A Guide to the Formulation of Plans and Goals in Occupational Therapy

Sue Parkinson, Rob Brooks

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000262315
• Edition: 1
• Topic: Medicine
• Subtopic: Occupational Therapy

This practical guide for occupational therapists introduces a tried and tested method for moving from assessment to intervention, by formulating plans and measurable goals using the influential Model of Human occupation (MOHO).

Section 1 introduces the concept of formulation – where it comes from, what it involves, why it is important, and how assessment information can be guided by theoretical frameworks and organised into a flowing narrative. Section 2 provides specific instructions for constructing occupational formulations using the Model of Human Occupation. In addition, a radically new way for creating aspirational goals is introduced - based on a simple acronym - which will enable occupational therapists to measure sustained changes rather than single actions. Section 3 presents 20 example occupational formulations and goals, from a wide range of mental health, physical health and learning disability settings, as well as a prison service, and services for homeless people and asylum seekers.

Designed for practising occupational therapists and occupational students, this is an essential introduction for all those who are looking for an effective way to formulate plans and goals based on the Model of Human Occupation.

Part I Understanding the concept of a formulation

1 Where does the idea of formulation come from?

DOI: 10.4324/9781003046301-1

A brief history

Case formulation is firmly established in psychotherapy (Eells 2001) and in psychology, where one of the roles of a qualified psychologist is to take a lead on psychological formulation within the team (BPS 2011). It is also beginning to find favour in medicine (Macneil et al. 2012), mental health nursing (Rainforth and Laurenson 2014) and social work (Lee and Toth 2016). It is perhaps more surprising that case formulation has only just begun to be mentioned in occupational therapy literature (Brooks and Parkinson 2018); given that occupational therapists profess that they are not diagnosis-led (Robertson 2012).

Although occupational formulation is in the early stages of development, the foundations have been well-prepared. Back in 1969, the occupational therapist, Line, argued that the case method was a scientific form of clinical thinking, and encouraged the development of ‘problem statements’. These statements placed the person’s problems

‘in relation to assets and liabilities in social adaptation, activities of daily living adaptation, and disease adaptation … [supporting] the philosophy that occupational performance may be improved by strengthening assets as well as minimizing liabilities’ (Rogers 1982)

By the 1980s, occupational therapists were moving further away from the medical model and were redoubling their efforts to assert their occupational focus with varying degrees of success. Cubie and Kaplan (1982), for example, voiced their concern that many of the clinical decisions made by occupational therapists were based on intuition rather than a consistent reasoning process. They called for a more systematic approach to case analysis, based on the Model of Human Occupation (ed. Taylor 2017), and called for assessment tools to be developed to gather relevant occupational data.

Box 1.1 Author's note

by Sue Parkinson

I first heard about case formulation being used by occupational therapists when listening to Suzie Willis talk about ‘Conceptualising clients from standardised assessments’ at an Occupational Therapy conference (Willis and Forsyth 2003). A few years later, I was fortunate to be inducted into the same conceptualisation process, as part of a scholarship of practice with the UK Centre of Outcomes, Research and Education (UKCORE), directed by Kirsty Forsyth, Lynn Summerfield Mann, and Gary Kielhofner (Forsyth et al. 2005a). I began to witness how formulation and measurable goals could transform the therapeutic relationship and occupational therapy outcomes, and by 2010 I was being invited to talk about my experiences with others.

My ideas regarding how to structure formulations and measurable goals have continued to develop over the last decade, and have been shaped by working with hundreds of wonderful occupational therapists, including Lisa Jamieson, who described formulation as the ‘key for unlocking potential’ (Jamieson and Parkinson 2017).

Figure 1.1 The ideals of formulation.

The Model of Human Occupation (ed. Taylor 2017) now offers a range of formal and informal assessments (Taylor 2017), but difficulties with articulating professional reasoning persist. The prevalence of psychological formulations may even have the power to distract occupational therapists from their occupational focus. For instance, Weiste (2016) was concerned that occupational therapists should focus on more than emotional regulation if they are to offer practical solutions to problems of everyday life, but did not appear to question why occupational therapists were spending their time offering counselling rather than more occupation-based interventions. In her article – Formulations in Occupational therapy: managing talk about psychiatric outpatients’ emotional states – formulation was viewed simply as an ongoing process of reframing and redirecting a person’s focus during a conversation.

Even when occupational therapy interventions are occupation-based, therapists may not be writing their treatment plans in a way that persuades the reader of its occupational relevance or importance (Page et al. 2015). More specifically, they may be neglecting the importance of their tacit knowledge, and in doing so they risk under-optimising their interventions (Carrier et al. 2010). This is a matter of real concern for theorists and practitioners who are convinced that the core skills of an occupational therapist lie not only in their visible interventions but also in their reasoning skills which are too often invisible – a concern that was articulated by Turner and Alsop (2015):

‘The challenge for all occupational therapists is to make the invisible reasoning processes visible through the appropriate use of profession-specific language in discourses, assessments, reports, outcome measures, presentations and conversations, so that sound evidence is shown to underpin occupational therapists’ visible practice’ (p747)

Occupational formulation provides the ideal platform for showcasing occupational reasoning skills. Connell (2015) goes so far as to recommend that occupational therapists should contribute their unique perspective to an integrated formulation, which she argues is necessary for a multidisciplinary approach in forensic services. This process requires that occupational therapists are able to offer a coherent formulation that others can comprehend in the first place. Thompson (2012) sets out a more ambitious plan, by urging the profession to practise case formulation in all complex cases, allowing their reasons for tailoring interventions to each person to be defined and made transparent. This call has been actively pursued by occupational therapists using the Model of Human Occupation (MOHO) (ed. Taylor 2017). So much so, that formulation is finally being recognised as a vital part of the occupational therapy process (Brooks and Parkinson 2018, Forsyth 2017) which would benefit from having a universal structure (Brooks and Parkinson 2018).

Box 1.2 Author's note

by Sue Parkinson

I would not be recommending the process of occupational formulation if I did not have experience of its feasibility and effectiveness across a range of occupational therapy services. Much of this experience stems from having worked as a Practice Development Advisor for occupational therapists in a large healthcare organisation in the UK, where MOHO had been adopted and occupational formulation had been introduced. A service-wide audit demonstrated that the vast majority of my occupational therapy colleagues were able to meet our agreed standards for occupational formulation, and a later survey indicated that it was possible for formulations to be documented in the majority of occupational therapy case notes (unpublished data).

The organisation in which I worked provided services for mental health and learning disability, and had facilities for children, adults, and older adults in community and inpatient settings. The only services struggling to document fully-developed formulations were those in fast-paced acute settings with high caseload turnovers. Even here, however, occupational therapists were able to verbalise the outlines of formulations, produce succinct summaries and proceed to negotiate measurable goals based on the long-term issues identified, rather than short-term aims. Given that my clinical work was predominantly in acute mental health, this outcome continues to inspire me. I have always believed that inpatient settings offer more than short-term relief, and I am thrilled that even the most rudimentary of occupational formulations can pave the way for a person’s recovery journey as they transition into the community.

In more recent years, I have explored the potential for occupational formulation with occupational therapists working in physical services, where occupation-centred practice has proved to be a challenge. It has been heartening to see how occupational formulation can offer the prospect of countering a process-led culture, and allow therapists to demonstrate their ability to be truly person-centred. These encounters have led me to agree wholeheartedly with Rob Brooks in endorsing the occupational formulation process across the breadth of occupational therapy practice (Parkinson and Brooks 2018).

References

• Brooks R, Parkinson S (2018) Occupational formulation: a three-part structure. British Journal of Occupational Therapy, 81(3), 177–179.
• Carrier A, Levasseur M, Bédard D, Desrosiers J (2010) Community occupational therapists’ clinical reasoning: identifying tacit knowledge. Australian Occupational Therapy Journal, 57(6), 356–365.
• Connell C (2015) An integrated case formulation approach in forensic practice: the contribution of occupational therapy to risk assessment and formulation. The Journal of Forensic Psychiatry and Psychology, 26(1), 94–106.
• Cubie SH, Kaplan K (1982) A case analysis method for the Model of Human Occupation. American Journal of Occupational Therapy, 36(10), 645–656.
• Eells T (2001) Update on psychotherapy case formulation research. The Journal of Psychotherapy Practice and Research, 10(4), 277–281.
• Forsyth K (2017) Therapeutic reasoning: planning, implementing, and evaluating the outcomes of therapy. In: RR Taylor ed. Kielhofner’s Model of Human Occupation: Theory and Application. Philadelphia: Wolters Kluwer. 159–172.
• Forsyth K, Mann LS, Kielhofner G (2005a) Scholarship of practice: making occupation-focused, theory-driven, evidence-based practice a reality. British Journal of Occupational Therapy, 68(6), 260–267.
• Jamieson L, Parkinson S (2017) Unlocking potential: case formulation and measurable goals in a prison setting. Occupational Therapy News, 25(3), 36–38.
• Lee E, Toth H (2016) An integrated case formulation in social work. Towards developing a theory of a client. Smith...