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Recreational Therapy Practice Models

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Gretchen Snethen

on 20 March 2014

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Transcript of Recreational Therapy Practice Models

Recreational Therapy
Practice Models
Schematic representation of therapeutic recreation services
Facilitate communication about services
Enhance accountability
Provide guidance on the delivery of services
Practice models represent the philosophical perspective of the profession
- Theoretically driven
- Theory represents a belief of how people learn or change behavior.
- Well designed models incorporate this into services
Content Models
- Provide a definition of "what is" therapeutic recreation
- Substantively, what can a practitioner do?
Process Models
- Provides the "how" or the "means"
- How can therapists help clients achieve specific goals
- How are services delivered?

Leisure Background
Perceived freedom
Intrinsic motivation
Enjoyment, self-expression, relaxation, social interaction
Often defined by activity
* Improved health * Improved well-being
* Decreased depression (or other symptoms)
Some models use recreation/leisure as a tool to produce other outcomes.
Leisure or recreation participation the outcome or product of services
Means & End
"Therapeutic recreation practice models must complement and be able to co-exist within the context of the larger health and human service delivery systems in which therapeutic recreation services are delivered"
Public Policy
Professional Organizations
Standards of accrediting bodies
CARF, Joint Commission
Societal trends/needs
inclusion, diversity, advances in technology, least restrictive environment, promotion of independence
Models are two dimensional
Difficult to encompass the full breadth of practice
The real world and consumers are not static
Evaluating Models
Merit (intrinsic value)
Theoretic underpinnings
Graphic depiction
Clarity of terms/concepts
Direction for practice/research
Worth (extrinsic value)
Relevance to health care
Relevance to public policy
Societal relevance
Applicability to specific agency
Points to Consider
Societal Context
Multicultural or cross-cultural application
Adaptation of the environment
Use of technology
Interdependence not just independence
Reflection of current & most appropriate language
"Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (WHO, 1984)
Consideration of the whole person

Does the model fit within this broader context of health?
Quality of Life/ Well Being
General sense of happiness
Satisfaction with life and environment
Encompasses: health, recreation, culture, rights, values, beliefs, and aspirations
(Healthy People 2020)
Cost Containment
Maximize services delivered in the home and community
Minimize inpatient services
Ensure efficient and outcome driven services
Collaborative services between professions

Do models promote the efficient delivery of services? Can services be delivered in the home or community environment?
Health Protection Goals (CDC)
Healthy people in every stage of life
Healthy people in healthy places
People prepared for emerging health threats
Healthy people in a healthy world

Do models promote services that could deliver outcomes in these areas?
Are quality of life and well being promoted through the model?
Leisure Outcome Models
Leisure Ability Model
Key Features of the Model
Purpose: The ultimate outcome of therapeutic recreation services is the improved ability of the individual to engage in a successful, appropriate, and meaningful independent leisure lifestyle that, in turn, leads to improved health, quality of life, and well-being.

Process: As the client moves along the continuum from functional intervention to recreation participation and then starts to master the skills that are relevant for participation in enjoyable and satisfying leisure experiences, their freedom increases and the therapeutic recreation specialist’s control decreases. The client can enter the continuum at any point and the movement within the model does not have to be linear.

Targeted Outcomes: “the overall anticipated outcome of therapeutic recreation service delivery is a satisfying leisure lifestyle- the independent functioning of the client in leisure experiences and activities of his or her choice”

Theoretical Framework:
Grounded in leisure theory;

Major Terms/Definitions:
Functional intervention addresses physical, cognitive, affective, and social functioning that is required for leisure involvement.
Leisure education “focuses on the acquisition of knowledge and skills to make informed choices for leisure participation”.
Within leisure education there are four subcomponents, which consist of: leisure awareness, social interaction skills, leisure activity skills, and leisure resources.
Recreation participation is to provide fun, enjoyable, and self-expression opportunities within an organized delivery system.
Recreation participation can serve at least 6 roles consisting of: “practice and application of skills, inclusion into community services, normalization of institutional routines, focus on well aspects, expression of a leisure lifestyle, and diversion of palliative care.”

Theoretical Underpinnings:
learned helplessness, mastery or self-determination, intrinsic motivation, internal locus of control and causal attribution and flow.

Graphic Depiction:
Clear, concise and comprehensive; serves to communicate to recreation therapist and other professionals, managers, and consumers the purpose, goals, means, uniqueness, and scope of practice of therapeutic recreation services.

Clarity of Terms and Concepts:
The model was updated and with the newest version the difficulty with the terms treatment and social skills have been resolved. The three major components and sub components that make up the model are now concise, distinct, and parallel.

Direction for Practice & Research:
Uses the systems approach for the development of specific programs within the different service components. Functional intervention and leisure education strategies are designed in order to facilitate predetermined, observable, and measurable client outcomes. The model can be implemented in the assessment, planning, implementation, and evaluation (APIE) process of therapeutic recreation.

Perceived Application:
The model can be applied to any setting and can be used for any population as well.

(Stumbo, & Peterson, 2009)
Therapeutic Recreation Process Model (TRAM)
The model addresses any individual who has physical, mental, social, or emotional conditions that prevents them from participating in leisure.

Quality of Life/Well-being:
The model uses functional intervention, leisure education, and recreation participation in order to achieve and improve a client’s well-being and quality of life.

The model is practiced in a variety of settings such as community-based, inpatient, one-on-one programming and group-orientation.

Health Protection:
If individuals are successfully able to achieve functional intervention, leisure, education, and recreation participation then they are able to maintain a healthy leisure lifestyle. It is important for the individual to become independent and successful although they have assistance, but the necessary outcome is to achieve independence.

Societal Context:
Once an individual is slowly able to achieve leisure lifestyle on their own they do not require assistance all the time allowing them to make an easier transition into society.

Key Features of the Model


Targeted Outcomes:

Theoretical Framework:

Major Terms/Definitions:

Theoretical Underpinnings:

Graphic Depiction:

Clarity of Terms and Concepts:

Direction for Practice & Research:


Quality of Life/Well-being:


Health Protection:

Societal Context:

Perceived Application:
Provide a brief description of the settings, populations, and/or ways you believe this model is most appropriate

(Stumbo, & Peterson, 2009)
Health & Wellness Outcome Models
Health Protection/Health Promotion (HPHP)
Key Features of the Model
For clients to achieve the highest level of health. Through this model “TR is identified as enabling the client to recover following a threat to health (health protection) and achieve optimal health (health promotion).”

Three main components of the model: prescriptive activity, recreation, and leisure to help people overcome barriers to health and enable them to grow toward their highest levels of health and wellness. This model represents a continuum of health that ranges from poor health/illness to overall well-being/optimal health.

Targeted Outcomes:
Optimal health and wellness. Health and wellness are the goals; recreation and leisure are the means of reaching this goal.

Theoretical Framework: The foundation of this model is centered around humanism, wellness, actualization, and health. This model assumes that “human beings have an innate or inherent drive for health and wellness that can be nurtured by nonjudgmental, caring professionals.” Additionally, this model assumes that “people have a stabilizing tendency that comes into effect when there is a threat to health and an actualization tendency that motivates growth-enhancing behaviors leading to health promotion.” Overall, the model assumes that humans have a natural tendency toward health protection and health promotion.

Major Terms/Definitions Health, health protection, health promotion, wellness, prescriptive activities, recreation, and leisure

Prescriptive activities→ short exercises/activities that target specific goals/outcomes. Used with clients in poor health as a way to get them engaged in activities that can lead to feelings of self-efficacy, empowerment, excitement, and enjoyment.

Recreation ‘intervention’ → used for restorative properties (means to an end) as clients transition from poor health to optimal health.

Leisure→ provides the avenue for optimal health.
Theoretical Underpinnings: Strong theoretical foundations of humanism, Strong theoretical foundations of humanism, wellness, actualization, and health. Model is criticized/questioned for the model’s assumption that all humans have an inherent drive for health. Scholars suggest leisure and motivation theory should be incorporated into the model since leisure is a main component of the model.

Graphic Depiction: Based on a continuum of health. Graphic is simplistic, but incomplete and not clear-cut. The graphic doesn’t show movement or clearly depict the ultimate goal of health promotion/health protection. In 2009, model was modified to include current terminology of the field, yet the graphic remains unclear.

Clarity of terms and concepts: Major weakness of the model is the ambiguity of terms. It shows little difference between the meaning of prescriptive activity and recreation. Needs more clarity between the model’s 3 components of prescriptive activity, recreation, and leisure. The concept of flow is related to recreation in this model, whereas it is typically associated with leisure - this leads to confusion.

Direction for practice and research: By defining the client as “anyone who wants to improve his/her health”, the lines between recreational therapy and other health service professions become unclear. The model does not operationalize (measure) the term prescriptive activity. Overall, the model needs to operationalize the aspect of holistic health and health promotion/health protection.

Health: This is a major component of the model. Regardless if an individual is in good health or in bad health, the concept of health is addressed in several sectors, including: healthcare systems, along with the larger healthcare market indicating its importance in people’s lives.

Quality of Life/Well-being: Wellness is one of the goals from this model. This aspect of the model pertains to an individual’s drive to achieve optimal health and quality of life. This aspect is strictly self-directed with minimal guidance from a TR specialist after the individual’s goal is met.

Cost-Containment: Not directly addressed in this model. It is a weakness of the model.

Health Protection: This is one one the ultimate outcomes of the model, it is even included in the title. According to the model, through prescriptive activities, leisure, and recreation, health protection and promotion can be attained.

Societal Context: Not directly mentioned in the model, but it is assumed across cultures that health is a universal value. If all cultures and societies value health, then this model is applicable. This model seems to be directed toward the individuals, and not group-directed.

Perceived Application:
Adults receiving physical rehab facility
Adults/seniors in a long-term care facility
Children in an acute rehab facility

(Austin, 2009)
Optimizing Lifelong Health through TR (OLH-TR)
Key Features of the Model
Purpose: To assist clients in enhancing their general health and well-being across their lifespan by working to achieve and maintain certain leisure lifestyles. With this goal in mind, the recreation therapists can promote health and well-being by providing ways for the client to minimize the impact of a disease or disabling condition.

Process: The model consists of four elements for the recreation therapist and the client to work through.
(1) Selecting, which consists of the RT and the client setting goals which are appropriately related to the client’s function and the environment. These goals should focus on the skills and capabilities of the client.
(2) Optimizing. During this stage, the RT uses leisure education to inform the client of resources in their environment, and assists the clients in selecting and participating in appropriate interventions.
(3) Compensating involves the RT educating clients in assistive technology, social or psychological efforts to compensate for the loss of a skill.
(4) Evaluating is the process of making decisions about interventions based on needed client inputs such as money and time and weighing the potential outputs of the former three processes.
Targeted Outcomes:
General health and well-being through the lifespan (healthy leisure lifestyles)
Increased client awareness of adapted leisure opportunities
Increase in skills needed to participate in leisure opportunities with a disability
Knowledge of resources in the community
Ability to participate in leisure experiences interdependently, and understanding the importance and necessity of doing so.
Decreased length of stay in clinical/medical environment due to increased independence and awareness.
Theoretical Framework:
(1) Health Enhancement refers increasing behaviors that clients may use to increase their health on an individual and societal level.
(2) Reform in health and human services refers to shorter stays in clinical environments due to increase independence, education and awareness of the client.
(3) Life-course perspective refers to the Baltes’ and Baltes’ theory of human aging and adaptation, and infers that clients will continue to grow and reinvent themselves throughout the lifespan in response to changes surrounding them. This is the reason for the continuity in the model depiction.
Major Terms/Definitions
APIE process - process of assessing, planning, implementing and evaluating
Leisure education - the processes of educating clients on matters pertaining to increasing a healthy leisure lifestyle, whether through individual sessions or a class.
Healthy Leisure Lifestyle - optimal level of health received through participating in leisure opportunities that are individualized and tailored to the client, and from which the client receives optimal satisfaction.
Independence - being capable of participating in or adapting leisure experiences on one’s own.
Dependence - relying on others to discover, adapt and assist in participation of a leisure experience.

Theoretical Underpinnings:
Authors of the model claim it is based on “a life-course perspective which merges health enhancement and self-care approaches” and was founded on the previously discussed concepts (a) health enhancement, (b) reform in health and human services, and (c) the life-course perspective. The life-course perspective is based on Baltes’ and Baltes’ human development theory of aging and adaptation (OLH-TR: we reinvent ourselves in response to changes -- needs, resources, health, environment). Baltes’ and Baltes’ theory was on the concept of selective optimization with compensation.

The merit of this model is arguable. Because it lacks relating the model directly to age, or the aging process specifically, it is suggested that it does not have a true life-course perspective. There are concerns regarding the use of Baltes’ and Baltes’ theory as it was meant to be a process and not individual elements, and also that is from an outside discipline -- which could affect its true, original intent.

The authors of the model (Wilhite, Keller, & Caldwell) assume that successful adaptation to aging is similar to successful adaptation to disability or illness. “Successful adaptation” is not clearly defined by the model and does not explain how it might change through aging.

Systems theory is also discussed but not fully explained within the OLH-TR model, breaking it into four components: selecting, optimizing, compensating and evaluating. The “evaluating” component appears as one of the four and also as the feedback loop. The author reminds us that in systems theory, feedback should occur in each stage.

Baltes’ and Baltes’ theory and systems theory may not have been used literally within the OLH-TR model, but the concepts do appear relatable to TR, and serve as a good foundation. Ross & Ashton-Shaeffer encourage further exploration its relatability to the above theories as well as continued development.

Graphic Depiction: At first glance, it is difficult to identify what is going on. After reading the description and understanding the process, it is easier to comprehend. The concentric circles are described as functioning like a “ball bearing” (opposing rotation) and use the process of the inner circle to increase interdependence, a balance between dependence and independence. The graphic suggests this process leads to the health enhancement outcome which is the diamond area surrounding. It shows both the TR specialist and the TR client within the diamond as well. It is not clear why the terms on the outside of the diamond (Health and Human Services Systems; Resources, Opportunities, Environments; Clients’ Needs; Healthy Leisure Lifestyles) are in that location and how that ties back to the process. The graphic sits on a small pedestal, as if it is suggesting an imbalance in any of the sections could cause it to tip -- too much independence vs. too much dependence. There may be room for improvement. It is acknowledged that it is difficult to visualize this non-linear model as a two dimensional image.

Clarity of terms and concepts:
“Health” and “Healthy leisure lifestyle” are used throughout the presentation of the model but are not clearly defined. The authors of this model acknowledge this weakness.

Not mentioned in this section of the article but worthy of clarification is the concept of “successful adaptation”, mentioned earlier.
Health: This model promotes general health and targets minimizing or preventing the impact of disabling or dysfunctional conditions, or secondary conditions.

Quality of Life/Well-being: Increasing an individual’s ability to participate in meaningful activities through leisure education, adaptation and health promotion, will likely yield an increase in overall satisfaction and perception of quality of life.

Cost-Containment: This model can be utilized by RT professionals working in home and community settings, where environmental barriers can be addressed. Outcomes are efficiency are monitored through the APIE process. Inpatient services aim to be minimized through health promotion and engaging in a healthy leisure lifestyle.

Health Protection: The model suggests that “a healthy leisure lifestyle includes a flexibility that enables individuals to make continuous accommodations to internal and external changes”.
For example, individuals may be better able to cope with changes and stressors, decreasing the chance for a decline in physical or mental health. Following this model will enable individuals to develop positive leisure skills and behaviors to decrease the likelihood of illness and functional decline.

Societal Context: The targeted outcomes of this model can be applied cross-culturally since disabilities are not culturally specific (though adjustment may be experienced differently due to societal views which may vary culturally). Adaptation of the environment is one of the components of the model, as it aims to educate individuals on available leisure adaptations to successfully participate in their interests. Another key component is interdependence, and the model focuses on maintaining that balance. This model is “current” and reflects shifts in healthcare, viewing the “whole” person, and individualizing care.

Perceived Application:
Physical disabilities/rehabilitation hospitals: In this setting, RT’s can assist clients with newly acquired physical disabilities how to adapt leisure and recreation experiences. Through leisure education classes, clients can learn about the opportunities available to them with adapted leisure, as well as the adaptive equipment and community resources to continue a level of involvement after discharge from the rehabilitation setting. With this education, clients can perhaps attain a level of independence earlier, and may be able to be discharge more quickly. They will also gain the ability to continue to learn and grow throughout their lifetime, using the resources and newly acquired skills and abilities.

Mental/Behavioral Health: In this setting, clients with pre-existing mental and behavioral health conditions, such as Bipolar Disorder or Schizophrenia, and clients with perhaps newly acquired conditions such as Major Depressive Disorder, may learn how to combat some of their symptoms with leisure and recreation opportunities. In this setting, the social aspect of the model that focuses on interdependence may assist these clients in understanding some of the benefits of working with others in their life to reach an optimal level of health and wellness through leisure. Clients can also learn of community resources available to them, which could perhaps lead to less hospitalizations or institutionalizations in the future, as this population often deals with the “rotating door” of re-hospitalizations.

Developmental Disabilities: These clients may also benefit from the idea of interdependence that is stressed in this model, however, as many people with developmental disabilities may live with or rely on others for assistance in many areas of their lives, this model may also help these clients to grow in their independence. By allowing opportunities for clients to grow and learn new skills, and practice them with an RT in a safe setting, this model will allow these clients to eventually become more independent in their leisure pursuits, and more educated about community resources and adaptive equipment that is available to them.

(Wilhite, Keller, & Caldwell, 1999)
Leisure and Well-being Model
Key Features of the Model
Purpose: The LWM was developed by Carruthers and Hood in 2007 to develop and encourage emphasis on a client’s potential and strengths, rather than their shortcomings or deficits. The model also strives to increase well-being and the value of leisure in a client’s life.

Process: To guide TR practice, the process of the systems-based LWM requires two components, Developing Resources and Enhancing Leisure Resources. A combination of finding, developing and mastering the use of psychological, social, cognitive, physical and environmental resources as well as learning how to find and utilize leisure that is meaningful, creates positive emotions and is conducive to personal values, is the process of the LWM. The process of educating and creating a working model of finding and using leisure experiences that are “optimally challenging and engaging, and that lead to sustained personal effort and commitment to the experience” is the ultimate goal (p. 314).

Targeted Outcomes: Outcomes of the LWM include positive affect, emotion and leisure experiences, as well as a state of successful, meaningful engagement with one’s life and the creation and expression of one’s full potential.

Theoretical Framework: Strongly based on theories of leisure behavior and Seligman and Csikszentmihayli’s positive psychology, the LWM involves all of the dimensions of a leisure lifestyle (activity, motivation, setting, time) and how it may affect all types of well-being (psychosocial, cognitive, spiritual, physical) (Heintzman, 2002).

Major Terms/Definitions:
Enhancing Leisure Experience- consists of five subcomponents, savoring leisure, authentic leisure, leisure gratification, mindful leisure and virtuous leisure.
Developing Resources- consists of five subcomponents, including physical, social, cognitive, physical and environmental resources. The first four resources are acquired intrinsically, and the fifth, extrinsically.
Well-Being- a state of successful, satisfying and productive engagement with one’s life and the realization of one’s physical, cognitive and social-emotional potential.

Theoretical Underpinnings: The LWM is largely based on positive psychology and leisure behavior, using therapeutic recreation interventions to facilitate the development of resources, with well-being as the ultimate goal. Instead of focussing on deficit reduction, the LWM explores the importance of cultivating strengths and capacities of the client.

Graphic Depiction: Pictured below is The Foundation Graphic for the LWM. In addition to this graphic, the authors have also presented The Resource Development Framework for the LWM. The Foundation Graphic provides an overview of the LWM as a systems-based model and demonstrates the interaction between enhancing the leisure experience and developing strengths and resources. Having multiple graphics leaves room for confusion.

Clarity of terms and concepts: The main terms used in the LWM are: Enhancing Leisure Experience, Developing Resources, and Well-Being. These terms are clearly and appropriately displayed. There is a lack of consistency surrounding the sub-components. For example, social connectedness is a sub-component under Environmental Resources, however the authors talk about it while discussing Social Resources, but no connections between the two is ever made (p. 230).

Direction for practice and research: According to Ashton-Shaeffer and Ross, “The LWM has great potential for practice, but needs to be further developed to provide sufficient directions for practice and the APIE process.” (p. 230). The LWM does not have a clear starting point to begin a treatment plan, nor does it have clear roles between therapist and client. At the same time, however, it is open-ended enough to allow a therapist to create an entire program within its boundaries. It seems that this model would be most helpful to an experienced therapist.

Health: The LWM relates to the goal of health in a holistic way. The emphasis placed on emotional well-being as well as physical, cognitive, social and spiritual health describes a model that addresses an individual’s complete picture of health.

Quality of Life/Well-being:This model takes into account a person’s potential and values in the context of leisure. Included in the resource development graphic is the importance of psychological resources, including happiness, emotional regulation, sense of meaning and autonomy. Quality of life is often based on someone’s capacity for happiness and satisfaction of life, and the LWM addresses this thoroughly.

Cost-Containment: Services can be provided in the home and/or community, but as discussed earlier, the efficiency of service delivery can be challenged by the lack of a clear starting point.

Health Protection: The LWM shines a spotlight on the fact that eliminating problems alone, does not result in healthy individuals. Relief of suffering is significant, but the development of positive strengths and an improvement in quality of life is also vital.

Societal Context: Due to it’s strength-based approach, this model represents a paradigm shift in the TR field. The LWM highlights the interconnectedness of leisure and well-being, and show that leisure directly affects the development of positive resources.

Perceived Application:
The LWM seems to be applicable for all settings and all populations.

Most Relevant Populations: Individuals with EBD, individuals with mental illness, individuals with chronic illness, aging adults, individuals struggling with addiction

The information in this article does not do this model justice. The LWM is generally quite simple: A TR professional facilitates a client’s ability to participate and engage in a leisure activity to address the challenges he or she is faced with, while also supporting the development of positive emotions and increased quality of life.

(Hood, & Carruthers, 2007)
Leisure-Spiritual Coping Model
Key Features of the Model
The main focus of this model is on well-being inferring that spirituality is an integral part of wellness.

This model is process-oriented transactional, dynamic, and relational. The model is based off Folkman’s transactional model of stress and coping and Gall’s spiritual framework of coping. The model may on many levels of stress and coping at any time due to spirituality being multidimensional.

The model is composed of 5 components:
1. Spiritual appraisal: The tendency for individuals to initially appraise a major stressor within the context of spiritual causes. This component includes primary (i.e. how event negatively affects one’s spirituality) and secondary appraisals (i.e. how one will use spirituality to aid in coping) which determine the type of leisure-spiritual coping behaviors one will choose to employ.
2. Person factors: One’s religious denomination and doctrine and whether one has an intrinsic or extrinsic religious orientation as this component often plays an important role in how one copes with stress.
3. Leisure-spiritual coping behavior (defined below)
4. Leisure-spiritual connections/resources (defined below)
5. Leisure-spiritual meaning making (defined below)

Targeted Outcomes:
To increase one’s ability to cope, adapt to, and transcend life challenges; and to increase one’s well-being and overall quality of life through spirituality and leisure.

Theoretical Framework:
Spirituality had been found to have an important role in recovery for people with mental illness.
Recreation and social activities have been identified as spiritual activities, and spirituality has the power to influence one’s health, quality of life, and functioning.
Both leisure and spirituality may aid in the development of positive coping strategies built upon self-determination, social support, a sense of empowerment, palliative coping, and mood.

Major Terms/Definitions
Spiritual appraisals: When people experience a life stressor, they often begin by appraising the situation within the context of spiritual causes (i.e. God, fate).
Primary spiritual appraisal: The extent the event negatively affect one’s relationship with God or other sacred aspects of one’s life.
Secondary spiritual appraisal: The assessment that spiritual coping strategies may be helpful in dealing with the life stressor.
Person factors: One’s religious denomination and doctrine; intrinsic vs. extrinsic religious orientation.
Leisure-spiritual coping behaviors: Organizational religious practices, private religious/spiritual practices, non-traditional spiritual practices, sacralization (i.e. being sensitive to the sacred via meditation and relaxation), grounding (i.e. diversion via jogging, gardening, tai chi), contemplative leisure (i.e. being open and aware), leisure as time and space for renewal (holidays), and being away (i.e. getting away from everyday environment).
Leisure-spiritual connections/resources: Mediating factors to stress and include connections with nature, others, and the transcendent other (i.e.God).
Leisure-spiritual meaning making: Using leisure experiences to discover meaning in a stressful situation and using leisure as a way to express spirituality.
-Intrinsic religious orientation: A selfless motivation to pursue purpose and meaning in life for its own sake and an internal understanding of transcendence.
-Extrinsic religious orientation: Based on comfort, safety, guilt, anxiety, or external pressure that is not faith related.
Theoretical Underpinnings:
One of the model’s strongest areas due to its principles integrating stress, coping, spirituality, leisure, and health and wellness.
Leisure and spirituality are strongly connected through theory.
Disability is neglected in the theoretical framework.

Graphic Depiction:
Clear and easy to understand
Need for use of model is clearly a stressor in model and outcome is clearly well-being.
Progression through all components are logical with the exception of arrows connecting leisure-spiritual meaning-making back to the stressor that lack an explanation.

Clarity of terms and concepts:
Unfamiliar terms such as “primary” and “secondary leisure appraisals”, “person factors”, and “sacralization” are clearly defined.
”TR worldview” is never defined and it criticized as being an afterthought to make the model more fit to therapeutic recreation.

Direction for practice and research:
The case study provided is thoughtful and insightful but does not explain how the model can be used in therapeutic recreation programming.
It is suggested that questions related to one’s spiritual appraisal should be included in the assessment process, yet examples of questions are not provided.
It is suggested for individuals to move from extrinsic religious orientation to an intrinsic religious orientation with no details about one would go about doing so.
The case study used to illustrate the model does not include services by a recreation therapist making it unclear if the model is applicable to the APIE process, a central component to TR.
Framework for research is provided by including sound theoretical background but calling for more investigation into the spiritual-leisure connection.

This model fits into the broader context of health, for the models outcomes is targeted on increasing one’s ability to cope, adapt to, and transcend life challenges and to increase one’s well-being and overall quality of life through spirituality and leisure. This outcomes of this model focus on the mental and social-being of an individual. This model is used to help someone going through a stressful time that are often physically related (e.g. terminal illness) and allow enable someone to connect spiritually focusing on their mental and social well-being, thus focusing on the holistic view of health of an individual.

Quality of Life/Well-being:
In this model it uses spirituality and leisure as a coping mechanism and outlet for this stress to promote the well-being. This model attempts to maintain and increase an individuals quality of life in a stressful situations.

This model can complement the direction of moving services outpatient, for the model does not set a type of setting and by focusing on spirituality and leisure, is very viable in an outpatient setting. Also, this model focuses on the psychosocial perspective of an individual experiencing a stressful event. If RT uses this model to help an individual in a stressful situation in can limit the need for medications and psychology services, decreasing the cost for treatment.

Health Protection:
This model does not exactly fit into the health protection model in the outcomes of preparing for health threats or healthy people in healthy places, for the model focuses on maintaining/increasing wellness after a stressor or challenging life event is presented. However, it does fit into helping people stay healthy in stages of life (e.g. when someone is presented with cancer, getting older).

Societal Context:
This model can fit into societal context, if the focus on using spirituality as a coping mechanism does not focus on a specific religion, for the US population beliefs in such a variety of religions. If the model explores multiple religions, spiritual beliefs, and does not single out anyone into following a certain practice in can fit into societal context. However, presentation of this model needs to be broad and not single any individual religion out.

Perceived Application:
Settings that are religious based (e.g. nursing homes associated with a certain faith, a catholic hospital, and outpatient religious affiliated support group, etc)
holistic and nontraditional practices are valued and utilized
for cultural or ethnic groups where spirituality is a foundation of their belief system
This model may be suitable in a mental health setting based on the theoretical framework that spirituality has been found to be important for many with psychiatric disability.

(Heintzman, 2008)
Self-Determination & Enjoyment Enhancement
Key Features of the Model
Purpose: Used to support participants in achieving the goals of self-determination, enjoyment, and ultimately, functional improvement. The model is based on the premise that experience self-determination and enjoyment can lead to functional improvement.

Process: A closed-system model, in which six psychological outcomes (components) are targeted through specific strategies. All components of the model interact with and are interdependent upon each other and, therefore, all components must be operation for the model to work. The model is intended to be implemented in a holistic fashion since a change to one component will likely cause a change in others.

Targeted Outcomes: Self-determination, intrinsic motivation, perception of manageable challenge, investment of attention, enjoyment, functional improvement.

Theoretical Framework: Csikszentmihayli - Optimal Experience; Deci - Theories of Self Determination and Intrinsic Motivation

Major Terms/Definitions
1) Component: one of six psychological outcomes targeted by the model
2) Self-determination component: “acting as a primary causal agent in one’s life and making choices and decisions free from external influence or interference”
3) Intrinsic motivation component: motivation that is driven internally by enjoyment or interest in the task/activity itself, not through external influence“the means to and result of self-determination”
4) Perception of manageable change component: related to flow; “implies an awareness of the challenge being presented and perception of ability to meet the challenge.”
5) Investment-of-attention component: “concentration, effort, and a sense of control”
6) Enjoyment component: “the result of investing one’s attention (the investment-of-attention component) in actions that are intrinsically motivating (intrinsic motivation component).”
7) Functional improvement component: the result of increased involvement due to engagement in an intrinsically motivated activity that provides an individual with challenge, freedom, and enjoyment.
Theoretical Underpinnings:
Based on Csikszentmihalyi’s theory of optimal experience and Deci’s theories of self-determination and intrinsic motivation.
The main criticism of the model seems to revolve around the functional-improvement component
Some research (Mobily 1999) has concluded that the model is "unusually sound in its integration of theory and practice;” however, other research (Caldwell 1998) has challenged the validity of the multiple theoretical links between components.
Not many examples of what makes the model credible; author’s note that the causal relationship between enjoyment and functional improvement is not well documented.

Graphic Depiction:
The graphic depiction provides direction for the delivery of therapeutic recreation services using clear components and strategies.
The facilitation strategy box in the upper left-hand corner includes skill assessment related to perception of manageable change, leading one to assume that this may be the entry point into the system, although it remains unclear.
Graphic is easy to read and appropriate for the purpose of this model.

Clarity of terms and concepts:
The titles of the components are clearly identified and defined.
The material in the boxes is less than clear due to the inability of the reader to decipher whether the material in the boxes is meant to be processes, outcomes, or a combination of both. The text clarifies that the boxes contain strategies for facilitating the psychological components (outcomes) identified in the circles; however, this is not clearly labeled in the graphic description of the model.
With the addition of the functional-improvement component, the model's title does not accurately describe it, and its title is too long to be very useful.

Direction for practice and research:
There may be ambiguity between the components that may be problematic for implementing the model in practice as well as researching the efficacy of the model.
The scope of therapeutic recreation practice, as directed by this model, might become unclear and might not distinguish therapeutic recreation from other treatment modalities due to the strong presence of the enjoyment-enhancement and functional-improvement components
Due to the lack of clarity, the model does not lend itself to be easily implemented in accordance with the APIE process.

Health: The model intends to address both psychological components, as well as, physiological functional improvement. However, to be more compliant with a holistic view of health, the model could be improved by incorporating emotional and spiritual components.

Quality of Life/Well-being: With intrinsic motivation, enjoyment and self-determination being core components of the model, as well as, the concept of flow being incorporated into the components this model certainly promotes improved QoL and well-being. The model actually goes one step further and promotes that idea that these increases to QoL can lead to functional improvements as well.

Cost-Containment: The strategies employed by this model can certainly be delivered in a home, community or outpatient setting. In many of the cases -- such as assessing skills, making adaptations, reducing distractions, and developing self-awareness, for example -- it may actually be more beneficial to to facilitate services in a client’s real community and outside of an artificial, inpatient environment. It may be argued that enjoyment is a difficult outcome to objectively measure (or bill for), but the inclusion of functional improvement in the model helps moderate this.

Health Protection: Many of components of the model work collectively to increase participation in activity. Activities that are cognitively stimulating, physically demanding, or have a social aspect (to name a few) can have health benefits across multiple domains and, therefore, increasing participation in these activities can help prevent and/or combat a myriad of potential secondary conditions.

Societal Context: The model uses appropriate language and focuses on psychological components that are relevant across cultural contexts. However, the model focuses closely on the micro-system of the individual and does not take environment or context into consideration.

Perceived Application:
Inpatient or Outpatient Physical Rehabilitation
Inpatient or Outpatient Mental Health

(Datilo, Kleiber, & Williams, 1998)
Some models address both
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