Why do we bother with “realistic”?

WARNING: this post may upset occupational purists but please do approach it with an open mind.

So I was participating in #OTalk at 6am 14th January and it was all about the “Power Of Ideas” in OT….anyway, as I tend to do, I got sidetracked talking to some of the participants about what the actual aim of OT is. The usual stuff came up about “independence” “QoL” etc and I had my say about the client’s goals, not ours. One person said to me “the problem with acute hospitals is the goals are not always achievable…”

So this got me thinking and I had a “lightbulb” moment. What if it’s the process and not the outcome that determines health improvement? I have a feeling that you’re going to go “Duuurrr Brock” but I think I’ve just made an important mental connection for myself in how that fits in OT, and raises some questions about current OT theory.

For centuries people have talked about the journey being more important then the destination with regards to life and development but very recently I’ve been wondering if this same theory applies to occupational engagement.

We are a profession that is based on an observed pattern of health benefit. People observed that by engaging in “occupations” health seen to improve. This has been the basis for almost all models and frameworks in the profession since its inception. Kielhofner collated this idea into the Three Core Assumptions of Occupational Therapy:

1. Humans have an occupational nature
2. Humans can experience Occupational dysfunction
3. Occupation can be used as a therapeutic agent
(Kielhofner, 1997)

Many people will argue that the link between occupation and health is more concrete than just an assumption. But the evidence I’ve seen so far is merely re-observations of that original pattern. People engaging in “occupations” = health was improved. Now before anyone gets their cranky pants on, I’m not here to dispute this link. I think I’m more reflecting on a possible need to refine it.

You see recently I have questioned where exactly that health effect comes from during the process of occupational engagement, and there are a few possible ways of looking at it.

Firstly, if we are to believe everything we’ve ever been taught about goal setting (SMART, etc.) then obviously the value is in achieving the goals that are most important to us. Failing brings little/no value and we simply need to try again or reevaluate our goal to breed success the next time. In Occupational Engagement terms I read this as the end point of being able to engage in a chosen occupation being where the health value is in the process of occupational therapy. It doesn’t matter how we get there as long as we get there.

Secondly, there are those that believe that both the journey and the destination are of equal importance. It has often been said to me that the endpoint provides the motivation for the journey to take place. Sounds feasible.  Motivation is something that is a lot more complex then I believe most therapists give it credit for so saying that the ends provide the motivation is once again an assumption that may not fit with all cultural or contextual factors.

The idea that I’ve recently been toying with is that maybe the health effects (or at least the majority of them) are contained within the process of engaging in occupation rather than the end goal of being able to.

We have a client who has a psychosis. they have goals that are completely unreachable for whatever reason should we be focusing on making their goals more realistic or engaging them in the process to chase their unrealistic goals. Think about that in terms of health impact, not morals or values etc

This would mean that there would be health benefits to an individual working towards occupational goals that would normally be classified as “unrealistic.”
This would mean that there would be health benefits to an individual working towards occupational goals that they never achieve.
This would negate the use of the SMART goal format.
This would promote the use of client constructed frameworks such as Solution Focused Brief Intervention and the Kawa Model.The flow on effect would be:Clients would be 100% in control of their treatment. Therapists would not be able to transpose their own values system over the top of client goals, aspirations and dreams.
We would have a profession that would foster a client’s intrinsic motivation
We would be providing a health service that would nurture Hope…….
Kielhofner (1997) Conceptual Foundations of Occupational Therapy 2nd Edn. Philadelphia. F.A.Davis

One thought on “Why do we bother with “realistic”?

  1. Before you throw SMART goals out, perhaps the way of looking at this is: who is the goal realistic for? I have always been amazed at what those I work with achieve – often beyond my limited OT mind could imagine. Many a person has taught me not to limit them because of my small mindset but to rather embrace their ideas and work with them. If it is truly unrealistic, they will come to terms with that and change their focus. However, as I have said, I have been amazed in my career what people have been able to achieve when they have engaged in occupation and been allowed to “go for it”. So let’s keep the SART goals in place as they help with direction and focus but let us reconsider whose reality is the goal being measured against.

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