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The Vona du Toit Model of Creative Ability (VdTMoCA)

Laura Murphy

Lead OT

Horton Rehabilitation Services

Ascot Villa

Background to the VdTMoCA

Background to the VdTMoCA

So what is it?

  • An Occupational Therapy practice model originating from South Africa.

  • Founded upon the theory of creative ability developed by Vona du Toit in the late 1960s and early 1970s. 

  • The model describes stages or levels of creative ability

  • These levels are sequential and there can be

progression and regression through the levels.

(Developmental frame of reference)

'Creativity'

  • CREATIVE ABILITY– the ability to express oneself, freely, without anxiety, limitations or inhibitions.

  • CREATIVE CAPACITY – the maximum creative potential an individual has, and which could possibly develop under optimum circumstances

  • Creative capacity varies from one individual to another and is influenced by factors such as intelligence, personality, mental health, environmental opportunities and security.

Measuring Creative Ability

VOLITION

1 - Motivation

2 - Action

Creative ability and capcity

Environment

  • Creative ability is constantly influenced by the environment

  • Environment can be easy to relate to - WITHIN an individual's creative ability.

  • Environment may provide challenges – GREATER than an individual’s creative ability

The AIMS of the VdTMoCA

The AIMS of the VdTMoCA

The VdTMoCA enables the team to:

  • Determine clients efficiently in terms of their occupational performance

  • Provide interventions aimed at specific areas of need, implemented at the right time and in the most cost-effective manner

  • Provides guidelines to structure and guide intervention. Interventions can be designed with performance levels in mind, ensuring optimum opportunity for improving or maintaining performance.

The Levels

Motivation Action

Level 1 - Tone

• Reflects mere existence

• No outward signs of volition

• No evidence of initiative or effort

• Action is haphazard, automatic, no observable purpose,

pre-destructive

• Fleeting contact with materials / objects

• Largely unaware of others, lack awareness of themselves

as separate from environment

• No evidence of awareness or control of bodily functions

• Large care giving component required – largely

dependent

• Typical of a patient in a coma, or in a catatonic state

Level 1 - Tone

Level 2 -

Self Differentiation

  • Action is destructive, leading to incidentally constructive at the end stage

• Poor awareness of bodily functions, needs assistance to manage personal care.

• Lack community survival skills.

• Initially focussed internally, but then becomes aware of people as go through the level.

  • Clients usually on their own; pacing, sitting apart etc.

• Starts to interact with environment, but involved in the

process of ‘doing’; no end product. Attention span brief.

• Lack initiative, effort erratic and rarely seen.

• Clients on this level are usually found in chronic

institutions, eg institutionalised long-term

patients, or very unwell.

Level 3 -

Self Presentation

  • Action is explorative.

• Involved in material and tools, but with poor handling and composite concept

• Poor end product - regular supervision needed

• Clients often vulnerable – little awareness of safety aspects eg crossing road, hobs

• Routine not structured – needs external support

• Personal care, beginning stage needs lots of support, by end of stage clients becoming interested in grooming

• Brief, egocentric contacts with people - eg will chat to others that smoke if chance of getting a cigarette

• Start to become aware of norms

• High levels of anxiety, and low self-esteem

Level 3 -

Self Presentation

Level 4 -

Passive Participation

Difficulty initiating tasks and sustaining effort,

able to complete tasks but needs prompting

• Comprehensive task concept

• Volition directed to: completing products, participating with others, establishing norms and expectations

• Starts testing norms

• Personal care and domestic tasks generally consolidated

• Working things out cognitively & emotionally – often quiet

• Function well when things are going well, but tend to

struggle when stressed

• Community skills limited to familiar situations and routines

Creative Ability Phases

Creative Ability Phases

Each level covers a wide range of skills and occupational behaviours. In order to distinguish whether the individual is at the beginning, middle or end of the level, the following phrases are used:

  • Therapist-directed phase (TDP): the person demonstrates skills and behaviour of both the previous and the current level.

  • Patient-directed phase (PDP): the person’s occupational behaviour is generally characteristic of that level, and can be maintained relatively independently.

  • Transitional phase (TP): the person’s overall occupational behaviour is characteristic of the level, but they demonstrate some skills and behaviours of the next level.

Assessment

Who is this person???

The individual

The MDT

Assessment - 2 Steps...

Assessment - 2 Steps...

  • Essentially completed by OT with information from the MDT
  • Familiar and unfamiliar activity
  • Observation, interview, tasks

1: Observe and

evaluate client’s

current skills

and abilities in

four areas

2. Establish the

client’s level and

phase of creative ability in each of the four areas

Step 1: Assessment of skills and behaviours in 4 Occupational Performance Are...

Step 1: Assessment of skills and behaviours in 4 Occupational Performance Areas (OPAs)

Personal Management: ability to care for self: washing; dressing; caring for

personal belongings; grooming; toileting; money management; road safety etc.

Social Ability: - ability to communicate and interact with familiar and unfamiliar people: form acquaintances; make friends; develop relationships; comply with social norms.

Work Ability: - ability to be productive: initiate, sustain and conclude tasks;

develop new ideas; manage self, workload and resources; work effectively;

evaluate self and product through realistic judgement.

Constructive Use of Free Time: - ability to use free time in a balanced, constructive, recreational and socially acceptable manner to obtain pleasure and to de-stress.

Step 2: Establish the level

Step 2: Establish the level

Creative Participation Assessment (CPA) Tool

Overall level of Self Presentation Ttransitional

Activity Participation Outcome Measure (APOM)

(Casteleijn, 2010)

  • Specific tool aligned with the VdTMoCA
  • Provides baseline and final outcome data of functional ability in eight domains of activity participation
  • Identifies the person’s overall activity participation and generates a spider graph that visually represents change.

Components of Assessment

Components of Assessment

The degree of each component will differ across the levels

Task Concept

Task Concept

1: Understanding the task as a whole

2: Identifying with the task

3: Task selection

6: Task evaluation and satisfaction

5: Task completion

4: Task execution

Concept Formation

2: ELEMENTARY (SD)

Still physical but incorporates function:

- It burns

- It's a drink for when

thristy

1: BASIC (Tone)

Related to sensory processes:

- Brown

Hot

- Wet

- Teabag is squidgy

4: ABSTRACT (PP...)

All concepts:

- Social

- Break time

- Comfort/distraction

- Pleasure, politeness

- Understands stages of making tea

3: COMPOSITE (SP)

Categorising:

- Knows difference between loose leaf and teabags

- Knows different types of tea e.g. earl grey, herbal, iced tea

A Cup of Tea

Effort

  • Effort is essential for change to occur.

  • Effort is:

• exertion of one's self in activity participation

• putting one's self into activity participation

• actively applying one's resources i.e., motivation and mental and/or physical functions, skills and/

or abilities, in active engagement with activity.

Not trying (no effort)

Trying - trying hard (effort)

Trying hard – trying hardest (maximum effort)

To get someone to apply effort there needs to be

CHALLENGE

Intervention

AIMS of intervention

AIMS of intervention

  • To maintain or improve creative ability through attention to the individual, their life experiences, their interests and the components of their current level and phase of creative ability.

  • The level above their current identified level tells us what we, with the individual, are aiming towards.

Treatment principles

incorporating Mosey’s tools of OT practice

Treatment principles

incorporating Mosey’s tools of OT practice

The Treatment Guide (Manual pg 25 onwards)

The Treatment Guide (Manual pg 25 onwards)

  • For each level, the model provides detailed guidance for enabling client engagement across the four Occupational Performance Areas (OPAs).

  • The intervention guidance enables the team to design and deliver intervention that is aligned to the needs of clients.

  • This is done as a team (e.g. the daily routine and running of the ward; how ward rounds and community meetings are facilitated), and by individual disciplines e.g. Psychology, Art therapy, Nursing or OT.

  • A consistent 24 hour approach by the team is needed.

  • The treatment guidance can be individualised to the person and included within care plans.

Case Example

Miss K

Miss K

  • Female in her 50s
  • Diagnosis of Paranoid Schizophrenia since age 17 - Section 37 (History of arson). Repeated hospital admissions and failed placements.
  • Previously married with children. Divorced 1990s and lost contact with children. Now regained some contact.
  • History of non-engagement with services and non-compliance with medication
  • Lack of insight into mental health condition and risks. Resistant to exploring these.
  • Personal management - good skills, knowledge and quality, independent, related delusional beliefs (re. cleanliness). Poor diet due to delusional beliefs.
  • Social ability - focus on own needs drives action, lacks interest in others and socialising, poor tolerance of others, communication skills vary, incidents of verbal and physical agression and racism. Likes to be in control (anixety particularly with the unfmailiar). Lacks trust. Very guarded.
  • Work ability - Knows what to do and what tools to use in familiar activities, reduced task concept in unfamiliar activities with poor problem solving skills and poor frustration tolerance - can give up easily, lacks interest and identification with activities, poor evaluation skills. Lack of effort - remains in comfort zone.
  • Use of free time - Limited constructive use. Uses leave otherwise engages in passive activities or waits in corridors for structured breaks e.g. smoking, tea breaks, leave.

LEVEL OF CREATIVE ABILITY?

Self Presentation

TDP

AIMS of intervention for SP/TDP

Aims

  • Improve self-esteem, decrease anxiety
  • Improve self awareness
  • Improve social awareness - commnuication
  • Improve acceptable behaviour in different situations
  • Improve basic tool handling
  • Improve awareness of effect of self on evironment and others
  • Experience fun/enjoyment

Intervention

  • Sensorimotor activities that are explorative in nature and stimulate emotions.

  • Role development; providing a sense of ownership, responsibility and achievement. Build self esteem.

  • Activities that are directly related to Miss K's likes and dislikes. Includes 1:1s and groups. Improve identification with activities.

  • Approach by introducing activities and opportunities, with no expectation to participate; work to Miss K’s need for a sense of control. Make her aware of what is available and invite her to watch. Allow the space and people in it to become familiar.

  • Introduce challenge but in a slow and sensitive manner in order not to damage trust and rapport. Make expectations clear.

  • Allow Miss K the space to explore new activities and opportunities through the relationship that she is building with particular members of the MDT team; do not at this stage attempt to get her to do more/other activities than those within her current routine. Protect the trust and rapport she is building within the service, hoping this will open her up to working with others e.g. Psychology.

"The Project"

Implementing the VdTMoCA as the MDT model on Ascot Villa

2017

With Dr Wendy Sherwood

Key Aim:

Improving the service’s ability to better understa...

Team understanding the levels of creative ability

2 cases chosen by the MDT

Key Aim:

Improving the service’s ability to better understand and meet service users’ needs

Interventions

Team understanding the levels

Laura has completed initial ‘training’ sessions with Therapies staff (Music Therapist, Occupational Therapists, Art Therapist, Psychologists).

Laura refers to the model in MDT meetings (documents and discussions) including ward rounds, CPAs and other reviews.

VdTMoCA Manual created for staff

Model introduced into monthly reflective practice by Laura, providing a structure for discussion and a way of supporting understanding of service users.

Team understanding the levels

Activity Co-ordinator (AC) completed Level 1 training in October 2017 and is supported and supervised by Laura in implementing principles of the model

Ward staff (Nurses, Support Workers, Ward Manager and Deputies, Consultant and Specialty Doctor) trained in the model in January 2017

2 Cases chosen by the MDT

Note writing: Laura includes VdTMoCA language and concepts in documentation shared with the MDT including JADE progress notes, ward round documents, monthly CCG updates.

Activity Co-ordinator (AC) completed Level 1 training in October 2017 and is supported and supervised by Laura in implementing principles of the model

Activity Participation Outcome Measure (APOM) and Assessment Summary and Intervention Plan completed by Laura with MDT input and support from Wendy. Key Nurses involved in the process

2 Cases chosen by the MDT

Assessment summaries and treatment guidance shared by Laura in ward rounds and CPAs which were attended by Care Coordinators and CCG representatives. Model positively received.

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