory. Am J Occup
Ther 23: 319-322, 1969
13. Boulding K: The Image, Ann Arbor:
University of Michigan Press. 1961
14.Burke ,IP: A clinical perspective on
motivation: pawn versus origin. Am J
Occup Ther 31 :254-259, 1977
15. Kluckltohn C: Values and value orienta-
tion in the theory of action: an explora-
tion in definition and classification. In
Toward a General Theory of Action, T
Parsons, E Shils: Editors. Cambridge,
MA: Howard University Press, 1951
16. Matsutsuyu J: The interest checklist.
Am J Occup Ther 23: 323-328, 1969
17. Koestler A: Beyond atomism and
holism-the concept of the holon. In
Beyond Reductionism, A Koestler, RJ
Smithies, Editors. Boston, MA: Beacon
Press, 1969
18. Heard C: Occupational role acquisi-
tion: A perspective on the chronically
disabled. Am J Occup Ther 31: 243-
247,1977
19. Matsutsuyu J: Occupational therapy: a
perspective on work and play. Am J
Occup Ther 25: 291-294,1971
20. Smith MB: Competence and socializa-
tion. In Sociafization and Society, John
Clauser, Editor. Boston, MA: Little
Brown and Company, 1968
21 Reilly M: Play As Exploratory Learning,
Beverly Hills, CA: Sage PUblications,
1974
22. Bruner J: Nature and uses of immatur-
ity. In Pfay: Its Role in Development
and Evolution, J Bruner, A Jolly, K
Sylva, Editors. New York: Basic Books,
1976
23. Bruner J: The skill of relevance or the
relevance of skills. Saturday Rev,
April 18,66-73, 1970
24. Weiner N: The Human Use of Human
Beings, New York: Avon Books, 1967
The American Journal of Occupational Therapy 581
A Model of HUnIan Occupation,
Part 2. Ontogenesis fronI the
Perspective of Telllporal Adaptation
(theory, treatment model, development)
Gary Kielhofner
T his IS the second in a series of
four papers that discuss and pre-
sent a model of human occupation.
The fzrst paper presented the
structure and content of the
model. This paper conceptualizes
change according to the model. It
introduces the systems concept of
hierarchy into the model as a
foundation for explaining its
ontogenesis. Two facets of change
are proposed. The first facet is a
series of stages through which
occupation is processed. The
second is a description of onto-
genesis through the life span from
the perspective of temporal
adaptation.
A
n earlier article introduced the
first part of a model of occupa-
tion, its structure, and content (1).
This paper adds to the model a de-
scription of how occupation evolves
through the life span and an expla-
nation of the process of change.
Hierarchy, a systems concept, is
introduced into the model to de-
Gary Kielhofner, M.A., Dr.P.H.,
OTR, is Assistant Professor at the
Medical College of Vzrglma, Vir-
ginia Commonwealth University,
Richmond, Virgima.
scribe the process of ontogenesis or
change.
Hierarchy in Ontogenesis
A central problem in the study of
ontogenesis is how a system changes
from one state of affairs to another
over time. Hierarchy refers to laws
that explain how a system is organ-
ized along a continuum of increas-
ing complexity over time. Change
in an open system is a continual
reorganization of the system that
results from the system's action.
Thus, by choosing to act and by
acting, the system affects its own
change. Hierarchy provides an ex-
planation of how that change builds
upon and reorganizes the products
of previous experience and results
in increasing complexity.
Two factors influence hierarchi-
cal change in an open system-the
system's own internal tendencies
and the demands that the environ-
ment places on the system. These
two factors come together in the
throughput-ou tpu t- input-feedback
cycle of the open system. The cen-
tral problem of change in occupa-
tion is to explain how a system with
a global tendency toward exploring
and mastering its environment is
transformed into a socially func-
tioning, productive, and self-satisfy-
ing entity. The hierarchical change
of occupation proceeds from this
undifferentiated, innate tendency
toward exploration and mastery to
individual competence in occupa-
tional roles. The steps and processes
in this hierarchy of change are the
topics of this paper.
The proposed structure and con-
tent of the model are represented in
three subsystems, volition, habitua-
tion, and performance (I). As Fig-
ure I demonstra tes, the voli tion
subsystem contains the structural
components whose function is to
choose or enact output. Change in
the entire system is initiated at this
level where conscious decisions for
action are made. The system's ac-
tion that results from these choices
is what organizes change in the sys-
tem. In the infant the volition sub-
system is undifferentiated. The
output, which is enacted by the sub-
system at this time, is curious ex-
ploration. This output generates
internalized canons or rules that mir-
ror the conditions and constraints
of external reality and thus organize
action into flexible strategies for
dealing with the environment,
namely skills (4). Skills are eventu-
ally organized into larger routines
The American Journal of Occupational Therapy 657
Figure 1 A model of the occupational behavior system: structure and content
THE HUMAN SYSTEM
VOLITION SUBSYSTEM
VALUES
INTERESTS
PERSONAL
CAUSATION
Input
1
HABITUATION SUBSYSTEM
INTERNALIZED ROLES
HABITS
1
Output
1
PERFORMANCE SUBSYSTEM
1
SKILLS
FEEDBACK
FIgure 2 A hierarchy of change in volition and its influence on hierarchical change in the
lower subsystems
Organization of the Volition Organization of
Subsystem Lower Subsystems
Achievement .. Role
Qj
Cl
c:
('CI
.r:.
()
'0
c:
Competency Habit
.2
ti
CI
..
'6
.2
tiU;
Exploration

Skill
::l >.
"0'"
0.0
.. ::l
Q.U)
influence on lower subsystems
that are habits, and those, in turn,
are organized into roles. The organ-
ization of rules into skills, habits,
and roles is the basi<=- hierarchy
through which occupation is pro-
cessed (5). The volition subsystem
enacts the action that yields skills,
habits, and roles. These are the
components of the lower-level sub-
systems. As Figure I demonstrates,
the habituation subsystem is com-
posed of habits and internalized
roles, and the production subsystem
is composed of skills. Thus, the
volition subsystem is responsible
for organizing the content of the
lower subsystems.
Since the voli tion subsystem gov-
erns change in the other subsys-
tems, an examination of ontogene-
sis or change must begin with it.
The volition subSyStem is differ-
entiated along a series of hierarchi-
cal steps, each representing more
complex challenges. This hierar-
ch icaI differen tiation of the voli tion.
subsystem has been conceptualized
by Reilly as a transformation from
curious exploration to competency
to achievement (4). The continuum
from explora tion to achievement
represen ts an increase in levels of
excitement or challenge that are
necessary to sufficiently arouse the
organism as it becomes more com-
petent and capable. These three lev-
els of motivation in the volition
subsystem parallel the organiza-
tional levels of skills, habits, and
roles in the two lower subsystems
(see Figure 2).
Exploration, competency, and
achievement, the hierarchical levels
of organization of motives, govern
the organization of change in the
lower subsystems. This means that
the motive of exploration is optimal
for genera ting ski lis, the moti ve of
competency for organizing habits,
and the motive of achievement for
acquiring competent role behavior.
Since the volition subsystem enacts
the action of the system that pro-
cesses change, its choices determine
what the change will be. By examin-
ing each of the three hierarchical
levels of the volition subsystem and
the action they serve to enact, this
process can be explained.
ExploratIon is the lowest level of
enactment and is best described as
658 October 1980, Volume 34, No. 10
doing something for its own sake,
for the pleasure involved in the
doing (4). Exploratory behavior is
associated primarily with the free
play of childhood and ongoing ac-
tion throughout the life span when
the system is confronted with new
or novel situations and explores the
environment for information. Nov-
elty always implies the unknown; it
begins with the unknown world
which the infant explores through
play and extends to the unknowns
an individual facesas he/she moves
through a succession of roles. The
exploratory motive yields explora-
tory action that yields the skills that
become tools for survival.
Competency is the next and more
complex level of motivation (4).
Exploration gives way to practice
according to models or standards of
normal behavior. Behavior organ-
ized at this level builds upon earlier
skills that are integrated according
to social norms or expectations and
thesystem'sown internal standards.
Through the system's output, mo-
tivated by competency, these skills
are organized into larger routines,
namely habits.
At the third level, the achieve-
ment motive energizes behavior.
Here, role requirements are a cen-
tral organizing force. The individ-
ual seeks to achieve a role or posi-
tion in the social group. The group,
in return, requires the performance
of certain tasks according to stan-
dards in order to occupy the position.
When the system internalizes the
role demands, they become auto-
matic guides to behavior that or-
ganize habits into larger routines,
the routines of role behavior.
When the system has successfully
internalized roles as guides to ac-
tion, it has completed the process of
change from undifferentiated glo-
bal tendencies toward exploration
and mastery, to fulfillment of the
environment's demands. This hier-
archical process is repeated over and
over each time a person enters into
novel aspects of the environment or
encounters new roles or role require-
ments. Importantly, this is also a
critical process for adaptation to
disability. The novelty may be the
process of exploring and mastering
the world with an altered body or
perception. The hierarchical change
from exploration to competency to
achievement not only characterizes
ongoing change, but is represented
in gross changes during the life
span. That is, during different
phases of the life-continuum, ex-
ploration, competency, or achieve-
ment will be the major motivational
mode of the volition subsystem.
The Ontogenesis of Occupation
during the Life-Continuum
The next part of the model illus-
trates the ontogenesis of occupa-
tion from the conceptual focus of
temporal adaptation. Temporality
is a universal property of occupa-
tion (6) and thus a useful perspec-
tive for occupational therapy.
While the model is based on gen-
erally accepted realities or require-
ments of Western life, it may not
characterize the life changes of
deviant or disabled persons. Con-
tinuing research in occupational
therapy will be needed to elaborate
and clarify the nature of occupation
in the lives of persons who must
make an alternative adaptation to
life.
Before examining the ontogene-
sis of occupation in the life span, a
definition of occupation is needed.
Occupation is the purposeful use of
time by humans to fulfill their own
internal urges toward exploring and
mastering their environment that at
the same time fulfills the require-
ments of the social group to which
they belong and personal needs for
self-maintenance. The social or-
ganization of the human species is
such that occupation mainly in-
cl udes actions tha t exist on a con-
tinuum of play and work. Within
play, Man organizes his behavior
and initiates change in the self and
society (4). Within work, Man is
productive for himself and main-
tains himself through self-care.
Within work, Man is also produc-
tive for the social group and main-
tains the group through his labor.
Thus, play energizes change; work
maintains the individual and the
social group. Both exist in a har-
monyor balance that is character-
ized in the use of time divided
between work and play on a daily,
weekly, yearly, and life-long basis.
The ontogenesis of occupation
occurs through a life-long series of ex-
periences shaped by internal choices
and external social demands and
expectations. Throughout ontogen-
esis, there is a changing critical bal-
ance between play and work (7).
Since both play and work originate
from the same global tendency
toward exploration and mastery,
they interrelate throughout the life
span. Figure 3 depicts this relation-
ship. The diagram divides the life
span into the four major life stages:
childhood, adolescence, adulthood,
and old age. Figure 3 graphs the
general configuration of daily life
over the four life stages. It demon-
strates changes made in organizing
daily time use as the person pro-
gresses through these life stages.
Figure 3 also describes the yields of
work and play during each stage or
level of organization of human oc-
cupation. The Figure briefly de-
scribes the major features of work
and play at each level, and demon-
stra tes how the organiza tion a teach
level prepares the system to move to
the next level. Finally, it depicts the
interrelationship or balance of work
The American Journal of Occupational Therapy 659
and play at each of the four levels of
organization. It incorporates the
levels of exploration, competency,
and achievement to describe the
major motivational energy at each
life stage. Each of these features will
be discussed, according to the four
life stages, in the sections that
follow.
Childhood. The human species
has evolved the longest period of
immaturity among animals (8). As
a feature of social organization, the
child is largely left alone during
this period to play. Play is the cen-
tral activity of the immature indi-
vidual and organizes behavior for
effective transactions with the en-
vironment. This effectiveness is
dependent on the play action
through which reality is explored
for the rules of competent behavior
(4). The skill-building and rule-
genera ting acti vi ties of play prepare
the child for the student role and
the adult world of work. As the
child effectively interacts with ob-
jects, events, and people, a sense of
self as competent and a growing
repertoire of skills develop. In play,
the child explores the world for per-
sonally pleasing activities and, thus,
develops interests. In addition to
this playful learning, the family
and other institutions socialize the
child according to what behaviors
are val ued, and they provide models
for organizing behavior. Thus, in
play the volition subsystem is differ-
entiated and organized.
In play, the child assimilates vast
stores of information and imitates
adult models. The child is, impor-
tantly, assimilating information
and values from the family concern-
ing occupation. The child must
eventually learn appropriate times
to put aside play and use his time to
complete work. Parents and others
increasingly pressure older children
to set goals and to discipline them-
sel ves for more prod ucti ve use of
their time. Through such activities
as chores, the child learns about
organizing time for productivity
within the family, and later, within
the larger social group. Thus in
play early habit structures are
developed.
School attendance provides other
experiences in which the child must
organize productive behavior, gain
a sense of competency, and build
habits necessary for maintaining
the more formal role of student.
The child learns how to organize
time and action toward ~ l i l l m n t
of role responsibilities. These hab-
its and role behaviors are essential
for later productivity since one must
meet the demands of time in order
to adapt to the adult world of work
(9).
As shown in Figure 3, curious
play during childhood contributes
toward organization of action into
skills as the child explores reality.
There is very little work, initially.
Later, chores and school comprise
the major productive requirements
of childhood. Play supportS the
emerging worker role through skill
and habit development and explora-
tion of adult roles in imaginary
play.
Adolescence. The primary ener-
gizing force of adolescence is the
urge to develop competence in adult
roles (10). The adolescen t struggles
to organize past experience with the
current demands of society and
peers and the pressure of aspired
goals (II). The adolescent must
organize past skills with demands
for new roles into a more complex
habit structure (12).
The adolescent faces increased
responsibilities and must shift from
external control and dependence on
parents to internal control and
mature interdependence with oth-
ers (10). In adopting the self-determi-
nating adult role, he or she devel-
ops a hierarchical set of values that
guide his or her life plan. Interests
are narrowed down into a smaller
field and add to the stabilization of a
life pattern. These values and inter-
ests contribute to the ongoing
commitment process of occupa-
tional choice.
As shown in Figure 3, adolescent
play is characterized by devotion of
time to personal hobbies, group
games, and social events. Hobbies
develop a sense of competence and
realistic assessment of personal
skills, especially skills with objects.
Skills are integrated into habits of
craftsmanship where personal stan-
dards of excellence are important.
Games and social events are the
arenas in which skills are integrated
into habits of sportsmanship such
as cooperation and competi tion.
These learnings support organiza-
tion of the system toward the worker
role. Work is practiced as school is
continued and chores become more
routine and demanding; part-time
work may also be undertaken. The
most critical component of work is
occupational choice in which a com-
mitment toward a worker role is
being processed.
Occupational choice is the major
transition of occupational behavior
that bridges the continuum from
childhood play to adult work (13).
It occurs over a period of years,
preceding and following adoles-
cence, during which the individual
generates internal values and inter-
ests and responds to expectations to
prepare for and enter into the world
of work. As the adolescent develops
the ability for abstract thinking, he
becomes increasingly aware of his
placemen t in time (10). The adoles-
cent is primarily future-oriented and
plans for the approaching adult
role. During the occupational choice
process, the person develops a grow-
660 October 1980, Volume 34, No. 10


Figure 3 The balance and interrelationship of work and play during the life span
Levels of Organization of the Occupational Behavior Career
'tl
~
CHILDHOOD
I
ADOLESCENCE
I
ADULTHOOD
I
OLD AGE
0.
0

::l >.
o III
I I
0- I
011.
Time spent
I
I
I
",all
... ~ in play I I
I

::l ...
00
I
I
: r ~
I
tn>.

Time spent in

.!: III I
~
I
work
III
~



I
en
'tl Reality is explored via curi- I Competent behavior is

Relaxation and recreation

Play allows the explora-


I
~ osity for rules of compe- I learned and experienced support the worker role. tion of past achievements
>-
tent action. I in games. personal hob- Exploration of novel situa- and the unknown future,
~ I bies, and social events. tions allows new roles to and maintenance of com-
>.
11.
be taken on. I petence through leisure
I
I
pursuit of interests.

I
Exploration I Competency

Achievement Exploration
o ~ Skills for productivity are I Personal interper-

Play supports the worker and Retirement leisure
c. ...
.- 0 acquired and work roles sonal competency are de- I
roles by providing an signals that the produc-
; ~
explored through imita- I veloped in a matrix of co-

arena of retreat and re- tive obligation to society


gall
tion and imagination. I operation yielding habits

juvenation. Exploration in been fulfilled. Past


: : : ~ has
III III I of sportsmanship &crafts-

novel situations allows work has earned for the


'iiiii:
manship.
the ongoing development the right to lei-
a:: person
of new competency for Leisure replaces
I sure.
work. I work as the major source
I
of life satisfaction.
I


Productive behaviors are I The work role is practiced

There is entry into worker I Retirement bri ngs re-


'" 'tl
practiced through chores I and the commitment pro- I roles with the requi re- I duced expectations for
'iii
and in school I cess of occupational

ment of establishing and I productivity and personal


~ I choice takes place.

maintaining a productive I capacities for productive


>-
0

and self-satisfying career action are waning.


~
ing awareness of the self and of capacities. In the realistIC period of Adulthood. The adult period of
outer reality. early adulthood, the individual in- life is characterized by the drive for
Occupational choice occurs In corporates reality factors into the achievement; the tendency toward
three periods: fantasy, tentative, and ro Ie being prepared for or ext'rcised. effecti veness is borne ou tin the con-
realistic (l3). The fantasy period The choice is a compromise between text of achieving wilhin family and
occurs during pre-adolescent laten- personal desires and the opportuni- community roles (see Figure 3)
cy, at which time the mdividual ties and limitations in the envi- Adulthood is generally organized
chooses occupations attractive for ronment. around procreative and/or produc-
the moment from the perspective of The process of occupational tive roles. The adult, whatever hiS
the pleasure they yield. This is a choice is not entirely age-specific or her personal values and interests,
crucial step in which the child tries nor irreversible, and the cycle may IS in a period of life when social ex-
on the idea of fulfilling an adult recur (14). The occupational pectations require useful contribu-
role and at the same time experiences choice process is culminated when tions to the social grou p, its processes,
positive emotion. the individual successfully enters and its continuation. The adult
In the tpntative period of adoles- the adult world of work in some must achieve a sense of efficacy and
cence, the choice is made in terms of productive role. Work nt'ed not be the concomitant habits and skills
morestablesubjective [actors, inter- paid labor, but can be any socially for work role performance. Socie-
est, values, and a sense of personal organized adult productive role. ty's expectations and the individu-
The American Journal of Occupational Therapy 661
aI's valued goals are blended into an
"internal sense of social timing that
acts as a prod to progress through
the social events of the lifeli ne" (15).
This internalized social clock sets
the sequential progress and pace of
change through adult life.
While adulthood appears to be
characterized by a long period of
stability, it is also a period of change.
Whether becoming a spouse or par-
ent, or entering a new job, adult life
is organized around a process of
entering, maintaining, and re-enter-
ing a sequence of social roles.
Therefore, although adulthood is
characterized by achievement, it also
requires reorganization of the system
along the hierarchical continuum
from explora tion to achievemen t.
This process has been characterized
as "anticipatory socialization,"
which involves a person's explor-
ing new norms and expectations
that will be associated with a new
role about to be assumed (15).
Work is broadly defined here as
any consistently organized pattern
of an individual's productive con-
tribution toward the maintenance
of self, family, or some other social
group. Not all theories or studies of
work behavior have such an open-
ended view of work, but their con-
clusions concerning its meaning
and organization will largely gener-
alize to this broader defini tion of
productive behavior.
Work has been the dominant fea-
ture of the human struggle for per-
sonal and group survival and the
building of culture. Therefore, work
has traditionally been valued highly
by society (19). It is a central factor
in the daily life of most adults (16),
and the work role serves as a major
organizing component of the inter-
nalthroughput of the system. Work
has a stabilizing effect on the daily
life pattern (16). It requires adher-
ence to strict temporal requirements
and usually binds the worker to the
clock (9).
Work not only tends to stabilize
the life style of the adult, but is a
principal factor in self-identity. In-
dividuals come to perceive them-
sel ves in terms of their con tribu-
tions to the labors that sustain
society as they internalize produc-
tive roles (17). Work is the arena
where most adults validate them-
selves and is a major component of
self-esteem (9). Work is also poten-
tially a major source of personal
satisfaction if the adult is ?ble to
usefully employ and expand his or
her interests and abilities (18).
Play, which served in the longi-
tudinal sense to prepare the person
for work, now serves the purpose of
supporting the work routine (14).
This change in the nature and role of
play in adulthood is reflected in the
term recreation, which is generally
used to describe adult play. Play
recrea tes or regenera tes energy to
support the worker role (4). PIa yful
exploration is still an important
means for change in the adult. Man's
nature as a playing creature never
subsides and play remains a central
feature of adult occupation.
Throughout adulthood, work satis-
faction is linked to the abi li ty to
balance work and play.
In later adulthood, another ex-
ploratory phase in the hierarchical
organization of occupation begins:
the preparation for old age and
retirement. In this life stage a pro-
cess, not unlike the occupational
choice process, takes place (19). The
individual begins in mid-life ob-
serving and interacting with suc-
cessfully retired individuals who
serve as role models. Later, there is a
period of developing interests and
skills that can be used upon retire-
ment. There are realistic explora-
tory encounters with environmen-
tal tasks at retirement, and the choice
process culminates with successful
entry into the retired role. This
choice process, however, is not
always a smooth one, especially
where forced retirement or early
disability enforces the transition.
Whatever the mechanism, most in-
dividuals who survive to old age
must make the change to a retired
role.
Old Age and Retirement. Old age
has been popularly thought of in
terms of disengagement of the indi-
vidual from mainstream life, from
society's value and meaning, and
eventually from life itself (20).
Rather than disengagement, cross-
cultural research suggests a more
universal transition from a mode of
active mastery to passive mastery of
life and a turning toward the magi-
calor supernatural (20). Old age
need not result in disengagement of
the individual from society. If soci-
ety provides a valued role for the
elderly, old age can be a period of
intense social participation and a
form of social rebirth (20).
This social rebirth takes the form
of organizing a long history of life
experiences into a new level. Ra ther
than experiencing disintegration of
the occupational role, the retired
person can move toward the inte-
gration of life experiences. There-
fore, retirement and old age are con-
ceptualized as a natural phase of life
wi th its proper life roles. The tran-
sition from intensive productivity
to leisure can be a positive and
rewarding experience or it can be-
come a social disability, depending
on the individual, his or her history
of experience, and the external cir-
cumstances during old age. The suc-
cessful system continues to enhance
its nature and to play out its tenden-
cies. The basic drive toward curios-
i ty and effectance continues through
adulthood to old age. What takes
place is a metamorphosis that builds
662 October 1980, Volume 34, No. 10
on the stages of life already accom-
plished. The older person explores
his past and the unknown future in
this life stage. Although personal
capacities are waning, one's sub-
stantial personal history can be
drawn upon as a source of self-
satisfaction in the transition from
acti ve to passive mastery. In addi-
tion. the maintenance of activity
(usually leisure activity) is crucial
for achieving a balance in daily life
during retirement and old age.
This is a period in which the
older adult must recognize and ac-
cept both decreasing ca paci ty for
productivity and a changing set of
expectations from society. Produc-
tivity is now focused more on self-
maintenance and family participa-
tion than on contribution to society
at large. Successful retirement re-
volves around the ability to transfer
to a daily life pattern in which lei-
sure replaces work as a primary source
of satisfaction (19). Like the play of
childhood, the leisure of old age
signals decreased expectations for
performance and is focused on gains
and satisfaction to the individual
rather than to the group. Successful
retirement requires not only an atti-
tude of acceptance of this changing
role, but also a supportive environ-
ment that values the role of old
age. Like work, leisure requires its
own special set of skills and the
reorganization of the pace and use
of time. The abili ty to find a sense of
competence in activities and inter-
ests beyond former work roles makes
the critical difference between de-
spair and hope in old age (19).
Discussion
This article continues the descrip-
tion of a model of human occupa-
tion. The unfolding of occupational
beha vi or over the I ife span was dis-
cussed according to the perspective
of temporal adaptation. The two
major elements are the concept of
hierarchy in ontogenesis and the
characterization of work and play
over the four life stages. Hierarchy
provides a schema for understand-
ing increasingly complex motiva-
tion for and organization of behav-
iorduring the life span. This schema
is a backdrop for the understanding
of and problem solving about the
disorganized occupational behavior
of pa tien ts or clients. Since all open
systems change hierarchically, the
changes that are desired in occupa-
tional therapy must also proceed
according to hierarchical principles.
The occupational therapy clinic
should. be designed to provide a
hierarchical set of challenges that
correspond to the exploration, com-
petency, and achievement hierarchy
of motivation.
The presentation of the ontogen-
esis of occupation should serve as a
schema for understanding normal
changes in the life span. This pre-
liminary description focused on the
usual ontogenesis of work and play,
that which is anticipated or expected
in American culture. Empirical re-
search will be needed to explicate
the many particulars of an occupa-
tional life-span theory, especially
with reference to disabled persons.
However, the present description
should provide general guidelines
for identifying problems of occupa-
tional dysfunction-namely, instan-
ces when disability is associated
with gross deviations from this
usual occupational sequence.
The generation of clinical inter-
vention from the model is a com-
plex task requiring a thorough un-
derstanding of the model. The next
step in explaining this model, be-
nign and vicious cycles, will bring
the model closer to a clinical focus.
A final article will discuss in more
detail the application of this model
in assessment and intervention.
REFERENCES
1. Kielhofner F, Burke JP: A model of
humanoccupation,Part 1. conceptual
framework and content. Am J Occup
Ther34: 578-586,1980
2.Von Bertalanffy VL: General Systems
Theory, NewYork: Braziller, 1969
3,KielhofnerG: Generalsystemstheory:
Implications for theory and action in
occupational therapy. Am J Occup
Ther32: 637-645,1978
4, ReillyM:Play As Exploratory Learning,
Beverly Hills, CA: Sage Publications,
1974
5,Reilly M: Occupational Behavior
Workshop, Boston, 1978
6, Kielhofner G: Temporal adaptation: a
conceptualframeworkforoccupational
therapy.Am J Occup Ther 31:235-242,
1977
7,Shannon P: Work-playtheoryand the
occupational therapy process, Am J
Occup Ther26: 169-172, 1972
8. BrunerGS: Natureand usesof imma-
turity,In Play: Its Role in Development
and Evolution, J Bruner, A Jolly, K
Sylva,Editors.NewYork:BasicBooks,
1976
9,NeffWS: Work and Human Behavior,
NewYork: Atherton Press, 1968
10.ColemanJC:Psychology and Effective
Behavior, Glenview,IL:ScottForesman
& Co, 1969
11.Josselyn 1M: The Adolescent and His
World. New York: Family Service As-
sociation ofAmerica, 1963
12,Erickson EN; Childhood & Society,
New York: William/Norton & Co, Inc,
1950
13,Ginzberg E, et al.:,Toward atheoryof
occupational choice. In Vocational
Guidance and Career Development,
HJ Peters, JC Hansen, Editors, New
York: Macmillan Co, 1971
14,Ginzberg E: Towardatheoryofoccu-
pational choice: A restatement. Educ
Guid Q 20: 169-176, 1972
15.KimmelDC:Adulthood and Aging: An
Interdisciplinary. Developmental View.
NewYork: JohnWiley& Sons, 1974
16.SuperDE: The Psychology of Careers,
NewYork: Harperand Rowe, 1957
17,CaplowT:The Sociology of Work, New
York: McGrawHill BookCo, 1954
18.Herzbe.rg F: Work and the Nature of
Man, Cleveland,OH:WorldPublishing
Co, 1968
19,Wong PK: Toward an Occupational
Therapy, Gerontology Theory, unpub-
lished Master's thesis, University of
Southern California, Department of
OccupationalTherapy, 1969
20.Gutman D: Alternativestodisengage-
ment: the old men of the highland
druze,In Time Roles & Self in Old Age,
New York: Human Sciences Press,
1976
The American Journal of Occupational Therapy 663
A ModelofHUnlanOccupation,
Part3,BenignandViciousCycles
(treatmentmodel,adaptation,dysfunction)
Gary Kielhofner
Earlier papers in this series con-
ceptualized occupation as an open
system phenomenon, with change
the central theme. This paper
presents an explanation of adap-
tive and maladaptive changes in
the concept of benign and vicious
cycles. Hypothetzcal case materzal
is used to illustrate how the model
could be applied to an explana-
tion of change in occupational
behavior. The paper also outlines
how the concept of benign and
vicious cycles, as conceptualized in
the present model, can guide clini-
cal intervention.
T
Wo earlier papers in this series
presen ted the structure,
content, and ontogenesis of the mod-
of human occupation (1,2). The
subject of this third paper, benign
and vicious cycles, is a critical con-
cept for understanding the process
of human adaptation. The paper
also begins a delineation of the rela-
tionship between human occupa-
tion and adaptation to life in
general.
TheNatureofCycles in Open
Systems
The model of human occupation
conceptualizes the human being as
an open system (I). According to the
model, the basic process that under-
lies change is a cycle. The cycle is a
series of component processes that
Gary Kielhofner, M.A., Dr. P.H.,
OTR, is Assistant Professor,
Department Of Occupational
Therapy, Medical College of Vir-
ginia, Virginia Commonwealth
University, Richmond, Virginia.
occur when the system interacts
with its environment. These pro-
cesses are output, feedback, input,
and throughput (3). Output con-
sists of both information (e.g., an
expectation or intention and ac-
tion.) Feedback is information that
informs the system of both the pro-
cess and consequences of its output
(3). (For instance, proprioception is
information about one's present
movement, and a letter grade is
information about one's past per-
formance in school.) These forms of
feedback serve to guide ongoing
action and to modify the internal
makeup of the system. Input is
information that enters the system
because of some action in the envi-
ronment. (Parent's "baby talk" and a
classroom lecture are both exam-
ples of input.) Like feedback, input
can change the system. It is a basic
property of the open system to
change and reorganize itself on the
basis of incoming information (4).
This allows the system to adapt to
conditions in the environment.
Throughput refers to the process-
ing of incoming information. In
this dynamic process the system not
only organizes its existi ng structures
for performance, but reorganizes
itself toward demands of the envi-
ronment for new output (4). Thus,
throughput rearranges the internal
makeup of the system (its structure)
and, by so doing, makes possible
changes in the system's future out-
put (function). In this way, the
input, throughput, output, and feed-
back cycle links the ongoing organ-
ization and reorganization of the
system to the demands of the external
environment. The cycle refers to the
process whereby information enters,
changes the system, results in new
output, and brings new informa-
tion to the system via feedback. Just
as the a tom is a basic building block
of physical systems, the open system
cycle is a basic building block of the
organization of living systems. Since
it is the system's own action or out-
put that generates new information
for change, the open system is said
to be self-transforming (4).
The self-transformation of an
open system is always directional.
That is, the system changes along
some con tinu um of characteristics.
Adaptive change is hierarchical: the
system changes in the direction of
increased complexity and differen-
tiation, allowing more flexible ac-
tion in interacting with the envi-
ronment (5). The directional change
of a system has been referred to by
Smith as a traJectory (6). This tra-
jectory of change is influenced by
two critical factors-the internal
characteristics of the system that
influence its output, and interac-
tion with the environment of the
system. Innate characteristics and
experientially learned character-
istics join with environmental con-
di tions to exert their rela ti ve infl u-
ences when the system interacts with
the environment.
The innate characteristic of the
system that energizes human occu-
pation is the urge toward explora-
tion and mastery of the environ-
ment (I). Learned characteristics
are those preferences and abilities
that result from experience. These
have a guiding effect on the trajec-
tory as the system interacts with its
environment on an ongoing basis.
The following example of an early
occupational experience in a hypo-
thetical child's play should illus-
trate this process:
The American Journal of Occupational Therapy 731
Johnny has in recent weeks been
playing in his father's woodwork-
ing shop while his father works
there. He has explored tools and
materials and gained a sense of their
properties and purposes. His father
serves to encourage his exploratory
efforts, demonstrates some tech-
niques, and serves as a role model.
Johnny's satisfying experience with
woodworking has generated an in-
terest in the occupation. He decides
with his father's help to undertake
the constructive project of making a
birdhouse.
As Johnny begins to play and
execute the birdhouse with his fa-
ther's assistance, he generates feed-
back. In this case the feedback is
information of his success with the
project, and the satisfaction that
goes with achieving a goal. J ohn-
ny's success, of course, is made pos-
sible by the earlier exploratory play
that familiarized him with many of
the tools and processes involved in
the craft. His earlier playful prac-
tice also allowed him to gain skill
and proficiency in using the tools
and working with the materials.
Now the earlier learned skills are
reorganized under a more complex
undertaking of constructing a
product.
This example is characteristic of
countless experiences that consti-
tute childhood occupation. Their
cumulative effect usually results in
a skilled and self-confident adult
who can enter the world of work.
The model of human occupation
presents a means of conceptualizing
this process in systems terms. The
major portion of the model consists
of the cycle already described. In
addition, the model specifies inter-
nal components of the open system
(I). These include three subsystems-
volition, habituation, and produc-
tion. The structure of the volition
subsystem consists of values, per-
sonal causation, and interests. The
function of this subsystem is to
enact the system's output. The habit-
uation subsystem consists of inter-
nalized roles and habits; it func-
tions to maintain the system's out-
put into patterns and routines. The
production subsystem consists of
skills, and its function is to produce
output. These are the subsystems
that allow output and that are
changed during the throughput pro-
cess as information enters the sys-
tem via input and feedback.
By using the model of human
occupation depicted in Figure I, the
example of johnny's play can be
examined. The volition subsystem
contains the basic tendency of the
organism to explore and master the
environment. It functions to enact
exploratory action. This subsystem
initiates the cycles represented in
Johnny's play. The output, early
exploration, results in the devel-
opment of an interest that, in turn,
influences further output. At the
same time, the exploratory action
yields feedback (information) that
is processed in throughput to reor-
ganize the system. This reorganiza-
tion includes the development of
the interest in woodworking, a
strengthening of personal causa-
tion (belief in the efficacy of action),
and the development of woodwork-
ing skills. This process prepares the
system for the next round of action,
which involves more complex con-
structive action. The changes in the
system that take place as a result of
earlier exploratory action make pos-
sible success in the construction of
the birdhouse. The construction ac-
tivity will also serve to reorganize
the system in the direction of in-
creased interest, skill, and self-con-
fidence, resulting in a continued
investment and useful habits in the
occupation of woodworking.
The cycle of interaction of the
system with its environment thus
propels the system in a trajectory of
change. No cycle, or trajectory is as
simple or as isolated as the hypo-
thetical example just reviewed.
Many occupations are engaged in
simultaneously with varying de-
grees of success. Occupation always
involves a mixture of risk, failure,
and success. What is important is the
balance between success and fail-
ure. The direction in which the
scale is ti pped is the direction of the
trajectory. The balance between suc-
cesses and fail ures is a direct resul t
of the match between the system's
capacities and the requirements of
the environment.
Changing a system requires not
only altering the system, but also
altering the balance between the
system and its environment. Two
important concepts for engineering
any change process are, first, that no
system can be evaluated or under-
stood in isolation from its particu-
lar environment, and second, an
environmental change is the surest
way to effect permanent organized
change in an open system. The
object of any planned change pro-
cess is to influence the system's tra-
jectory. The judgments required in
making change can be found in the
concept of benign and vicious cycles.
These cycles provide a means of eval-
uating the quality and results of a
given trajectory and allow an analy-
sis of its fea tures to guide planning
for change.
Benign and Vicious Cycles
Cycles of interaction between the
system and its environment result
in a trajectory of change that can
either support or threaten the adap-
tation of the system(6). A benign
cycle is one that results in a trajec-
tory that supports adaptation. Adap-
tation requires the system to satisfy
732 November 1980, Volume 34, No. 11
its own in ternal urge to explore and
master, as well as fulfill the demands
of the environment(7). A vicious
cycle does none of these things.
Smith describes the benign cycle-
as follows:
If the person comes to believe in his
own efficacy-to have generalized
feelings of competence-he is likely
to see and to seek out opportunities
and to try. His sense of efficacy gets
confirmation from his successes,
and he has the security to learn from
his failures. In this process of active
engagement with the world, he ac-
quires the knowledge and skills that
make subsequent successes more
likely. (6, p 12)
The vicious cycle has opposite
characteristics:
Conversely, the person who is
launched with a belief in hzs own
incompetence sees threats instead of
opportunities, holds back and
doesn't try, misses out on acquiring
the skills required for success, is
therefore likely to fail when he does
venture to try, and produces con-
firmation for his negatwe belief.
(6, p 13)
As these two passages dem-
onstrate, benign and vicious cycles
involve both internal beliefs and
external objecti ve successes and fail-
ures. Internal convictions leading
to success and failure in engaging
the environment are only half of the
adaptive process. The second and
equally important component of
adaptation is the internal pleasure
or displeasure associated with suc-
cess and failure. Thus, any view of
adaptation includes meeting envi-
ronmental requirements and yield-
ing personal satisfaction. Thus, a
benign cycle benefi ts both the sys-
tem and the environment. If either
system or the environment is not
satisfied, the system is in a vicious
cycle. The following section will
give examples of both types of cycles
and demonstrate how the model can
serve to explain them.
The Benign Cycle
Assuming that the balance of inter-
actions between Johnny and his
environment have been positive, he
will progress through occupational
development in a benign cycle. The
following is a description of that
benign cycle in this hypothetical
case as he enters adulthood:
John's original interest in wood-
working has grown through ado-
lescence into an occupational
choice commitment. John con-
tinued his hobby of woodworking
throughout his later childhood, be-
coming proficient in the techniq ues
of the craft and increasing his abil-
ity to produce fine woodworking
products.
While John was an above-average
student in school, he was most out-
standing in the high school shop
classes. The shop instructor, who
was himself a professional cabinet-
maker, became an important role
model for John. This allowed John
to come to value the skills of wood-
working so that he began to seri-
ously consider cabinetmaking as a
trade when he finished school. The
shop instructor arranged for John
to become a part-time apprentice
with a local cabinetmaker during
the summer of his junior year. This
experience solidified his choice.
Upon graduation from high school
John became a full-time appren-
tice; within the year he was earning
an income and moved out of his
parents' home into an apartment.
After two years of successful work as
a cabinetmaker, John was a satis-
fied young worker with dreams of
one day returning to college to
complete a degree in architecture
and expand his constructive talents.
In addition, John has a serious rela-
tionship with a girl friend, and they
are contemplating marriage in the
near future.
John's occupational role now in-
cludes new forms of recreation.
Since his childhood hobby has be-
come a trade, he has developed new
leisure interests. John has become
involved in motorcycle racing and
often spends evenings and weekends
driving his motorcycle on country
trails. He is an avid participant in
other sports and attends social af-
fairs and public entertainment with
his girl friend. On the whole John's
occupational life is balanced and
provides him with satisfaction.
John's experience of the benign
cycle can be conceptualized in the
model of occupation. This concep-
tualization is portrayed in Figure 2.
In John's benign cycle, the system's
output or action consistently fills
the demands presented by the phys-
ical and social environment. John
successfully completed the student
role and met social expectations
(input) for entry into a worker role.
At the same time, he is able to fulfill
the interests and values he had de-
veloped. These two factors signal
positive adaptation. His interest in
woodworking sustained his output
or action so that ongoing practice
and feedback developed habits of
craftsmanship and skills of a com-
petent woodworker. These skills and
habits were later consolidated into
an internalized role when John
chose woodworking as a vocation.
In this way each of the three subsys-
tems-volition, habituation, and pro-
ductiorl-interacted to converge on
this occupational choice.
Since John performed consis-
tently well in an area he valued, his
The American Journal of Occupational Therapy 733
Figure 1 A cycle in the open system
Throughput
Volition Subsystem
PERSONAL:
",CAUSATION -- - - --- '"l
, I
/ ------1
I-
Z
, , - I
w
,:, . Habituation Subsystem : :2
CDZ
/" - . I
Expectancy :SO
(:- -- - --"Habits - -----.,. a:
:;
Action Z
"'" Production Subsystem W
, ,
"" I
''-.... SKILLS U
FEEDBACK
feedback was consistently positive.
This, in turn, enhanced his sense of
personal causation so that he could
enter his worker role with confi-
dence and even consider further
education to pursue his interest and
vocation at a higher level. These are
the important internal dimensions
of a benign cycle. The necessary
prerequisites for this state are the
balance between interests, values,
and personal causation that enact
behavior, and the role behaviors,
habits, and skills that make possible
fulfillment of the choices enacted at
the higher level. When these prereq-
uisites are met the internal system is
in good order.
The other major portion of a
benign cycle, fulfillment of external
environmental demands, is also evi-
denced in John's case. Social re-
quirements for entry into a produc-
tive role have been met. John has
also successfully completed high
school, another socially valued ac-
complishment. Since both internal
satisfaction and external demands
are met, the system is adapting and
thus is in a benign cycle. Evidence
of continuation of the benign cycle
is John's valued goals for future
role taking (marriage) and expan-
sion of his present trade through
obtaining a degree in architecture.
An important component of this
benign cycle is the interrelationship
of subsystems within the system.
The volition subsystem contains
the system's preferences and aspira-
tions and its values for engaging in
occupation. The habituation sub-
system organizes behavior into large
routines that reflect choices made
by the volition subsystem. The per-
formance subsystem allows the per-
formance of skilled action to fulfill
those choices. The balance among
these subsystems is necessary for
fulfilling both internal satisfaction
and external demands.
The Vicious Cycle
Vicious cycles may begin from birth,
precipitated by some incurred dis-
ability. These cycles may also de-
velop slowly as a result of interac-
tions with the environment. Vicious
cycles may begin with disorganized
action (e.g., the child with senso-
rimotor difficulties) that fails to
meet the demands of the physical
environment. They may be precipi-
tated by interactions with the social
environment that produce demands
beyond the capacity of the system to
adapt. They may also be the result
of demands being decreased to such
a degree that the system is no longer
challenged to perform, and the voli-
tion subsystem's urge to mastery
cannot find expression (e.g., a home-
maker's depression following the
"empty nest" syndrome). Vicious
cycles exist wherever the require-
ments of the system to fulfill the
urge to explore and master the world
cannot be fulfilled and/or where
the environment's demands are not
met.
A vicious cycle may be illustrated
in terms of the model by again
returning to the hypothetical case:
One evening as John was engaged
in his usual recreation of motocross
cycle racing he took a spill from the
bike i;ind seriously fractured and dis-
located a vertebra. The accident left
John paralyzed below the pectoral
region, quadriplegic.
After.several weeks of ini tial shock
and denial, John has become quite
depressed. He sees all of his life
plans destroyed. He feels helpless
and out of control. He cannot derive
satisfaction from his former work or
leisure interests. His daily routine is
foreign and revolves around the
734 November 1980, Volume 34, No. 11
---
Figure2 The benigncycle inahypotheticalcase
INPUTand
FEEDBACK
Volition
Feedback
on
Successful
Behavior
Habituation
Role
Demands
For
Competence
Feedbackon
Successor
Performance
Failureof
Skills
hospital schedule rather than reflect-
ing his own roles and habits. John
expects that he will always be an
invalid and sees no reason to learn
to care for himself. He fears that his
girl friend will no longer find him a
desirable partner. In short, John
finds nothing in the future to which
he can attach his efforts and nothing
in the present from which he can
derive satisfaction.
The above events can be seen as a
total disintegration of the system
with a clear trajectory toward malad-
aptation. The model depicted in
Figure 3 can demonstrate how the
vicious cycle is beginning to take
place. Importantly, the model will
allow some delineation of the ele-
ments of this vicious cycle and will
suggest some strategies for revers-
ing it. Within the system the spinal
cord injury and subsequent quad-
BENIGN
TRAJECTORY
OFSUCCESSFUL
ROLE PERFORMANCE
ANDPERSONALSATISFACTION
EntryintoWorkerRole
FulfillmentofStudent Role
-i1.l.!.U.aOUGHPUT
Personal Causation: Sense of com-
petency in a valued area of performance
Valued Goals: degree inarchitectureandmarriage
Interests: Woodworking,sports,socialactivities
Internalized Roles: vocational role of
cabinetmaking and independent role
ofsinglehomemaker
Habits: craftsmanship,dailyhomemaking
routines
Skills: Developmentofskillsinavarietyof
areas that supportboth workand play
FEED CK
OUTPUT
Expectancy
ofSucces and
Goals
Consistent
Competent
Performance
Exercise
of
Skills
ENVIRONMENT ~ ~
riplegia can be seen as a disruyion
of John'S performance subsystem.
Underlying neurological and ana-
tomical functions are severely and
permanently impaired. They are
critically out of balance with the
other subsystems and will require a
major reorganization if adaptation
is to take place. In the meantime.
the organization of the system and
its interaction with the environment
are in jeopardy.
Since the performance subsystem
is drastically altered, it limits and
disrupts the habituation and voli-
tion subsystems. Habitual routines
that called upon skilled action in
the organization of patterns of be-
havior are no longer effectual.
Temporal patterns are externally
enforced in the hospital routine and
have little or nothing to do with the
control exerted by the habituation
subsystem.Skills that were needed
for role performance can no longer
be called upon. Thus, role perfor-
mance disintegrates. A new role of
patient and disabled person emerges
as old expectations are lifted. Thus
input to the system in the form of
demands for performance practi-
cally ceases.
Since the two subsystems asso-
ciated with the production and
maintenance of output are dis-
rupted, the output of the system is
interrupted or becomes minimal.
As a consequence, feedback is dras-
tically altered. Positive feedback on
successful performance is replaced
with feedback on failure. Those
competencies that allowed a strong
sense of personal causation are now
mostly 10st.The output of the sys-
tem, John's daily patterns of work
and play that had provided the posi-
tive feedback. is now severely lim-
ited. Input to the system largely
The American Journal of Occupational Therapy 735
Figure3 Theviciouscycle in ahypotheticalcase
Input
and
Feedback
Volition
Noorlittle
opportunity
forchallenge
Feedback on
Fi:l.ilure
Nochallengeor Habituation
expectation-for"
peH'ormanceIn
occupalfon
NofeedbackOn
performanceto Performance
adjustand
maintainskills
consists of information concerning
the dim prospects for recovery, and
the limitations and problems that
john must face. Also, since expecta-
tions for performance have been
removed, john has no environmen-
tal demands that can challenge his
response and allow to fulfill
his urge to mastery. Thus, each
cycle of in teraction of the system
with the environment is likely to
result in further progress along a
negative trajectory toward malad-
aptation.
Implications of the Vicious Cycle
for Change and Therapy
Any changes in the system must
begin with the volition subsystem
(2). This system, which enacts out-
put. is critical for initiating cycles
that can result in restoration of a
positive trajectory. The environ-
VICIOUS
TRAJECTORY
OF FAILURE
IN ROLE PERFORMANCE
AND LOSS OF PERSONAL
SATISFACTION
Lossof rolesand the
satisfactionofrole performance
THROUGHPUT ---....
Personal Causation: Loss of confidence
and sense ofhelplessness
Valued Goals: Given upas unattainable
Interests: Inconsistentwith capacities
Internalized Roles: Given upas no longer
viable
Habits: Breakdown due to lack of output
to maintain them
Skills: Anatomical and neurologicalcomponents dis-
rupted. Degeneration of skillsthatare notexercised
Output
EX'pectancy
ofFaifure
NoGoals
Inconsisfent
0"' Poor .
Performance
Few or
NoSkills
Used.
FEEDBACK ..
.ENVI.RONMENT
mental conditions are also of criti-
cal importance. The implications
for occupational therapy at this
point are twofold. This first is that
therapy should serve as an envi-
ronment that can begin to present
demands for performance and elicit
the enactment of responses that
can result in positive feedback.The
occupational therapy clinic is an
important source of input to the
system and a critical environment
in which benign cycles can develop.
The second implication for ther-
apy is that it is critical to recognize
how the volition subsystem can
begin to function. It was noted in an
earlier paper that the volition sys-
tem begins with a global undiffer-
entiated urge for exploration and
mastery (I). Change is processed
through three levels of motivation
in this subsystem-exploration,
competency, and achievement (2).
These three levels, in turn, yield
corresponding and hierarchically
organized skills, habits, and roles.
All of these behaviors have been dis-
rupted in the system and therapy
must begin with the lowest level of
motivation in the volition subsys-
tem-exploration-and the lowest
level of behavior organization-
skills.
During the initial period of ther-
apy, it will be important that John,
with a body drastically altered, begin
to explore his own action in the
world. Here, the arts, crafts, games,
and other activities of the clinic that
provide low demands for perfor-
mance and provide maximurn stim-
ulation of curiosity and explora-
tion are critical. john must literally
rediscover how to be in the world as
a physical being. Since action is the
736 November 1980, Volume 34, No. 11
major means of providing this in-
formation to the system via feed-
back, it is critical that John be
allowed La explore as wide a variety
of activities as possible in the clinic.
The environment must be presented
La him as one in which he can
explore actions and activities and
relearn the effects he can now have
on the world. Imponantly, this stage
of therapy will begin La yield new
skills as John learns La use his
remaining movement to accom-
plish tasks. As a result of his explora-
tion' he should begin La generate
new interests more consistent with
his remaining physical capacities.
A final and important result
should also be the restoration of a
beginning sense of personal causa-
tion based on the exploration and
discovery of what is still possible La
do. This stage of therapy is crucial
for reversing the vicious cycle. On-
going assessment should carefully
moniLar any changes in the system,
especially the volition subsystem.
The therapist must be careful La
manage the milieu of therapy so
that exploration and curiosity are
encouraged and fostered. Much like
the child who must discover his
being in the world through play,
John must relearn his own being in
the world in a playful and explora-
tory manner where the consequences
and potential failures in action are
kept at a minimum.
The next stages of therapy should
continue to follow the hierarchy of
change. Challenges should be in-
creased to elicit a sense of compe-
tency. Here the therapist should
take advantage of the natural urge
toward mastery, John should begin
to establish routines and gain com-
petence in self-care, the first and
critical element of work and pro-
ductivity for self.
In the final stage, the therapist
seeks La reintegrate the volition sub-
system with the skills and habits of
the lower subsystem. While envir-
onmental demands for performance
may be altered, they should still
exist. John's potential for reenter-
ing a worker role should be as-
sessed. Again, assessment begins
with the volition subsystem, and
focus should be on the retention of
any valued goals that existed before
the inj ury. In this case, John's plans
La return La school and become an
architect are still consistent with his
remaining capacities. Exploration
of this possibility might be under-
taken as pan of occupational ther-
apy. IfJohn is able to re-establish a
connection between his values and
the skills and habits generated in
therapy, one can then expect that a
benign cycle is likely La follow, with
progression to the achievement
stage of the volition subsystem. The
goal of this trajectory would be to
re-establish the occupational role
that included work, play, and self-
care, and a balance between them.
This discussion demonstrates that
normal sequences of development
and organization should be tapped
in the therapeutic process. Disabil-
ity represents a disruption of a total
system with biological, psychologi-
cal, social, and cultural compo-
nents. Reorganization of that sys-
tem is a complex process requiring
allention La several components
within the system and La the sys-
tem's interaction with the environ-
ment.
Summary
This paper presents the third pan of
a model of human occupation, a
conceptualization of change in the
system that allows judgments La be
made concerning the adaptive sta-
tus of a patient or client. Adaptive
and maladaptive changes are seen
as a process of benign and vicious
cycles. The cycle represents the basic
process of interaction between the
system and its environment that
shapes change in the system.
Adaptation was defined as a pro-
cess requiring both internal satis-
faction to the system and fulfillment
of the environment's demands. Be-
nign cycles allow both of these
requirements La be met; vicious
cycles fail to meet one or both. A
hypothetical case was used to illus-
trate both benign and vicious cycles
and to discuss the implications for
trea tmen t in the case of the vicious
cycle. Occupational therapy is con-
ceptualized as an environment in
which the human system acts to re-
store, maintain, or achieve a benign
cycle. Identifying the components
of a vicious cycle allows more thor-
ough clinical decision making be-
cause it points to factors in the
vicious cycle that block the benign
cycle.
A final and fourth paper in this
series will further discuss the impli-
cations of the model of occupation
for occupational therapy. It makes
use of clinical cases from occupa-
tional therapy practice to illustrate
application of the model.
REFERENCES
1. Kielhofner G, Burke JP: Model of
human occupation, Part 1. Structure
andcontent.AmJ Occup Ther34: 572-
581, 1980
2. KielhofnerG: A modelofhumanoccu-
pation, Part 2. Ontogenesis from the
perspectiveoftemporaladaptation.Am
J Occup Ther34: 657-663, 1980
3. Bruner J: The organization of early
skilledaction.Child Dev 44: 1-11,1973
4. von Bertalanffy L: General Systems
Theory, New York: George Braziller,
1962
5 WeissP(Editor):Hierarchically Organ-
ized Systems in Theory and Practice,
NewYork:HafnerPublishingCo.,1971
6. Smith MB: Competence and adapta-
tion.AmJ Occup Ther 28: 11-15, 1974
7. White R: Strategies of adaptation: An
attempt at systematic description. In
Coping and Adaptation, G Coehlo, 0
Hamburg,JAdams,Editors.NewYork:
BasiC Books, 1974
The Amerzcan Journal of Occupational Therapy 737
A Model of Hunian Occupation,
Part 4. Assessnient and Intervention
(treatment model, theory)
Gary Kielhofner

This paper, the last of four, com-
pletes the presentation of a model
of human occupation. Its purpose
is to illustrate how a model of
occupation can be applied in
clinical practice. Three major
assumptions concerning occupa-
tional therapy that underlie this
model are described, the three
parts of the model presented ear-
lier are reviewed, and the use of
the model in assessment to gener-
ate plans for treatment is dis-
cussed. Four case histories are used
to demonstrate assessment and
intervention.
Janice Posetary Burke
Gary Kielhofner, M.A., Dr. P.H.,
OTR, is Assistant Professor at the
Medical College of Virginia, Vir-
ginia Commonwealth University,
Richmond, Virginia.
Janice Posatery Burke, M.A.,
OTR, is Director of Training in
Occupational Therapy, University
Affiliated Program, Childrens
Hospital of Los Angeles, Califor-
nia, and Clinical Professor, Occu-
pational Therapy Department,
University of Southern California,
Los Angeles, California.
Cynthia Heard Igi, M.A., OTR, is
Project Director, Special Services
for Groups, Inc., and in private
practice, Los Angeles, California.
Cynthia Heard Igi
T
hree preceding papers in this
series proposed several facets of a
single model of human occupation.
This model, it was asserted, could
guide practice in all areas of disabil-
ity and in a variety of settings. The
model itself is only a .tool that
organizes material from a broader
science of human oq::upation. This
paper addresses the process of using
the model as a tool in practice.
Three assumptions underlie the
application of this model in prac-
tice. Reilly points out that occupa-
tional therapy is directed toward
enabling Man to fulfill his innate
need jor "occupation and ... the
rich and varied stimuli that solving
Jjfe problems provides him" (l, p 5).
According to this primary assump-
tion, humans are occupational crea-
tures who cannot be healthy in the
absence of meaningful occupa-
tion. Reilly has also stated the
second assumption: "Man, through
the use of his hands as they are ener-
The American journal of Occupational Therapy 777
gized by mind and will, can influ-
ence the state of his own health" ( 1, p
2). According to this assertion, occu-
pation can shape the health of a
person, and can thus serve as a
means to health.
The first two assumptions assert
that occupation is both a basic hu-
man activity essential to health and
a healing process. A third assump-
tion is that for occupational ther-
apy to be instrumental as a means to
an end, it must embody the charac-
teristics of the end itself. This means
that occupational therapy must be
true "occupation." Therapy must
embody the characteristics of pur-
posefulness, challenge, accomplish-
ment, and satisfaction that make up
every occupation. Therefore, a the-
ory of occupation is critical to prac-
tice.
The idea that, by engaging in
occupation designed as therapy,
Man can restore, increase, and main-
tain his ability as an occupational
creature is the foundation of occu-
pational therapy. A theory of human
occupation serves to justify the
field's commitment to occupation
as a worthy goal for therapy. It also
demonstrates how therapy should
be organized and carried out. This
latter use of a theory of occupation
is the major purpose of this paper.
In the three earlier papers in this
series (2-4), several diverse concepts
relevant to an understanding of occu-
pation were interrelated in a pro-
posed model of human occupation.
This model can serve in several
ways to guide practice. It presents a
description of the normal or usual
organization and ontogenesis of occu-
pation in Western culture. As such,
it can be used as a guide or measure
from which to identify disorganiza-
tion of behavior and deviations
from patterns of ontogenesis. The
model also demonstrates organized
relationships between conceptual
entities. Thus, the model can serve
as a guide to assessment by po in ting
out which areas (concepts) are im-
portant to consider in assessment. It
also provides a framework to guide
interpretation of patient or client
data that can be compared to organ-
ization of the system demonstrated
by the model.
Application of the model re-
quires that therapy be conceptuaL-
ized as an organizing process. The
model demonstrates how occupa-
tional behavior is organized and
serves both as a framework for inter-
pretation of disorganized behavior
and for making decisions about the
kind of occupations that should be
employed in therapy to organize
behavior. The concept of organiza-
tion is central to the model and thus
. to assessment and intervention. The
relationships of components and
sequences of ontogenesis postu-
lated by the model characterize or-
ganized behavior. The understand-
ing of how parts of the model are
interrelated and how they are se-
quenced is important for employ-
ment of the model in therapy. The
cases that follow in this paper dem-
onstrate the focus on the organiza-
tion of behavior. Dysfunction is
conceptualized as disorganization
in the system. Similarly, therapy is
seen as a process in which the sys-
tem experiences organizing in-
volvement in planned occupations.
The model should be viewed as a
flexible tool, allowing variation in
its application rather than as a rigid
standard. Each therapistmightfin..d
it useful to employ the model in
ways that coincide with his,,Pr her
own styles of thinking and pipblem
solving. What is most essential to<\.
valid application of the model is anl
understanding of the concepts and
interrelationships it postulates.
This paper will demonstrate ways
in which the authors have been able
778 December 1980, Volume 34, No. 12
to use the model as a guide to prac-
tice in settings with different pa-
tient populations.
The Model of Human
Occupation
As a preface to discussing applica-
tion of the model in practice, this
section will briefly acquaint the
reader with the model presented
earlier. For a more detailed por-
trayal, the reader is referred to the
three previous papers (2-4).
The structure and content of the
model explain human occupation
as an open system (2). An open sys-
tem interacts with its environment
and is constantly changing as a
function of that interaction. Inter-
action of a system with its environ-
ment is a process of input, output;
throughput, and feedback. Open
systems are spontaneous and oper-
ate according to certain innate char-
acteristics. Those innate features of
the system that underly and ener-
gize occupation are the basic
human urge to explore and master
the world, which is expressed in
work and play. The system with its
innate drive in interaction with the
environment organizes its own be-
havior (2). The social organization
of the human group that allows its
young to play and requires its
mature members to produce for
themselves and the group is a criti-
cal dimension of the environment
that shapes occupation.
The internal organization of an
open system is conceptualized as a
number of interrelated subsystems
(2). This model proposed three sub-
systems each of which serves a dif-
ferent purpose. The subsystems are
organized into a hierarchy with the
higher governing the lower. Each
subsystem has its own structure and
function that determine its contri-
bution to the overall system. Struc-
ture refers to internal makeup or
..
components. Function is the par-
ticular way a subsystem contributes
to the output of the system.
In this model, the volition sub-
system is the highest level subsys-
tem (2). Its function is to enact
behavior. It guides the system's
choices of action. Its structure in-
volves three components-personal
causation, valued goals, and inter-
ests. Personal causation refers to the
individual's beliefs about the effi-
cacy of action; it guides action ac-
cording to the belief that a given
action, or set of actions, is likely to
achieve desired results or allow
mastery over the world. Valued
goals refer to those ends toward
which the individual is willing to
commit sustained action. Interests
refer to the disposition to engage in
actions for their own sake and be-
cause of the pleasing results they
can achieve. Personal causation,
valued goals, and interests all con-
tribute to the volition subsystem's
influence oyer the system's propen-
sity for action. In combination they
determine what the system chooses
to do. Since this subsystem deter-
mines what the individual finds
pleasing and satisfying to do, it
must be in harmony with other
internal subsystems and with the
environment's requirements. If
there is a gap between the volition
subsystem and the structure of
another subsystem or in the re-
quirements of the environment,
disorganization of the system can
follow.
The second subsystem is the habit-
uation subsystem (2). Its structure
is made up of habits and internal-
ized roles. It functions to maintain
action. This subsystem guides the
output of action that does not need
to be enacted through choice, action
that is routine and largely out of
consciousness. For instance, when
behaviors originally energized by
interest become routine, their or-
ganization becomes the function of
the habituation subsystem.
Internalized roles refer to expec-
tations from the environment for
productivity that have been incor-
porated into the internal makeup of
the system within the habituation
subsystem. Internalized roles are
important to the system's ability to
meet demands from the environ-
ment for consistent performance.
Habits are organized routines of
behavior; they incorporate skills
The concept of organi-
zation is central to the
model and thus to
assessment and
intervention.
into patterns of action that can
function automatically without the
conscious attention of the actor.
Since the system cannot be con-
stantly attending to all of its action
or constantly making choices about
action, this subsystem governs auto-
matic, routine, and habitual action.
The production subsystem is the
third, and lowest level, subsystem
(2). The function of this subsystem
is to produce action. Its structure
consists of skills-social, cognitive,
and/or physical actions organized
to an end. A skill involves the inte-
gration of such diverse components
as anatomy, neurological circuitry,
and cognition. Skills organize com-
quality of action and giving it that
characteristic referred to as skill.
The open system of human occu-
pation is conceptualized as being
made up of the preceding three sub-
systems. The organization of these
subsystems over time depends upon
the interaction of the system with its
environment (2). This interaction is
conceptualized as a process involv-
ing throughput, output, feedback,
and input. The major concern of
this model is with how information
is processed in interaction since
occupation is conceived of as pur-
poseful, informed action.
Input refers to information that
enters the system from the envi-
ronment. Expectations of the social
group for individual performance
is an example of such incoming
information. Throughput refers to
how information is organized with-
in the system to effect output. Each
subsystem and its components re-
quire and organize information for
action. For instance, values, skills,
and habits all contain information
about the self and the environment
and use it to organize action in their
own way. Throughput processes
incoming information and deter-
mines the output. The output of the
system refers to both the informa-
tion and action that the individual
puts forth into the environment.
The expectation that some action
will be enjoyable is an example of
informational output. Action can
be physical or social and always
involves some skill. It may be
guided by either higher level sub-
" ponents of the organism into pat- syslem depending on whether the
terns of action that achieve a given action is habitual or the product of
end under whatever conditions choice.
exist in the environment. Either the Fe.r:.dback completes the cycle of
volition or habituation subsystems the system. It is the means by
can trigger the system toward the which the system is informed of the
employment of a skill. Once the sys- results of its action. Feedback infor-
tem is in action, this subsystem mation influences subsequent or-
serves as a guide, controlling the ganization of the subsystems. For
The American journal of Occupational Therapy 779
Exploration, the urge to curiously manipulate the
environment, yields skills. As the system uses these
skills the urge to be competent takes over and
through practice the skills are organized into habits.
instance, feedback on action guides
the learning of a skill, determir;J.es
whether or not a particular activity
is interesting, and lets the system
know what the environment's re-
sponse to its role performance is.
This kind of information influ-
ences the formation and modifi-
cation of the structure of the
subsystems and, consequently, their
function. Thus the interaction of
the system with its
always affects the in tern al organiza-
tion of the system and influences
the direction of change.
Ontogenesis. The second part of
the model described the change of
the system over time (3). This part
presented two properties of the sys-
tem: 1. stages of change, and 2. trans-
formations that take place in the
organization of occupation dur-
ing the life span. Change in the sys-
tem is conceptualized as taking
place in three hierarchical steps.
Change is energized primarily
through the volition subsystem as
the system chooses alternatives for
action and is, in turn, influenced by
those choices as the action takes
place. The volition subsystem is
undifferentiated at birth and con-
sists only of the global urge to
explore and master the world. Sub-
sequent action and experience dif-
ferentiate this subsystem into valued
goals, personal causation, and inter-
ests. These three components in-
teract in such a way as to produce
motives that guide the system in
normal ontogenesis. These motives
are first exploration, then com-
petency, and finally achievement.
This means that the propensity of
the system in change will be first to
explore, then to use the information
gained through exploration to com-
petently engage the environment,
and finally, to seek achievement by
employing the skills gained to per-
form roles. These three stages of the
volition subsystem correspond to
the development of skills, habits,
and roles in the system. Explora-
tion, the urge to curiously manipu-
late the environment, yields skills.
As the system uses these skills the
urge to be competent takes over and
through practice the skills are orga-
nized into habits. In the final stage,
the achievement urge propels the sys-
tem to respond to external standards
for performance and an internal
sense of excellence. As the indi-
vidual seeks achievement of per-
sonal valued goals, action becomes
organized into internalized roles.
This three-stage process is re-
peated each time or period in life
when an individual comes into con-
tact with new situations or when
new activities are attempted. It is a
necessary process for organizing be-
havior to meet environmental de-
mands. This process is also critical
when patients or clients must learn
to cope with a disability. It charac:;i
terizes the system's organized
sponse to the environment's de-
mands for adaptation.
who competently and to his or
own satisfaction performs some I.
productive role has organized that
behavior through these stages.
The second property of the onto-
genesis of the system is the human
780 December 1980, Volume 34, No. 12
career (3). The concept of career is
used to describe the history and con-
tinuity of _change over time on a
macro scale. The stages of change
describe major changes in occupa-
tion during the life span . Four
familiar stages are described-child-
hood, adolescence, adulthood, and
old age. Each of these is character-
ized by a different configuration or
pattern of work and play. Move-
ment from one stage to the next
represents a reorganization of the
daily occupational patterns. In child-
hood, play is the predominant form
of occupation, and serves as a learn-
ing arena that is preparatory to the
adult work world. In play the child
learns and acquires values, inter-
ests, a sense of personal causation,
habits, and skills. Play is the pri-
mary interaction between the child
and its environment that organizes
the system. Over time, increasing
demands for productivity are made
of the child who learns to perform
chores and to be independent in
self-care. By the end of the child-
hood period, the individual is pro-
ductive for the self (self-care) and
has begun to learn to be productive
for the social group. During adoles-
cence, demands for productivity in-
crease substantially and the process
of commitment to the work role is
initiated. Play continues to be an
important arena for learning, al-
though now the demands for per-
formance in play are greater and
involve cooperation and competi-
tion.
By adulthood the individual has
usually entered some major work
role within the family or another
social system. The individual has
learned to be productive for the
social system and at the same time
to find satisfaction in the perfor-
mance of that occupational role.
For the adult, play is relaxation and
recreation and serves to support the
worker role. Adult play also serves
to maintain interests, consolidate
valued goals, and provide an arena
where new ideas and activities can
be explored. When disability occurs
in adulthood or when some kind of
disruption takes place in the sys-
tem's organization, play is still a
critical arena in which behavior can
be organized. This is why the arts
and crafts and sports that character-
ize adult play are so important to
occupational therapy.
In old age the individual leaves
the worker role for retirement or is
required to give up other produc-
tive but nonpaid occupational
roles. The transition may be abrupt
or slow, but it almost always in-
volves a relinquishing of productiv-
ity. In this state the older adult must
find satisfaction increasingly in lei-
sure, which is a major sphere of
occupation in old age.
In the transition from one stage
to the next, the individual must
reorganize daily temporal patterns.
He or she inust acquire a new orga-
nization of interests, valued goals,
habits, and so on. Each transition
requires a reorganized action of the
system. Transitions are often par-
ticularly troublesome times that
may result in failures of adaptation.
These are points at which occupa-
tional therapy intervention can
serve to restore a normal course of
occupa
0
tional ontogenesis.
Benign and Vicious Cycles.
While the human career concept
can guide treatment in a general
way, it provides no detailed expla-
nation for problems in the system.
The third part of the model intro-
duces the concept of benign and
vicious cycles, which does provide
such an explanation (4). Change in
a system means a change of .affairs
in the makeup of that system and its
relationship with the environment.
The concept of benign and vicious
cycles includes this kind of change
plus a trajectory. The trajectory refers
to the direction of change. Many tra-
jectories are built into social sys-
tems and affect the course of change
over time in the system. One exam-
ple is the human career outlined
earlier. Another trajectory is the
progression of grades through
school. These are examples of
benign trajectories. A vicious trajec-
tory is one that involves disorgani-
zation of the system and failure of
adaptation such as the deterioration
of a dying patient with a carcinoma,
or chronic depression leading to
suicide.
Since any trajectory depends on
the interaction of a system with the
environment, the process is called
a benign or vicious cycle. A benign
cycle is present when the individual
is competently performing the occu-
pational requirements of his or her
environment and is satisfied with
that performance. A vicious cycle
occurs when either internal satisfac-
tion or external demands, or both,
are not met.
A benign or vicious cycle is iden-
tified by examining that
are taking place in the subsystems
(their structure and functions) and
in the interaction between the sys-
tem and its environment (4). By
examining these factors, an expla-
nation for any vicious cycle can be
proposed. The explanation of the
vicious cycle is important informa-
tion for treatment of patients or
clients. When a vicious cycle is
identified and explained in assess-
ment, the model allows determina-
tion of what parts of the system or
the system's interaction with
environment are contributing to ,.
the vicious cycle. This information
guides the decisions about where to
begin therapy to reverse the vicious
cycle and reinstate a benign cycle.
In summary, the model serves to
guide treatment by: 1. identifying
critical concepts that should be at-
tended to in evaluation; 2. propos-
ing how behavior is organized and
thus providing a framework for
identifying disorganization of be-
havior; 3. positing a sequence of
change that characterizes adapta-
tion and can be used to organize
therapy; 4. proposing the concept of
career with stages of change in
human occupation, which serves as
a standard in assessment; and 5.
providing an explanation of func-
tion and dysfunction in the concept
of benign and vicious cycles, which
allows explanation of a system's
failure at adaptation and serves to
guide a plan for reorganizing the
system in therapy toward a benign
cycle. Each of these characteristics
of the model provides an alternative
for use in therapy. The particular
way that the model is used can
depend on the setting, patient pop-
ulation, and therapist. The several
facets of the model are simply pos-
sibilities for conceptualizing treat-
ment.
Using the Model for Assessment
and Treatment Planning
The model is a source of concrete
guidelines for what information
should be collected and of concep-
tual guidelines for interpreting and
integrating the information into
treatment plans. It can indicate what
data are important, and once
gathered, what they are likely to
mean. Because the model is com-
plex and multifaceted, there is no
sioJgle way of using it. However,
some general guidelines are pre-
sented here.
Assessment should yield data on
sevel;,al conceptual categories sug-
gested by the model. These catego-
ries are usually the subsystems, the
process of input, throughput, and
output; the environment, and the
The American journal of Occupational Therapy 781

stages of the life cycle. The model-
postulated relationships of these
conceptual categories help deter-
mine how the information is orga-
nized and interpreted.
The meaning of assessment data
is incomplete until several or all of
the parts (conceptual categories) of
the model are represented in the
information about the individual.
The composite description is used
to generate plans for the interven-
tion process. Composite descrip-
tion of the problem includes the
patient's or client's history of expe-
rience, environmental circum-
stances, and internal makeup. This
description can yield an explana-
tion of the person's vicious cycle or
of the potential of the person to
enter a vicious cycle. It also provides
guides for what experiences and
environmental conditions might
contribute toward reversing or pre-
venting that vicious cycle. Occupa-
tional therapy is then designed to
p r o v ~ e or recommend those ame-
liorating experiences and environ-
mental conditions.
Although the model may be used
in several ways, the following steps
are usually involved: 1. a review of
basic identifying data and/ or a screen-
ing evaluation to achieve a prelim-
inary orientation to the occupa-
tional behavior problem; 2. data
collection according to relevant cate-
gories suggested by the model and
compilation of the results into a
thorough description of the prob-
lem; 3. interpretation of the results
(composite description) using the
model as a conceptual backdrop;
and 4. generating a treatment plan
and recommendations. These steps
may be part of an ongoing process
and, thus, some of them will be
repeated in the course of assess-
ment.
To demonstrate how assessment
and treatment planning can be
undertaken, four cases will be de-
scribed in some detail here. Each is
from a different stage in the life
cycle and will be related to the
model in the fashion that is best
suited to the case. This demonstrates
how the model can flexibly accom-
modate different kinds of pa-
tient/client problems.
Case I: Childhood
Basic lndentifying Data. Eddie is a
6.9-year-old boy with cerebral palsy
and with moderate to severe athe-
toid quadriplegia. His intellectual
abilities are reported to be within
normal limits. Specific problems in
the areas of movement, posture,
hearing, and speeCh are noted. He
was referred to an outpalient clinic
for occupational therapy assess-
ment of his phy.sical and behavioral
status. This child walked indepen-
dently with an awkward, slow gait.
He was able to make his needs
known through verbalizations that
were characterized by dysarthria.
When chey were not understood, he
used gestures and ultimately re-
sorted to guessing games to com-
municate his wants. He was to be
attending a new school in three
months and the family was request-
ing information concerning
Eddie's assets and liabilities for this
ground games, craft projects, listen-
ing to records, or reading. Eddie
reportedly selected solitary reading
with each opponunicy given.
He received speech therapy and
physical therapy during classroom
time for up to seven times per week.
The teacher fell that this time away
from the class contributed to
Eddie's feelings of being diUerent.
Data and Description of the Prob-
lem. Assessment was directed to-
ward the child's motor dysfunctions
and their influence on his role as a
player, his role as a productive fam-
ily member, and his transition to-
ward the additional role of slUdent.
He was assessed by the following: a
reflex assessment, a motor assess-
ment, a visual perception test, an
invemory of accivities of daily liv- -
ing developed for this clinic, the
Play History (5), the Decision-Mak-
ing Inventory (6), a series of obser-
vations in the occu pa tiona l therapy
clinic, and semistructured inter-
views with Eddie and his family.
Assessment began with Eddie's
performance subsystem, which com-
prises movement and perception
abilities, as welJ as symbolic func-
tions such as decision making and
problem solving (2). Al though there
was considerable disruption in the
two functions of movement and
new class emollment. Thus, the perception, observations in the oc-
assessment was directed toward cupational therapy clinic revealed
making recommendations for that his decision-making and prob-
school and home. !em-solving abilities were good.
He is the oldest of two boys by 18 Strength in these symbolic skills
months and lives with both parents make difficulties in movement and
in an apartment. He attended a firsL, perception easier to overcome. He
grade class in a school that inte! was able to identify problems and
grates orthopedically handicapped choose from alternative solutions
children with a nonhandiclvped according to the criteria of the
population. He was in a classroom . Decision-Making Inventory. His
described by the mother as " loosely "' decision-making ability is further
structured" with "option time" evidenced by bis identification . of
periods. During option time, Eddie likes and dislikes in his choice of
could choose an ac,tivity that may toys and chores to perform at home.
include one of the following: play- The performance subsystem is
782 December 1980, Volume 34, No. 12
more fully described by examining
his output (i.e., his acting on ob-
jects, people, and events in the envi-
ronment). In self-care activities, he
was able to feed himself with a fork
once his plate was prepared; he
could write his name given ade-
quate time and space. He was un-
able to use a scissors or knife and
could not turn a faucet on or off. He
was unable to catch or throw a ball
and could not open or close fasten-
ings on his clothes or perform other
refined actions. His opportunities to
interact in events with people were
limited and hindered by involun-
tary .movements, impaired hearing,
and dysarthric speech. As a result of
the above evidence, it was con-
cluded that the performance subsys-
tem is severely constrained by motor
difficulties; symbolic activities were
in better order, indicating that he is
adapting to some of his limitations.
The habituation and volition sub-
systems were examined together to
identify t ~ e organization of Eddie's
habits and roles. At this age, his
primary role is as a player. The roles
of student and worker (i.e., produc-
tive family member) are emerging.
Of importance is the development
of habits to support those roles.
Eddie should be acquiring the abil-
ity to engage in cooperative play
with purposeful use of materials for
constructions, dramatizations of real-
ity, and building habits of using
tools (5). He should be experiencing
a wider range of environments to
develop flexibility in his habits. In
play, he should also be exploring
adult work roles. For example, in
playing "dress up," a favorite game,
he acts like a cowboy and is trying
on the role to see ho.wit fits. Finally,
he should be routinely exercising
productivity through independent
self-care and chores in the home.
Results of the play history indi-
cate that Eddie habitually played
with a younger brother and
younger girl, a neighbor. Play set-
tings were limited to an indoor
apartment area and infrequent op-
portunities for supervised outdoor
play in a small concrete area.
Mother reported his favorite toys to
be construction blocks and dress
ups. He enjoyed playing cowboys
and watching westerns on TV. He
reportedly liked clay, crayons, and
gross motor activities such as swing-
ing or trike riding. All of these tasks
required close supervision and var-
ious degrees of assistance. He also
enjoyed jokes, surprises, and dare-
devil rough housing with his
father. He least enjoyed group activ-
ities because he is "self-conscious,"
according to his mother and, re-
portedly, was easily frustrated by
his failures. He helped his mother
set the table and performed other
simple household tasks. He could
generally take care of himself inde-
pendently, except where motor dif-
ficulties limit him and when time
constraints did not allow him an
opportunity to complete all tasks.
In summary, Eddie had stable
patterns of play that were age appro-
priate. His play environments were
limited to places and persons with
which he was familiar and felt safe.
His role as a player, while not defi-
cient, was limited and would need
to be expanded as he moves toward
a student role. He also engaged in
dramatic play, chores, and self-care,
indicating movement toward the
worker role. Importantly, he was
able to derive satisfaction from his
actions. Although the volitional sub-
system is least developed at this age,
he was expected to express and d ~
upon interests and valued goals.
This was evidenced by his play and
his use of free time.
Although his subsystems were in
generally good order, several areas
of potential problems could be iden-
tified. Eddie was unable to perform
accurate, skilled movements and he
had decreased abilities to process
perceptual information. This dys-
function limited not only skills, but
also habit and role performance. To
move into the student role, Eddie
needed to be acquiring habits of
organizing time and energy toward
productive behavior that take into
account his physical limitations. In
school, a normal child would, for
instance, learn to assemble construc-
tion paper for a pasting project
quickly and efficiently in order to
complete the task and have the
opportunity of enjoying the success
of such a project. Such opportuni-
ties were impossible for Eddie be-
cause of his decreased physical abil-
ities, so that he either had to choose
other activities or develop a time
frame in which he can accomplish
more difficult tasks.
Finally, disruption at the voli-
tiorial level was possible. His physi-
cal problems limited the range of
behaviors he could enact. Thus, he
was at risk to realize his interests
and valued goals, and to develop a
sense of personal causation. For
instance, he was interested in draw-
ing but often failed at it. Also, he
valued his ability to be independent
in self-care but often had limited
opportunities because of time con-
straints to develop such skills needed
to fulfill that role requirement.
Eddie was experiencing an increas-
ing sense of failure from the incom-
plete and incompetent actions he
ofJen performed.
'Interpretation. The description
of the boy's subsystems demon-
strates that, while he was not pres-
ently in a vicious cycle, he was at
risk\to enter it. Importantly, despite
disability, he was still in a benign
cycle; this was his greatest strength.
The constraints on the overall sys-
tem begin with limitations in the
The American Journal of Occupational Therapy 783
4
performance subsystem. It should
be attended to instantly by activities
that increase skilled action and by
adaptive devices that enhance the
efficacy of limited skills. Where
limitations cannot be changed, the
other subsystems will have to com-
pensate. Although he had a number
of appropriate skills, he was expe-
riencing difficulty organizing those
skills into habits. For the system to
adapt to immutable limitations in
the performance subsystem, the
Eddie is a 6.9-year-old
boy with cerebral palsy
and with moderate to
severe athetoid
quadripledgia.
higher habituation subsystem must
organize limited skills into routines
that maximize them. This often
entails a longer time frame for the
accomplishment of most tasks.
Given the habit's accommodation
to limited physical skills, roles must
also be realistically enacted that are
within Eddie's capacity. Since
school demands largely symbolic
skills, he should fare well in the
student role. The greatest risk is in
the area of interpersonal relations.
At this point, the development of
peer relations (friendships) should
be encouraged and supported. Here
the teacher may be of great assis-
tance. Often, peers may need coun-
seling and instruction to overcome
barriers of fear, problematic com-
munication, and so forth.
Finally, the volition subsystem
needed attention. It is a positive
sign that Eddie had interests and
valued goals. He needed opportuni-
ties to perform tasks that provided
him with moderate degrees of chal-
lenge. Such tasks can be both in
play and within his productive fam-
ily role. These contribute to a sense
of self as a cause. Importantly, the
things that he had an opportunity
to do and could do overshadowed
his limitations. An attitude of ex-
ploration and problem solving
around his limitations allowed him
to compensate for many physical
limitations. By learning to value
such adaptive strategies, he will be
enabled to develop a strong sense of
self as a cause despite his severe
disability. '
Treatment Recommendations.
Play is the central focus of treat-
ment recommendations. It is in this
arena that Eddie would engage in
activities that result in skills and
habits for effective transactions
with the environment. Further, in
play, Eddie would have opportu-
nities to solve problems and make
decisions as he experienced his phys-
ical limitations. In increasingly
diverse and challenging play envi-
ronments, he could begin to make
the adaptations in the habituation
and volition subsystems that would
be necessary. The family appeared
to value his adaptations to his lim-
itations. This serves as a
paint to address deficient areas in the
volition subsystem. Peer interac-
tion needed to be encouraged and
nurtured in and out of the class-
room. Therefore, the following
recommendations were made to
Eddie, his family, and appropriate
personnel at the new school:
1. It was recommended that
Eddie join a scouting troop. This ;
would provide an opportunity to be
with peers. In addition, by of
the productivity model inherei)t in
scouting, he will have a chance to
develop beginning level skills in a
variety of age-appropriate activi-
ties. Scouting would also provide
him an opportunity to develop new
interests. Occupational therapy con-
784 December 1980, Volume 34, No. 12
sultation should be offered for the
scout leaders to facilitate Eddie's
adaptation to the group.
2. It was recommended that
Eddie receive ongoing treatment in
occupational therapy, physical ther-
apy, and speech therapy. These
three therapies would focus on def-
icits at the performance subsystem
level. Specifically, occupational
therapy would concentrate on re-
finement of skilled actions and on
building supports for the devel-
opment of habits needed in Eddie's
daily life (i.e., providing activities
that support the roles of player, stu-
dent, and family member). As part
of this process, occupational ther-
apy would provide assistive and
adaptive devices necessary to over-
come limitations in Eddie's motor
abilities for those activities he
chooses. Counseling for occupa-
tional choice should begin with a
focus on identifying Eddie's skills
and exploration of ways he can best
use them as a productive member of
society.
3. It was recommended that
Eddie's participation in the family
be carefully observed. His parents
have already demonstrated a natu-
ral style of requiring age-appro-
priate behaviors in chore-related ac-
tivities. A continuation of this mode
with increasing expectations and
challenge will contribute to a sense
of productive participation on
Eddie's part. This will not only give
him a sense of competence and
satisfaction in his role-filling pro-
cess, but allow him to develop skills
necessary for household activities
on his own. Accordingly, he should
be encouraged and permitted to
activities such as cooking.
' Periodic consultation with an occu-
pational therapist for problem solv-
ing to discover those activities that
Eddie can and wants to do and to
plan how those activities can be
He was ref erred to an
outpatient clinic for
occupational therapy
assessment of his physi-
cal and behavioral status.
adapted to enhance his perfor-
mance should be part of this plan.
4. It was recommended that an
occupational therapist consult with
the staff at the new school regarding
adaptations and expectations for
Eddie's psychosocial areas of perfor-
mance.
Case 2: Adolescence
Basic Identifying Data. Richard
was a 16-year-old male referred to
occupational therapy for prevoca-
tional and vocational training.
Placement in a residential facility
was anticipated be ca use of
Richard's delinquent behavior,
drug abuse, and parental request for
assistance. Psychiatrically, Richard
was diagnosed as having depressive
neurosis in a passive-aggressive per-
sonality, with associated drug and
alcohol abuse. Academically,
Richard was assigned to an educa-
tionally handicapped classroom
and his performance scores were in
the fourth grade level. Medically,
deafness was present in the left ear.
Data and Description of the Prob-
lem. As an older adolescent, occu-
pational decision making and tran-
sition from the student to worker
role were central concerns in assess-
ment. Instruments were adminis-
tered to assess motor and spatial
perception, decision making, and
problem solving in the perfor-
mance subsystem. In the habitua-
tion subsystem, activities of daily
living, pre-work, and work role be-
havior were examined. In the voli-
tion subsystem, interests and goals
were assessed. In adolescence, bal- choice level and associated skills
ance among the subsystems is impor-
tant (e.g., valued goals must be in
line with skills).
Fine motor and perceptual assess-
ments, specifically the Bennett
Hand Test (7) and the MacQuarrie
Test for Mechanical Ability (8),
yielded scores ranging from the 2nd
to the 20th percentile, indicating
severe deficits in fine motor skills.
An activities of daily living inter-
view devised for this setting re-
vealed satisfactory habits of self-
care, but deficits were noted in skills
and habits for community activities
such as banking procedures, money
management, and apartment liv-
ing, all of which would need to be
in order to support a worker role.
The occupational history, modi-
fied for this setting (9), revealed a
work orientation toward manual
labor with a concrete product as the
end result. Work role models had
been available and consistent
throughout his childhood. Further,
he demonstrated an ability to dis-
criminate between work and play
behaviors and their associated envi-
ronments. His work history con-
sisted of chores in the home with no
volunteer or paid experiences in the
community. Richard was able to
differentiate his fantasy occupation
from his reality-tested interests,
skills, and opportunities. Richard's
assessment of his own skills was
consistent with his observed skills;
therefore, he demonstrated the abil-
ity to process external feedback.
The Larrington Time Management
Inventory (10) revealed adequate
skills with strength present in short-
range planning and implementa-
tion, and projection of self through
time. Richard's stated occupational
choice is to be a machinist, which
correlates with his strong manual
interest area and work concept. In
summary, Richard's occupational
and habits appear in the tentative
stage with emphasis on skill acqui-
sition and available opportunities
(15-16 years).
Conclusions about Richard can
be drawn from the data by reference
to the life span scheme of the model
(3). As it indicates, adolescent work
characteristics are developed in
play, chores, and school, with criti-
cal elements being work role readi-
ness, commitment, and choice.
Richard participates in football,
boxing, and identified his social
activity as "car riding." Richard
was well liked by his peers, handled
his competitive feelings appropri-
ately, and exhibited a strong inter-
est in self-improvement. He had
performed chores in the home and
the facility, but had been unable to
succeed in school. However, when
placed in an educationally handi-
capped classroom, Richard per-
formed consistently with minimal
supervision. Correspondingly,
while in treatment, his drug behav-
ior was controlled by severe con-
sequences-loss of passes for social
activities and home visits.
Interpretation. The composite
profile drawn from these assess-
ments indicated deficits in fine
motor and perceptual tasks (per-
formance subsystem). He had defi-
cits in community living habits and
marginal habits of self-care and
time management (habituation sub-
system). His strengths in work role
development were largely in the
volition subsystem, where he had
J
interests and a life plan that con-
tribute to age-appropriate occupa-
i(onal choice. In summary, Richard
exhibited deficits in fine motor
skills idthe performance subsystem
and marginal organization of hab-
its for daily living. These subsys-
tems needed to be brought in line
with his more fully organized voli-
The American Journal of Occupational Therapy 785
tion subsystem, which was also his
greatest strength.
Treatment Plan. The focus in
treatment was on developing those
skills Richard would need for work
and to assist him in establishing
habits of self-care, work, and play to
support the emerging worker role.
Because of Richard's strong manual
interest, his low academic scores,
and his occupational choice, treat-
ment was directed to improve fine
motor and spatial perceptual skills
and tool use. The goal was that he
could read and interpret diagrams
independently. The occupational
. therapist provided information and
arranged on-site visits to work set-
tings to help solidify the occupa-
tional choice. He received training
and practice to improve self-care
and acquire habits for independent
maintenance in the community.
Also, he was given opportunities
for appropriate adolescent play
such as games, arts and crafts, and
social events. Within these, stress
was on developing critical elements
such as appropriate competence, co-
operation, and competition. After
two months of occupational ther-
apy, Richard was placed in a ma-
chine tool class at a nearby trade
school. His attendance was regular
and work performance excellent.
After six months, Richard was
given sessions in occupational ther-
apy on job hunting and interview-
ing. He obtained a full-time job as a
machinist engineer. One year later,
he was employed at the same job
and maintained an apartment.
Case 3: Adulthood
Basic Identifying Data. June is a
woman aged 31, with a diagnosis of
chronic schizophrenia, undergoing
her fifth hospitalization for a psy-
chotic break. Her occupational
role, before admission, was that of a
homemaker.
Data and Description of the Prob-
lem. Assessment instruments were
administered to determine her occu-
pational history, ability to manage
h.er daily life (performance and ha-
bituation subsystems), and interests
(volitional subsystem). The occu-
pational history (9) indicated poor
preparation for the homemaker
role, with no chores required of her
in childhood and no available role
model. June presently structures
her free time and leisure interests
around her children. She identified
Interpretation. The profile
yielded through the assessments in-
dicated deficits in the performance
and habituation subsystems. These
include poor time management and
activities of daily living skills, and
incomplete work role development.
Her strengths were in the volitional
subsystems; she had well-developed
interests and goals. By examining
the data in light of the model's life
span continuum (3), her problems
can be better understood. Adults
should use leisure time to provide
her college years when she worked, satisfaction and relaxation. The
... her occupa-
tional history, ability to
manage her daily life
(performance and habi-
tuation subsystems), and
interests (volitional
subsystem).
work role should be successfully
assimilated as the primary occupa-
tional role. June's work role and its
subsequent satisfactions were inter-
rupted to assume an occupational
role, homemaker, for which she did -
not have appropriate skills or hab-
its. June is now aware of this and is
seeking classes in home economics
and simple home repairs. Her leisure
time is severely deficient and does
not provide her with satisfaction.
attendedschool,andmarriedasthe Existence of June's major
most successful and satisfying peri- strengths were in the volitional sub-
od of her life. She worked as a cho- system and marginal to deficit areas
reographer for several years until in the habituation and performance
the birth of her first child. During subsystems. The volitional subsys-
her career years, her family was very tem contains the individual's
supportive. Once a mother, she image and desires that affect, orga-
stayed home, as she puts it, "to raise nize, and enact the habiLUation" and
her children properly." She was performance subsystems (2). Since
unable to manage her time, found the deficits occur at the lower two
housework boring, withdrew from levels, treatment was directed to-
community involvements, and her ward building skills and the institu-
marriage soon involved physical tion of daily habit patterns to allow
abuse. At the time she indicated consistent performance of a role.
strong interest in teaching children; The treatment focused on allowing
to dance. The Larrington Timti June to enact her already identified
Management Inventory (10) indi- a.nd stated goals and interests.
cated time disorientation in e ~ p e t Treatment Plans. The following
to time, day, month, and an inabil- ~ plans were developed and imple-
ity to structure time or set deadlines. ',. mented in June's treatment. Cul-
The Interest Checklist (11) revealed tural/educational activities were
activities of daily living and cul- used as a first step in leisure devel-
tural/ educational activities as her opment. For instance, she began to
two strongest areas of interest. attend concerts and movies while
786 December 1980, Volume 34, No. 12
still hospitalized. It was concluded
that support and interaction with
her peers would provide her feed-
back and improve basic problem
solvfog. Enacting her stated interest
asa volunteer at school was one way
of providing such social interac-
tion; it also helped to structure her
daily life, and allowed her to test out
her new occupational choice, a dance
teacher. As a result of these activi-
ties, she started to take control of her
life, stabilized a daily schedule, and
improved her basic activities of
daily living skills. Four months
after her hospital discharge, June
was still performing volunteer
work, attending a" short cuts for the
,homemaker class," and going to
dinner with friends weekly.
Case 4: Old Age and Retirement
Basic Identifying Data. Rose, a 64-
year-old woman recently retired
from a major metropolitan school
district in which she taught for
more than 30 years, was referred to
occupational therapy in a rehabili-
tation center. She was continuing to
recover from a severe car accident in
which she received multiple in-
juries including fractures of her
right wrist and forearm, right knee,
and left hip, which resulted in hip
replacement surgery.
She was able to sit upright for as
long as six hours. She tended to
deteriorate into a slumped posture
and, when reminded of it, reported
that it is too painful to right herself.
Medical treatment plans were broad-
ly defined as developing maximum
physical abilities needed for inde-
pendence. No contraindications are
present.
Data and Description of the Prob-
lem. This patient has a successful
occupational history that was threat-
ened by traumatic injury and its
residual effects. Further, she was in
the midst of a transition from the
worker to retiree role, which further
enhanced her risk to enter a vicious
cycle. Given her successful past,
evaluation focused on strengths
among the subsystems, since they
were central to her adaptation to
role change and probable physical
limitations. Data were collected
through observation, semi-struc-
tured interviews, the occupational
history (9), Interest Checklist (11 ),
and the Decision-Making Inventory
(6).
Within the volitional subsystem,
Rose reported her interests to be
evenly dispersed among activities of
daily living, social, recreational,
and cultural/ educational areas. She
enjoyed making small craft pro-
jects, reportedly engaged in regu-
larly scheduled social and recrea-
tional activities (cards, theatre
group), and enjoyed lectures and
classes. Rose described herself as a
self-reliant and self-initiating per-
son. Until her recent accident, she
reported that she could and did do
anything she set her mind to do.
She valued active involvement in
social activities (traveling, recrea-
tion) and had always seen herself as
helping others. This was true in her
professional as well as personal life.
Rose had been married for ten years
to a man who had Parkinson's dis-
ease. She speaks fondly of her rela-
tionship with him and the physical
care and assistance that she gave
him until his death six years ago.
Within the habituation system,
Rose was seen as a woman with
well-established patterns of behav-
ior. She walked about her neigh-
borhood to complete her chores.
She eagerly planned and participated
in trips to the theatre and other
points of local interest. She boasted
a well-rounded world traveling his-
tory. Her past occupational role
history included valued positions as
a teacher, wife, and aunt. Rose re-
ported no other history of family
roles, since she was an only child of
parents who "died at a young age."
At the performance subsystem
level, Rose was re-learning basic
skills needed to provide indepen-
dence in daily living tasks. She re-
quired moderate to maximum assis-
tance to transfer from her wheelchair
to a bed, chair, or toilet. She was
able to dress herself with the use of
adaptive equipment for lower ex-
tremity garments. No limitations
were noted in upper extremity move-
ments. She had already demon-
strated gains in self-care skills and
verbally expressed determination to
"beat this thing." Decision-making
and problem-solving skills were
intact and combined to form a
strong base from which to discover
how to solve problems of movement
as well as task completion.
Overall, Rose was an optimistic,
intelligent woman who was hard at
work in the rehabilitation process.
During vulnerable, disappointing
moments when she failed at an
attempted task, she would cry.
When asked what upset her, she
spoke of her fear of "losing my
independence." Clearly, she was re-
ceiving feedback on her failing per-
formance, which gave her little
sense of competence or satisfaction.
Interpretation. The recent acci-
dent was requiring reorganization
within all subsystems of behavior.
Rose had to learn new skills that
would be reorganized at the habit-
uation level into habits and roles.
Like, habits, role change is natural
ove/ the lifespan; however, this
woman was experiencing an abrupt
~ a n d possibly permanent change in
her abilities caused by her disabil-
ity. sfie needed to learn new habits
and skills and transform them into
new daily life patterns. Careful at-
tention had to be given to defining
realistic expected outcomes and
The American Journal of Occupational Therapy 787
I
aligning them with her attitude
about performance. She could not
perform the amount of activity she
used to in the same period of time,
which necessitated a reorganization
of her use of time. Attention was
also paid to Rose's processing of
feedback on actual outcomes. She
needed to internalize society's ex-
pectations for the retired role to
ensure that she would continue to
see herself as the origin of her own
behavior within the new retired
role.
Treatment Plans. Rose was self-
directed in her rehabilitation pro-
cess. The occupational therapist
carefully selected activities and
tasks that Rose valued, could per-
form, and successfully completed.
Focus was placed on skill develop-
ment at the performance subsystem;
however, the therapist was careful
to monitor alignment of behaviors
within all subsystems. Rose was
currently experiencing imbalance
amo!lg volition, habituation and
performance systems. She could not
do what she valued because of phys-
ical limitations; she interpreted this
as a loss of independence, which
was a highly valued behavior. Her
failures at independence needed to
be tempered and controlled by the
occupational therapist, who care-
fully matched needs to abilities.
Controlling the complexity of tasks
was critical if this patient was to
have rehabilitation experiences at
her desired level of competency and
satisfaction. Intervention was de-
signed to assist in reorganizing and
restructuring her habits and rou-
tines in alignment with her valued
goals and interests. For example, it
was important to her that she main-
tain her independence. One way in
which she defined that indepen-
dence was in her ability to prepare
her meals. Within the occupational
therapy setting, Rose was trained to
get around her kitchen in a wheel-
chair. This required redesigning
the use of space as well as teaching
work simplification techniques.
Shopping and chore activities
were reorganized in such a way as to
maximize her remaining strengths
and abilities, while minimizing in-
terference of her limitations with
her daily life. Those activities that
were most difficult and demanded
disproportionate amounts of time
and energy were dropped from her
routine. For instance, she arranged
to have her laundry taken out. Dur-
ing this stage of her treatment,
emphasis was placed on preserving
outcomes of activities while pro-
cesses for attainment were modified
and adapted. The result of reorga-
nizing these self-care aspects of her
performance was to retain time and
energy for the leisure pursuits that
she valued. Rose was able to con-
tinue her well-established interests
in creative handwork with no dis-
ruption. She made the necessary but
minor revisions in these activities,
which included more frequent rest
periods and hand and wrist exer-
cises. Discussions of leisure time
activities resulted in her recogni-
tion of the need for change in the
way she pursued her strong interest
in museum visits and other travel-
ing activities. Whereas. she had for-
merly done these alone, she joined
an organized tour group where she
got the assistance she .needed to get
around.
The treatment resulted in Rose's
being able to make the transition to
the retiree role successfully and ind
manner satisfactory to her. She was
able to maintain an active art<l ful-
filling routine by reorganizin'g her
activities and not overloading her 1
system. Thus, she preserved the bal-
ance between her valued goals and
interests and her habits, new role,
and more limited skills.
788 December 1980, Volume 34, No. 12
Summary
This paper completes a four-part
series presenting a model of human
occupation for clinical application.
Assessment and treatment planning
were the focus of the present article.
Four cases, each from a different
point in the life continuum, were
presented to demonstrate how the
model can be applied. These cases
are only indications of a few of the
multiple ways in which the model
can guide the therapist in clinical
practice. The model is only a tool
for use. The therapist, like a skilled
artisan, must become proficient in
its application if the tool is to be
effective.
REFERENCES
1. Reilly M: Occupational therapy can be.
one of the great ideas of 20th century
medicine. Am J Occup Ther 16: 1-9,
1962
2. Kielhofner G, Burke J: A model of
human occupation, Part 1. Structure
and content. Am J Occup Ther 34:572-
581, 1980
3. Kielhofner G: A model of human occu-
pation, Part 2. Ontogenesis from the
perspective of temporal adaptation.
Am J Occup Ther 34: 657-663, 1980
4. Kielhofner G: A model of human occu-
pation, Part 3. Benign and vicious
cycles. Am J Occup Thar 34:731-737,
1980 .
5. Takata N: Play as a prescription. In
Play as Exploratory Learning, M.
Reilly, Editor. Beverly Hills: Sage Pub-
lications, 1974
6. Westphal M: A study of decision mak-
ing. Master's Thesis, Department of
Occupational Therapy, University of
Southern California, Los Angeles
7. Bennett GK: The Bennett Hand Tool
oexterity Test, New York: Psychologi-
cal Composition, 1965
8. MacQuarrie TW: The MacQuarrie test
for mechanical ability. J Personnel Res
5:329-337, 1927
9. Moorehead L: The occupational his-
tory. Am J Occup Thar 231:329-334,
1969
1 O. Larrington G: An exploratory study of
the temporal aspects of adaptive func-
tioning. Master's Thesis, Department
of Occupational Therapy, University of
Southern California, Los Angeles, Cali-
fornia, 1970
11. Matsutsuyu J: The Interest Checklist.
Am J Occup Thar 23:323-328, 1969