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Occupational Therapy and brain injury

Having made this point that it is possible to understand behaviour through normal channels, it is but a short step to say that behaviour can also be controlled through the normal channels. It does not require long years of training in particular therapeutic techniques, but it requires a certain heed be taken of the details of ordinary behaviour.

We are perfectly familiar with the sorts of happenings which induce or occasion people to do things. If we were not, we could not get them to do what we wish, and the ordinary dealings between people could not exist. Customers could not purchase, officers could not command, friends could not converse, or children play, unless they knew how to get other people and themselves to do things at particular junctures. (Ryle 1986 P. 109).

The practitioner here is someone who takes this common knowledge to a new level of consciousness, such that they can actually create the situations which will bring about the kind of outcomes that their client needs. There is not much literature which can be easily found about the ways that the practitioner operates when they are working. I do not doubt that the work is being done, but it rarely finds its way into the published literature. Dickson (1998) gives one example in her description of work with a community programme

It is clearer to me now that there are also sometimes conditions or circumstances in peoples lives that preclude them from being involved in activities with a ‘real’ purpose and that the need for this involvement can be responded to. At Step Ahead we made poppies to sell to the craft shop; not to improve problem solving ability or self esteem or because it related to their occupational roles. We made munch lunch to feed the membership, to help newcomers feel at home and to provide a good reason for coming along; not to learn cooking skills or increase one’s confidence in their occupations, though these may come out of the process.

It seems to me that these ‘real’ purposes are derived from a common shared meaning that belongs quite naturally to the activity, for example, preparing food to share with others or an artefact to enjoy, give away, trade or barter. Having ordinary everyday reasons for doing things was the outcome here and enabling this involvement to occur involved careful facilitation.

This enabling role is easy to describe but difficult to explain. Making things happen involves being mindful of a myriad of factors that influence engagement yet seems so ordinary, so commonplace. It involves knowing what needs to be done and how to create it, what pitfalls might arise and how to avert them. Most importantly, it involves enabling the recipients of the service to become fully involved and fine tuning the experience to ensure that it retains its ‘reality’.

There are vignettes in the intellectual disability literature which show that this kind of understanding is being used in practice. This kind of practice is not based on some notion of therapy or education, the idea is not to create a job for the practitioner, but to provide real engagement for the client. The following story makes the point well, if one ignores the practitioner's continued focus on assertiveness and friendship.

Arthur is 40 years old and lives in his own home with two other men. He loves books and history, and has a fascination with cemetries and death. He was described by the staff as hesitant to try new things. They said, '‘we have to go slow with Arthur.'’ Arthur also tended to be a '‘yes-man,'’ willing to comply with whatever staff asked or expected him to do. Staff had been working on the goal of Arthur being more ‘assertive’ for quite some time.

An appropriate behavioural intervention for Arthur might include various social skills programs for assertiveness training and desensitization to novelty; in fact, various social skills programs had been tried to improve his assertiveness. A different approach was taken when his agency started to focus on people having more friends and being more a part of their community. Using his interest in books to hopefully lead to more social relationships, Arthur was assisted in beginning to volunteer at the community library. He had the job of dusting the book shelves; he reported on the importance of his visits to the library. After his first visit the staff inquired as to how it went. Arthur replied, ‘the books were really dusty. They really needed me.’

Arthur also almost immediately began to assert himself more. When the library staff gave him a name tag with his name misspelled, he immediately requested a new one. In addition, there was a marked transformation in his hesitancies.

Staff were willing to go with Arthur for as long as necessary, but after just two visits Arthur told them that they didn't need to come along anymore- he could walk by himself and handle it by himself. One staff said, ‘but Arthur what about walking home? It will be dark out.’ Arthur told her firmly, ‘But Sandy, there are street lights!”

Arthur’s sense of playing a valued role at the library catalyzed a whole new lifestyle for him. Whereas many of these changes could have been produced with enough programming time, when he had a chance to participate and contribute in a community setting totally separate from his agency programs, a qualitative shift happened that programming could not provide. Programs, no matter how good they are, and no matter how good their results are, perseverate the model of providing programs. Within the programming paradigm, the only thing programs lead to is the next program. (Weiss 1982)

This reminder of the different kinds of paradigms within which it is possible to work brings me to the stage where I need to make some points about the things which I have not been attempting to do here. I choose these particular aspects because I expect the reader to point out that these are things that I have somehow missed. These points have consumed a great deal of my time and energy, but they are not the focus of this thesis.

Next page: The person with brain injury




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