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 Edited by
Barbara J. Hemphill, DMin, OTR, FAOTA

Christine K. Urish, PhD, OTR/L, BCMH, FAOTA

 Senior Vice President: Stephanie Arasim Portnoy
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Names: Hemphill, Barbara J., editor. | Urish, Christine, 1965- editor.

Title: Assessments in occupational therapy mental health : an integrative
approach / edited by Barbara J. Hemphill, Christine K. Urish.
Description: Fourth edition. | Thorofare, NJ : SLACK Incorporated, [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2020012056 (print) | LCCN 2020012057 (ebook) | ISBN
9781630918132 (hardcover) | ISBN 9781630918149 (epub) | ISBN
9781630918156 (web)
Subjects: MESH: Occupational Therapy--methods | Mentally Disabled
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 Dedication
To Pat Pangburn, a very dear friend who assisted me over the past years and remains
in my memory. I want to thank her for her expertise in computer language, and her abil-
ity to challenge my ideas in a soft and loving manner. She was knowledgeable in various
writing styles, and I learned a great deal from her. During my association with her, she
was able to learn and understand the profession of occupational therapy and became an
asset to me while I was engaged in a variety of writing projects. I miss her very much.
—Barbara J. Hemphill, DMin, OTR, FAOTA
 Contents
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xix
Foreword by Marie-Louise F. Blount, AM, OT, FAOTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xxi

Part I Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 1 Assessment in Occupational Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Christine K. Urish, PhD, OTR/L, BCMH, FAOTA and
Barbara J. Hemphill, DMin, OTR, FAOTA
Chapter 2 Evidence-Based Practice and Assessment in Occupational Therapy . . . . . 15
Christine K. Urish, PhD, OTR/L, BCMH, FAOTA

Part II The Interviewing Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Chapter 3 Occupational Profile and Interviewing in Occupational Therapy . . . . . . . 39
Lisa Mahaffey, PhD, OTR/L, FAOTA
Chapter 4 Client-Centered Assessment: The Canadian Occupational
Performance Measure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Sue Baptiste, MHSc
Chapter 5 Social Profile: Assessment of Social Participation in Children,
Adolescents, and Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Mary V. Donohue, PhD, OT/L, FAOTA
Chapter 6 Activity Card Sort as an Essential Tool to Obtain an Occupational
History and Profile in Individuals With Mental Health Challenges . . . . . 77
Lisa Tabor Connor, PhD, MSOT, OTR/L and
Carolyn M. Baum, PhD, OTR/L, FAOTA

Part III Psychological Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Chapter 7 Writing as an Assessment Tool in Mental Health . . . . . . . . . . . . . . . . . . . . . 93
Kristine Haertl, PhD, OTR/L, FAOTA
Chapter 8 Creative Participation Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Jane Ryan, MBA/CHM, LOTR, CLT
Chapter 9 The Kawa (River) Model: Culturally Relevant Assessment in
Occupational Therapy Mental Health Practice . . . . . . . . . . . . . . . . . . . . . . 137
Brock Cook, BA, OT and Michael K. Iwama, PhD, MSc, BSc, BScOT

Part IV Cognitive Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Chapter 10 Performance-Based Assessments and
Neuropsychological Assessments: A Comparison . . . . . . . . . . . . . . . . . . . 155
Glen Gillen, EdD, OTR, FAOTA and
Emily Raphael-Greenfield, EdD, OTR/L, FAOTA
 viii Contents

Chapter 11 Cognitive Disabilities Model: Allen Cognitive Level Screen–5 and

Allen Diagnostic Module (2nd Edition) Assessments . . . . . . . . . . . . . . . . 179
Catherine A. Earhart, BA, OT Cert, OTR/L and
Deane B McCraith, MS, OT/L, LMFT
Chapter 12 Routine Task Inventory–Expanded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Noomi Katz, PhD, OTR
Chapter 13 Contextual Memory Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Emily Raphael-Greenfield, EdD, OTR/L, FAOTA;
Joan Toglia, PhD, OTR/L, FAOTA; and Ashley Hartman, MS, OTR/L
Chapter 14 Weekly Calendar Planning Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Joan Toglia, PhD, OTR/L, FAOTA and
Suzanne White, MA, OTR/L, FAOTA
Chapter 15 The Executive Function Performance Test . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Carolyn M. Baum, PhD, OTR/L, FAOTA and
Timothy J. Wolf, OTD, PhD, OTR/L, FAOTA

Part V Behavioral Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

Chapter 16 Assessments Used Within the Model of Human Occupation . . . . . . . . . . 279
Celeste Januszewski, OTD, OTR/L, CPRP and
Lisa Mahaffey, PhD, OTR/L, FAOTA
Chapter 17 The Assessment of Occupational Functioning–Collaborative Version. . . . 307
Christine Raber, PhD, OTR/L and Janet Watts, PhD, OTR Retired
Chapter 18 Role Assessments Used in Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Victoria Schindler, PhD, OTR, BCMH, FAOTA
Chapter 19 Australian Therapy Outcome Measures for Occupational Therapy:
A Measure of Global Client Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Carolyn A. Unsworth, BAppSci(OccTher), PhD, OTR

Part VI Learning Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

Chapter 20 The Performance Assessment of Self-Care Skills . . . . . . . . . . . . . . . . . . . . 359
Margo B. Holm, PhD, OTR/L, FAOTA, ABDA and
Joan C. Rogers, PhD, OTR, FAOTA
Chapter 21 The Comprehensive Occupational Therapy Evaluation . . . . . . . . . . . . . . . 371
Jennifer Allison, OTD, OTR/L and
Mary P. Shotwell, PhD, OT/L, FAOTA
Chapter 22 The Independent Living Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
Nadine Revheim, PhD, OTR/L
Chapter 23 Kohlman Evaluation of Living Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
Linda Kohlman Thomson, MOT, FAOTA
Chapter 24 Work-Related Assessments: The Worker Role Interview,
Work Environment Impact Scale, and
Assessment of Work Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
Brent Braveman, PhD, OTR/L, FAOTA
Chapter 25 The Test of Grocery Shopping Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Catana Brown, PhD, OTR/L, FAOTA
 Contents ix

Part VII Biological Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443

Chapter 26 Adolescent/Adult Sensory Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Catana Brown, PhD, OTR/L, FAOTA
Chapter 27 Spiritual Assessments in Mental Health Occupational Therapy . . . . . . . 457
Barbara J. Hemphill, DMin, OTR, FAOTA
Chapter 28 The OT-QUEST: The Occupational Therapy Quality of Experience
and Spirituality Assessment Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
Emily Schulz, PhD, OTR/L, CFLE, ACUE

Part VIII Additional Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515

Chapter 29 Measuring Life Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
Kathleen Matuska, PhD, OTR/L, FAOTA
Chapter 30 Goal Attainment Scaling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Ann Chapleau, DHS, OTR/L
Chapter 31 Stress Management Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
Franklin Stein, PhD, OTR/L, FAOTA

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
Appendix A Writing as an Assessment Tool in Mental Health: Resources . . . . . . . . . . 549
Appendix B Creative Participation Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553
Appendix C Routine Task Inventory–Expanded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
Appendix D Role Assessments Used in Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . 561
Appendix E The Performance Assessment of Self-Care Skills . . . . . . . . . . . . . . . . . . . . 575
Appendix F Definitions of Terms for the Comprehensive Occupational Therapy
Evaluation Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579
Appendix G KidCOTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
Appendix H List of Spiritual Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 593
Appendix I Life Balance Inventory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595

Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599

 Acknowledgments
I would like to thank my friends and colleagues and my husband who gave me the
courage and the support needed to accomplish this task. Without them, I could not have
completed this project. I want to extend my appreciation to the authors who contributed
to this endeavor. Through medical stresses, deaths, surgeries, heart attacks, and emotional
turmoil, theses authors maintained their dedication and commitment to this project. This
project could not have been completed without their steadfast tenacity. I am indebted to
their patient and faithful trust. I want to thank Christine Urish for her contribution as
secondary editor. Her editorial skills and knowledge added to the value of the manuscript.
—Barbara J. Hemphill, DMin, OTR, FAOTA

I would like to acknowledge the following individuals related to this work: Dr. Barbara
Hemphill for the opportunity to collaborate and contribute in a significant manner to this
exceptional scholarly work; Ms. Eliza Gillies, Ms. Mary Scheck, and Mr. Tom Crone for
the support and assistance during the writing and editing process; and the occupational
therapy students and clients over the years who provided ongoing motivation for me to
continue engagement in life-long learning and pursuit of clinical excellence. Lastly, to my
grandfather, Virgil Urish, who instilled a love for learning and reminded me I could “do
anything” if I put my mind to it.
—Christine K. Urish, PhD, OTR/L, BCMH, FAOTA
 About the Editors
Barbara J. Hemphill, DMin, OTR, FAOTA, received her Bachelor of Science degree in
occupational therapy from the University of Iowa. She received her Master of Science
degree in occupational therapy from Colorado State University. During her tenure as a
therapist at Ft. Logan Mental Health Center, she was fortunate to work with Dr. Maxwell
Jones, the founder of the Therapeutic Community Concept in mental health, and devel-
oped the B.H. Battery, a projective test based on analytical frame of reference. She began
her teaching career at Cleveland State University. She became an associate professor and
tenured in the department of occupational therapy at Western Michigan University. She
retired emeritus after 19 years. In addition to her degrees, she has an earned Doctor of
Ministry degree from the Ecumenical Theological Seminary in Detroit.
Dr. Hemphill has served on the editorial boards of the Occupational Therapy Practice
Journal and the American Journal of Occupational Therapy and presently serves on the edito-
rial board of the Occupational Therapy in Mental Health journal. She has written numerous
international, national, and state peer-reviewed papers. Her papers include two at the World
Federation for Occupational Therapy: one entitled “Holism in Occupational Therapy” and
the second entitled “Occupational Therapy and Spirituality: A Global Perspective.” She
has presented numerous papers at national occupational therapy conferences. Among
them are: “Methods in Spirituality: An Educational Experience,” “Spirituality in the
Treatment Setting,” “Spirituality in the Health Care Setting,” and “Spirituality as an
Occupation.” At the state level, she has presented papers at the Michigan Occupational
Therapy conference, and her presentations have included “Spiritual Assessments in the
Treatment Setting” and “Spirituality With the Intellectual Disabled.”
Her publication record has spanned over 25 years. Her most proud accomplishment is
having edited books on the topic of mental health assessment. Among them are The Evaluative
Process in Psychiatric Occupational Therapy, which was translated into Japanese; Mental Health
Assessment in Occupational Therapy; and Assessments in Occupational Therapy Mental Health.
She has published in the American Journal of Occupational Therapy and Occupational Therapy
in Mental Health. The topics range from marketing to depression to deinstitutionalization.
Her most recent publication focused on social justice and spirituality in occupational
therapy. She has been recognized for her contributions to education, research, and publica-
tions. She has served on state and national committees, most notably serving as chair of
the Ethics Commission of the American Occupational Therapy Association. Her awards
include Fellow of the American Occupational Therapy Association, as well as Fellow of the
Michigan Occupational Therapy Association. She was recently named among the most 100
influential occupational therapists in the past century.
Dr. Hemphill continues to contribute to her profession after retirement. She has taught
courses in spirituality to occupational therapy students online and in the classroom. Her
ministry is in the community. She has taught spirituality courses at senior centers and
retirement homes. She also taught a series of courses about C.S. Lewis and a PBS course
entitled “A Question of God,” a debate between Freud and C.S. Lewis.

Christine K. Urish, PhD, OTR/L, BCMH, FAOTA, graduated from Western Michigan
University in 1989 with a Bachelor of Science degree in occupational therapy. She began
her career working as an occupational therapist at an inpatient psychiatric setting
and inpatient/outpatient addiction treatment providing treatment to clients across the
 xiv About the Editors

lifespan. She completed her Master of Science degree in 1993 and returned to clinical prac-
tice. In 1994, she began her career in higher education at St. Ambrose University, teaching
in occupational therapy until June 2018. At present, Dr. Urish is a professor of occupational
therapy at Drake University. Christine completed her PhD from the University of Iowa
in 2005. Along the way, she has worked with the most amazing mentors, including Dr.
Barbara Hemphill, who was a motivating and encouraging force in her career from the
early days at Western Michigan University, at the start of her clinical practice, throughout
the completion of her PhD, and to the present day. Another mentor, Dr. Vilia Tarvydas,
encouraged her early writing career. Dr. Urish continues to engage in clinical practice
as an occupational therapist in behavioral health at the University of Iowa Hospitals
& Clinics. Dr. Urish is Board certified as an occupational therapist in mental health
by the American Occupational Therapy Association and is a Fellow of the American
Occupational Therapy Association. Dr. Urish has served in the past as affiliate President
for the National Alliance on Mental Illness and as President of the Iowa Occupational
Therapy Association. Dr. Urish is a tireless advocate for individuals with mental illness,
the profession of occupational therapy, and occupational therapy students.
 Contributing Authors
Jennifer Allison, OTD, OTR/L (Chapter 21) Lisa Tabor Connor, PhD, MSOT, OTR/L
Assistant Professor (Chapter 6)
School of Occupational Therapy Elias Michael Executive Director and
College of Health Sciences Professor
Brenau University Occupational Therapy and Neurology
Gainesville, Georgia Washington University
St. Louis, Missouri
Sue Baptiste, MHSc (Chapter 4)
Professor Brock Cook, BA, OT (Chapter 9)
School of Rehabilitation Sciences Lecturer (Occupational Therapy)
Faculty of Health Sciences College of Health Sciences
McMaster University James Cook University
Hamilton, Ontario, Canada Townsville, Queensland, Australia

Carolyn M. Baum, PhD, OTR/L, FAOTA Mary V. Donohue, PhD, OT/L, FAOTA
(Chapters 6 and 15) (Chapter 5)
Professor Occupational Therapist
Occupational Therapy, Neurology, and Associate Editor
Social Work Occupational Therapy in Mental Health
Washington University
St. Louis, Missouri Catherine A. Earhart, BA, OT Cert, OTR/L
(Chapter 11)
Marie-Louise F. Blount, AM, OT, FAOTA Director of Development
(Foreword) Allen Cognitive Group/
Clinical Professor, Retired ACLS and LACLS Committee
New York University California
New York, New York
Glen Gillen, EdD, OTR, FAOTA
Brent Braveman, PhD, OTR/L, FAOTA (Chapter 10)
(Chapter 24) Professor and Director
Occupational Therapist Programs in Occupational Therapy
Director of Rehabilitation Services Vice Chair
MD Anderson Cancer Center Department of Rehabilitation and
Houston, Texas Regenerative Medicine
Assistant Dean
Catana Brown, PhD, OTR/L, FAOTA Vagelos College of
(Chapters 25 and 26) Physicians and Surgeons
Professor Columbia University
Midwestern University New York, New York
Glendale, Arizona
Kristine Haertl, PhD, OTR/L, FAOTA
Ann Chapleau, DHS, OTR/L (Chapter 30) (Chapter 7)
Professor Professor
Department of Occupational Therapy Department of Occupational Therapy
Western Michigan University St. Catherine University
Kalamazoo, Michigan St. Paul, Minnesota
 xvi Contributing Authors

Ashley Hartman, MS, OTR/L Kathleen Matuska, PhD, OTR/L, FAOTA

(Chapter 13) (Chapter 29)
Occupational Therapist Professor of Occupational Therapy
Tender Touch Rehab Services St. Catherine University
Spotswood, New Jersey St. Paul, Minnesota

Barbara J. Hemphill, DMin, OTR, FAOTA Deane B McCraith, MS, OT/L, LMFT
(Chapters 1 and 27) (Chapter 11)
Professor Emeritus Occupational Therapy Director of Education and Research
Western Michigan University Allen Cognitive Group/
Kalamazoo, Michigan ACLS and LACLS Committee
California
Margo B. Holm, PhD, OTR/L, FAOTA,
ABDA (Chapter 20) Christine Raber, PhD, OTR/L
Professor Emerita (Chapter 17)
Occupational Therapy Professor
University of Pittsburgh Master of Occupational Therapy Program
Pittsburgh, Pennsylvania Shawnee State University
Portsmouth, Ohio
Michael K. Iwama, PhD, MSc, BSc, BScOT
(Chapter 9) Emily Raphael-Greenfield, EdD, OTR/L, FAOTA
Dean and Professor (Chapters 10 and 13)
School of Health and Special Lecturer
Rehabilitation Sciences Programs in Occupational Therapy
MGH Institute of Health Professions Department of Rehabilitation and
Boston, Massachusetts Regenerative Medicine
Vagelos College of
Celeste Januszewski, OTD, OTR/L, CPRP Physicians and Surgeons
(Chapter 16) Columbia University
Clinical Assistant Professor New York, New York
University of Illinois at Chicago
Chicago, Illinois Nadine Revheim, PhD, OTR/L
(Chapter 22)
Noomi Katz, PhD, OTR (Chapter 12) Licensed Psychologist
Director Private Practice
Research Institute for
Health and Medical Professions Joan C. Rogers, PhD, OTR, FAOTA
Ono Academic College (Chapter 20)
Kiryat Ono, Israel Professor Emeritus
Professor Emeritus Occupational Therapy
Hebrew University University of Pittsburgh
Jerusalem, Israel Pittsburgh, Pennsylvania

Lisa Mahaffey, PhD, OTR/L, FAOTA Jane Ryan, MBA/CHM, LOTR, CLT
(Chapters 3 and 16) (Chapter 8)
Associate Professor of Occupational Therapist
Occupational Therapy Denham Springs, Louisiana
Occupational Therapy Program
Midwestern University
Downers Grove, Illinois
 Contributing Authors xvii

Victoria Schindler, PhD, OTR, BCMH, Carolyn A. Unsworth, BAppSci(OccTher),

FAOTA (Chapter 18) PhD, OTR (Chapter 19)
Professor of Occupational Therapy Professor of Occupational Therapy
Stockton University School of Health, Medical and
Galloway, New Jersey Applied Sciences
Central Queensland University
Emily Schulz, PhD, OTR/L, CFLE, ACUE Adjunct Professor
(Chapter 28) La Trobe University
Assistant Clinical Professor Melbourne, Australia
Northern Arizona University Jönköping University
Phoenix, Arizona Jönköping, Sweden

Mary P. Shotwell, PhD, OT/L, FAOTA Christine K. Urish, PhD, OTR/L, BCMH,
(Chapter 21) FAOTA (Chapters 1 and 2)
Professor and Program Director Professor of Occupational Therapy
Occupational Therapy Program Drake University
University of St. Augustine for the Des Moines, Iowa
Health Sciences
St. Augustine, Florida Janet Watts, PhD, OTR Retired
(Chapter 17)
Franklin Stein, PhD, OTR/L, FAOTA Emeritus Associate Professor
(Chapter 31) Department of Occupational Therapy
Editor Virginia Commonwealth University
Annals of International Occupational Therapy Richmond, Virginia
Professor Emeritus
Department of Occupational Therapy Suzanne White, MA, OTR/L, FAOTA
University of South Dakota (Chapter 14)
Vermillion, South Dakota Clinical Associate Professor
Occupational Therapy Program
Linda Kohlman Thomson, MOT, FAOTA SUNY Downstate Medical Center
(Chapter 23) New York, New York
Occupational Therapist
Bellingham, Washington Timothy J. Wolf, OTD, PhD, OTR/L, FAOTA
(Chapter 15)
Joan Toglia, PhD, OTR/L, FAOTA Department Chair
(Chapters 13 and 14) Associate Professor
Dean and Professor Occupational Therapy
School of Health & Natural Sciences University of Missouri
Mercy College Columbia, Missouri
Dobbs Ferry, New York
Adjunct Clinical Professor of
Cognitive Sciences
Rehabilitation Medicine
Weill Cornell Medical College
New York, New York
 Preface
In 1982, the first edition of The Evaluative Process in Psychiatric Occupational Therapy
was published. The purposes of this text were to provide occupational therapy students
with knowledge about the evaluation process, to provide therapists with information
about assessments that was current and accurate, and to generate research for develop-
ing assessment tools. The text was translated into Japanese, and subsequent editions
were used in international occupational therapy programs. Other texts published were
entitled Mental Health in Occupational Therapy, and two texts were entitled Assessments in
Occupational Therapy Mental Health. All had the subtitle An Integrative Approach.
All texts have been focused on the original purpose. The common thread has been
research, and each chapter was written by the assessment’s originator or by an individual
extremely well-versed with research on the assessment. There is no intent in the text to
present or recommend any one assessment over another. There is no intent to endorse a
particular theory or frame of reference. The editors did not impose criteria for each assess-
ment’s usefulness or level of research development. It is the belief of the editors that prac-
titioners shall determine the usefulness and credibility of an assessment and encourage
students to do further research in assessments.
In the present edition, an attempt was made to include assessments that were currently
used and to include assessments from the previous editions. In order to be included in
this text, an assessment had to have 75% new material within the chapter. This was accom-
plished either through updating the literature review, research development, or adding
a case study. The chapters that are updated include “Client-Centered Assessment: The
Canadian Occupational Performance Measure,” “Writing as an Assessment Tool in Mental
Health,” “The Assessment of Occupational Functioning–Collaborative Version,” “Role
Assessments Used in Mental Health,” “The Performance Assessment of Self-Care Skills,”
“The Comprehensive Occupational Therapy Evaluation,” “Work-Related Assessments:
The Worker Role Interview, Work Environment Impact Scale, and Assessment of Work
Performance,” and “The OT-QUEST: The Occupational Therapy Quality of Experience
and Spirituality Assessment Tool.” The summary chapters include “Performance-Based
Assessments and Neuropsychological Assessments: A Comparison,” “Assessments Used
Within the Model of Human Occupation,” and “Work-Related Assessments: The Worker
Role Interview, Work Environment Impact Scale, and Assessment of Work Performance.”
There are 15 new assessments in this text and 1 assessment that was not included in the
second edition but is included in this edition. This assessment, the Kohlman Evaluation
of Living Skills, has been revised, updated, and received additional research to warrant
inclusion in this edition.
Each chapter includes the theoretical basis, including historical development, rationale,
and a literature review; a presentation of the research, including the statistical analysis;
the procedure about how the assessment is administered and materials needed; a presen-
tation of a case study if there is no research; and suggestions for further research. Each
author was asked to use language consistent with the current Occupational Therapy Practice
Framework: Domain and Process.
Spirituality has become an important part of the evaluation process in occupational
therapy. It is one of the client factors in developing client profiles and is a part of the
holistic triad. The chapter entitled “The OT-QUEST: The Occupational Therapy Quality
of Experience and Spirituality Assessment Tool” is updated, and a summary chapter on
“Spiritual Assessments in Mental Health Occupational Therapy” was added.
 xx Preface

Traditionally, the last section included a chapter on research. This content now appears
as part of the Introduction in a chapter entitled “Evidence-Based Practice and Assessment
in Occupational Therapy.”
It has been 12 years since publication of the second edition. Since that time, there seems
to be increased development of assessments and research on previous ones. An increased
number of occupational therapists are practicing in mental health and are seeing the need
to develop new assessments and revitalize ones that have stood the test of time. There
have been assessments developed in the areas of interviewing; psychological, cognitive,
and sensory learning; daily living; and behavior. Specifically, there has been a plethora of
assessment development in psychological and cognitive areas. The Kawa (River) Model,
Routine Task Inventory–Expanded, Weekly Calendar Planning Activity, and Executive
Function Performance Test are just a few. One other assessment that has received attention
and is new to this text is the Allen Cognitive Level Screen–5 and Allen Diagnostic Module
(2nd Edition). This screening and assessment is one of those that was developed over the
years and is now appearing for the first time.
The pressure to develop assessments specific to occupational therapy is ever expand-
ing as a result of the need to demonstrate the effectiveness of practice. This is evident in
the development of assessments and research being conducted on those that need further
development. This is a compilation of current assessments that have appeared in journals,
reported in workshops, presented at conferences, obtained from unpublished manu-
scripts, and observed through use. Like the previous texts, this is a book for occupational
therapists by occupational therapists. It is hoped that practitioners will encourage students
to conduct research to facilitate further development of assessments in mental health.
—Barbara J. Hemphill, DMin, OTR, FAOTA
 Foreword
In this fourth edition of a classic work that has been used by occupational therapists
over many years, Barbara J. Hemphill and Christine K. Urish have provided us with a
comprehensive exploration of assessments used by professionals and students in mental
health. Updating the previous editions and concentrating particularly on research into the
validity, reliability, and applicability of the instruments discussed has provided us with
a thorough and timely approach to the understanding of people coping with mental ill-
ness and the formulation of necessary efforts to aid these clients in moving toward more
fulfilling lives. The text is primarily valuable for its practical usefulness to occupational
therapists, students, and others who wish to select and use these instruments.
Thanks to the editors themselves, this essential update to our information about these
mental health assessments will provide a guide to a range of available instruments and
will lead necessarily to their informed and appropriate use. Barbara Hemphill has a
long, ground-breaking, and honored career in teaching and publication in occupational
therapy. Her record in these regards is clear, and she continues to contribute to our knowl-
edge and understanding in valued ways. Christine Urish, a young leader in mental health
occupational therapy, has contributed as writer and editor and has helped to make the
current edition a thorough and useful work. Professor Urish is a member of the occupa-
tional therapy faculty at Drake University, Des Moines, Iowa.
This fourth edition introduces and provides a wider range of assessments and some
changes in organization but is primarily valuable for its breadth of content and its integra-
tion of a range of approaches used in mental health today. The section on the interviewing
process, a key beginning and important clinical skill, introduces new instruments and
their utility and applicability. The section on psychological assessments adds much new
material, including many cognitive assessments. These range from traditional and long-
established instruments to new and updated measures. Sensory assessment, a new contri-
bution to this work, reflects a long-established interest in how sensory competence adds
to mental health. The section on learning assessments, in this edition a total of six chap-
ters, represents new approaches and authors, as well as the latest version of the Kohlman
Evaluation of Living Skills and pertinent research on that measure. A section on behav-
ioral assessments also represents a new approach to this area, with some new authors and
emphasis on the Model of Human Occupation, occupation itself (an important concept in
current professional thinking), and assessments of life roles and the part they play in the
attainment of personally satisfying mental health. Spiritual assessments are given greater
attention in this edition, with a variety of approaches to investigating and incorporating
spirituality into practice. The final section of the book presents measures on balance in
life activities and attainment of life goals. Both of these approaches have been carefully
studied among students and the general public. Altogether, a major advance in current
thinking and its application are assembled in this work.
The features of the new edition, of this clear and polished work, that deserve the most
attention are its thoroughness and strength, and particularly its emphasis on research
findings as they apply to all included instruments. Occupational therapists, students, and
others who use it will find its valuable assets to be its comprehensiveness and its clear
applicability to their work.
—Marie-Louise F. Blount, AM, OT, FAOTA
 Part I
Introduction
 1

Assessment in
Occupational Therapy

Christine K. Urish, PhD, OTR/L, BCMH, FAOTA

Barbara J. Hemphill, DMin, OTR, FAOTA

Man, through the use of his hands, as they are energized by mind and will,
can influence the state of his own health.
(Reilly, 1962)

In 2017, the 100th year since the advent of the occupational therapy profession, the
authors believe it is important to historically review how this text has evolved and
how it has affected the occupational therapy profession. When The Evaluative Process in
Psychiatric Occupational Therapy (Hemphill, 1982) was first published, the author proposed
a method for assessing patients. It was a structure for selecting assessments based on
the ability of the therapist to identify patient dysfunction and progress. This structure
allowed the therapist to select and use assessments from a broad repertoire to achieve an
integrative view of patients with emotional disorders.
In stepping back, one must consider how business was conducted in the 1970s and
1980s; there was no email, so networking occurred at professional conferences. Contracts
were initially typed using a manual typewriter and then typed using an electronic type-
writer; the U.S. Postal System was used to send and receive legal documents. Fast forward
to 2017, and contracts are created via word processing software on a computer, sent to
authors for their signatures, scanned, and returned—all electronically. For this edition
of the text, the authors worked collaboratively with contributors from around the globe,
often electronically, sharing the same computer screen to edit the work contained within
this text.

Hemphill, B. J., & Urish, C. K. (Eds.). Assessments in

Occupational Therapy Mental Health: An Integrative Approach,
Fourth Edition (pp. 3-13). © 2020 SLACK Incorporated.
 4 Chapter 1

This text has grown widely since the first edition was published in 1982 and has
been called a motivator for other occupational therapy assessment texts, such as Asher’s
(2014) Occupational Therapy Assessment Tools, now in the fourth edition. In this chapter, we
will provide a historical overview of the concept of assessment through the examination
of several lectures by Eleanor Clarke Slagle, providing an overview of the occupational
therapy process using the Occupational Therapy Practice Framework: Domain and Process,
Third Edition (American Occupational Therapy Association [AOTA], 2014), which contains
the official terminology of the profession, as a guide. Within this chapter, the ethics of
evaluation and assessment are considered, the current practice in relation to occupational
therapy assessment and reimbursement is examined, and an overview of the major sec-
tions contained within the text is provided.

Assessment and Slagle Lectures

Since the profession began in 1917, many things have changed; however, one com-
ponent has remained consistent—the occupational therapist examines the client’s level
of function through the assessment of occupational performance limitations to plan
effective treatment. In the 2017 compendium of the Eleanor Clarke Slagle Lectures from
1955 through 2016, several lecturers specifically addressed the role of assessment and the
evaluative process in occupational therapy (Padilla & Griffiths, 2017), specifically, the
1983 Eleanor Clarke Slagle Lecture “Clinical Reasoning: The Ethics, Science, and Art” by
Joan Rogers (as cited in Padilla & Griffiths, 2017). Occupational therapy practitioners are
directed first to consider the assessment question “What is the patient’s occupational sta-
tus?” (Padilla & Griffiths, 2017, p. 267). In 1983, Rogers (as cited in Padilla & Griffiths, 2017)
directed the profession to work toward the development of assessment instruments to use
in clinical practice. This contributor’s work can be found in Chapter 20, “The Performance
Assessment of Self-Care Skills,” developed with Dr. Margo Holm.
In the 2000 Eleanor Clarke Slagle Lecture “Our Mandate for the New Millennium:
Evidence-Based Practice,” Margo Holm (as cited in Padilla & Griffiths, 2017) directed
occupational therapy practitioners to examine evidence-based practice. The mandate
of evidence-based practice continues to be present within the profession. Occupational
therapy practitioners must consider the best assessment tools to utilize during the evalu-
ation process, as well as what strategies to utilize for collecting the best evidence to con-
tinue moving the occupational therapy profession forward. Practitioners and researchers/
scholars must work collaboratively in the development of measurement tools to justify
and further define occupational therapy services to the broader population. In Chapter 2,
this text addresses the concept of evidence-based practice as it relates to assessments in
occupational therapy in mental health.
Moving forward in the professional literature, the 2008 Eleanor Clarke Slagle Lecture
“Embracing Ambiguity: Facing the Challenge of Measurement” by Wendy Coster (as
cited in Padilla & Griffiths, 2017) reminded the profession of the significant importance
of measurement in clinical practice as it relates to reimbursement implication; however,
the profession must be mindful to not lose sight of the whole person. Coster (as cited in
Padilla & Griffiths, 2017) directed the profession to “go beyond selecting instruments with
the best reliability or predictive accuracy, or the application of modern methods such as
Rasch analysis. We must also examine and challenge some of the assumptions underly-
ing the current use of measures and the conclusions being drawn from this use” (p. 591).
Coster (as cited in Padilla & Griffiths, 2017) further noted that occupational therapists
must be willing to attempt different strategies to capture the client’s story and offered
 Assessment in Occupational Therapy 5

the following assessments as options to accomplish this goal: Activity Card Sort (Chapter
6) and the Model of Human Occupation assessments, such as the Occupational Self-
Assessment (Chapter 16). An additional assessment (although not suggested by Coster)
for consideration is the Kawa (River) Model assessment (Chapter 9). Lastly, Coster (as
cited in Padilla & Griffiths, 2017) encouraged occupational therapy practitioners to exam-
ine research or systematic reviews that concluded that therapeutic intervention “does not
improve function” (p. 599) because practitioners need to critically consider the outcome
measures utilized and determine whether the study examined more than basic physi-
cal function and to challenge study results due to the holistic nature of the occupational
therapy profession.
Within the past decade, two Eleanor Clarke Slagle Lectures have addressed the impact
of assessment on the profession of occupational therapy. Glen Gillen’s (as cited in Padilla
& Griffiths, 2017) 2013 lecture, “A Fork in the Road: An Occupational Hazard,” challenged
occupational therapy practitioners regarding how cognition was being measured. Clients’
lives and occupations are complicated, and as such Gillen (as cited in Padilla & Griffiths,
2017) suggested that occupational therapists “stop trying to convince ourselves and our
colleagues we can predict occupational performance from non-occupation based assess-
ments” (p. 692). Gillen shares further insights into cognitive assessment in the current
text in Chapter 10. The other Eleanor Clarke Slagle Lecture indirectly related to assess-
ment was the 2014 address given by Maralynne Mitcham (as cited in Padilla & Griffiths,
2017) entitled “Education as Engine.” Within this lecture, Mitcham (as cited in Padilla &
Griffiths, 2017) directed the profession to consider “education as a product, learning as a
process, and living as progress” (p. 708).
The current text embraces the notions purported by Mitcham (as cited in Padilla &
Griffiths, 2017). This text never intended to suggest or direct occupational therapy practi-
tioners toward one assessment over another. Rather, the text offers occupational therapy
practitioners the opportunity to critically examine assessments that are utilized within
the profession to foster education and best practice: the learning process. As occupational
therapy practitioners, we can demonstrate benefits to society and our clients through the
education process, lead change and learning in clients’ lives through therapeutic interven-
tion, demonstrate the power of the life journey when we engage in actions that improve
conditions for our clients, create lives of meaning, and transform that which is within our
hands. The occupational therapy process, which includes client assessment, is a key to the
journey of positive occupational engagement, performance, and living.

Assessment and
Occupational Therapy Practice Framework
The start of the occupational therapy process begins with the evaluation. The
Framework (AOTA, 2014) presents the professional terminology utilized by occupational
therapy practitioners and defines the domain of concern within the profession: occupa-
tion. The occupational therapy practitioner begins by conducting an occupational profile.
The Framework (AOTA, 2014) defines the occupational profile as “the initial step in the
evaluation process, which provides an understanding of the client’s occupational history
and experiences, patterns of daily living, interests, values, and needs. The client’s reasons
for seeking services, strengths and concerns in relation to performing occupations and
daily life activities, areas of potential occupational disruption, supports and barriers, and
priorities are also identified” (p. S10). Chapter 3 in this text provides insights into the
occupational profile.
 6 Chapter 1

Based on information gathered within the occupational profile, the occupational

therapy practitioner moves to analyze the patient’s occupational performance.
This [is the] step in the evaluation process during which the client’s assets and
problems or potential problems are more specifically identified. Actual perfor-
mance is often observed in context to identify supports for and barriers to the
client’s performance. Performance skills, performance patterns, context or envi-
ronment, client factors, and activity demands are all considered, but only selected
aspects may be specifically assessed. Targeted outcomes are identified. (AOTA,
2014, p. S10)
The occupational therapy practitioner considers all areas of occupation. An assess-
ment included in this text, Creative Participation Assessment, considers all areas across
the occupational therapy process (Chapter 8). Although it may appear that the occu-
pational therapy process is linear in nature, the evaluation process serves to direct the
intervention plan and its implementation and to review its progress toward targeted out-
comes; however, the occupational therapist may return to reassess an area of occupational
performance at any time during treatment. Effective assessment of a client’s occupational
performance is essential to the planning and implementation of therapeutic intervention
(AOTA, 2014). Within the analysis of occupational performance, the occupational therapy
practitioner may use multiple methods to assess the client, environment or context, occu-
pation and occupational performance. The Framework (AOTA, 2014) suggested that stan-
dardized assessments are preferred when available to facilitate the collection of objective
data impacting various aspects of occupation and performance. The occupational thera-
pist is directed to use valid and reliable instruments to facilitate identification of client
needs and to justify and support the necessity of therapeutic intervention. Occupational
therapy practitioners choose assessments taking into consideration the client needs and
beliefs and potential assumptions that underlie occupational performance, in addition to
the practitioner’s theoretical approach and access to psychometrically sound standardized
measures (AOTA, 2014).

Assessment and Ethics

Assessment in occupational therapy is utilized in clinical practice and in research.
Assessment can impact reimbursement and occupational therapy services available to the
client. As such, occupational therapy practitioners need to be aware of the ethics that gov-
ern the profession of occupational therapy (AOTA, 2015). The Occupational Therapy Code of
Ethics (AOTA, 2015) is a document reviewed and updated by the AOTA on a regular basis.
It is the responsibility of the occupational therapy practitioner to be aware of and follow
the Code of Ethics (AOTA, 2015) at all times.
The standards of conduct within the Code of Ethics (AOTA, 2015) that relate to the
evaluation process include the following: beneficence, autonomy, justice, veracity, and
fidelity. In the area of beneficence, occupational therapy practitioners are directed to
provide appropriate evaluation to meet client needs. Further, assessments are utilized
that are evidence based, current, and relate to the current scope of occupational therapy
practice (AOTA, 2015). The concept of autonomy directs the occupational therapy practi-
tioner to allow the client choice. In the area of assessment, the client is free to participate
or refuse to participate in any part of the assessment process. The occupational therapist
should explain the nature and purpose of the evaluation process, as well as the necessity
of the assessment being administered to the level of client understanding, to facilitate
 Assessment in Occupational Therapy 7

understanding of the process and the importance of assessment in effective treatment

planning and intervention implementation (AOTA, 2015). Justice guides the occupational
therapy practitioner to possess credentials necessary for the administration of specific
assessments, such as the Assessment of Motor and Process Skills discussed in Chapter
10, as well as to refrain from engaging in duplication/copying of assessment materials
that would infringe on copyright of the assessment materials. Within the area of verac-
ity, occupational therapy practitioners are required to report assessment results in an
accurate manner. Occupational therapists must communicate in a truthful manner at all
times because the client has a right to accurate information regarding the results of the
assessment(s) conducted. Furthermore, occupational therapy practitioners must represent
credentials and/or qualifications to administer specific assessments in an accurate man-
ner. Occupational therapy practitioners are required to maintain professional competence
in all areas of occupational therapy practice, including assessment. From the perspective
of fidelity, the occupational therapy practitioner is required to address incompetence or
impaired clinical practice that could jeopardize the safety of the client(s). For example, if
one occupational therapist observes a colleague who is impaired due to an addiction, has
been administering assessments for which he or she does not possess the requisite creden-
tials, or has been reporting assessment outcomes inaccurately, the occupational therapist
has a responsibility to address the behavior of his or her colleague (AOTA, 2015). Nearly
every standard of conduct can be addressed during the evaluation process and through
the use of assessments in occupational therapy. Within the changing landscape of health
care, occupational therapists need to be ever aware of professional roles and responsibili-
ties and engage in ongoing professional activity to maintain clinical competence.

Assessment and Current Health Care Climate

Coding for occupational therapy evaluation and reevaluation was updated as of
January 1, 2017. However, because health care is in a constant state of change, the occu-
pational therapy practitioner is directed to the American Medical Association’s Current
Procedural Terminology (CPT) manual for current information (AOTA, 2017). The change in
coding was designed to distinguish different levels of evaluation. This action was advo-
cated by the AOTA to reflect current occupational therapy practice. The new evaluation
codes (97165, 97166, 97167) reflect low, moderate, and high complexity. One reevaluation
code, 97168, was also included in the updated coding system (AOTA, 2017). The CPT man-
ual identified that occupational therapy evaluations must include an occupational profile
(see Chapter 3). The updated coding system assists the occupational therapy practitioner
in communicating the complete scope of occupational therapy practice and in promoting
the distinct value of the profession (AOTA, 2017).
In determining which code to assign, the occupational therapy practitioner must criti-
cally examine three elements: (1) occupational profile and history, (2) assessment of occu-
pational performance and identification of deficits, and (3) clinical decision making. The
occupational therapist must ensure that the code chosen ethically represents the patient
condition, the analysis of the occupational therapist, and the assessment/identification of
the client’s performance concerns and goals (AOTA, 2017). For the therapist to code the
client at moderate level of complexity, all three areas must be moderate; if one area is low,
then the client would be coded low.
First, the occupational therapist considers the occupational profile and history. The
key words in choosing a level for this area are the following: brief (low), expanded (mod-
erate), and extensive (high). When the occupational therapy practitioner conducts a brief
 8 Chapter 1

history and review of medical or therapy records relating to the presenting problem, the
code is considered low. An expanded history includes a review of the physical, cognitive,
and psychosocial history related to current functional performance. An extensive history
includes an additional review of these areas as related to current functional performance.
Second, the occupational therapy practitioner conducts an analysis of occupational
performance of the client. An assessment that identifies one to three performance deficits
that emanate in activity limitations or participation restrictions would be considered low
complexity (AOTA, 2017), with three to five performance deficits indicative of moderate
complexity and five or more performance deficits defined as high complexity. Levels of
assessment are also considered related to the complexity of the assessment from the per-
spective of data collection and analysis. Analysis of data from problem-focused assess-
ment is defined as low complexity, detailed assessment is moderate complexity, and com-
prehensive assessment is high complexity (AOTA, 2017). CPT defines performance deficits
in this category as being physical, cognitive, and psychosocial in nature.
Last, the occupational therapy practitioner considers what skills were utilized and
what aspects of the client affected the decision-making intensity. Within the area of clini-
cal decision making, the following key words are considered: problem-focused assess-
ment and limit number of treatment options. The finding that a modification of tasks or
assistance was not necessary would yield a low complexity code. Moderate complexity
relates to a detailed assessment and the consideration of several treatment options and a
modification of the task or assistance with assessment was necessary; the client may or
may not present with comorbidities. High complexity relates to a comprehensive assess-
ment with consideration of multiple treatment options and a significant modification of
tasks or assistance to facilitate the completion of the evaluation (AOTA, 2017).
Although it may appear the new coding system is complex and challenging, the pro-
cess is clear, and requirements are provided for occupational therapists to identify and
justify within documentation of the evaluation process (AOTA, 2017). Within the ever-
changing health care climate, occupational therapy practitioners must utilize measures
that are reliable and valid and must be able to assess the quality and value of therapeutic
services across a variety of clinical practice settings (Leland, Crum, Phipps, Roberts, &
Gage, 2015). The sections that follow describe how assessments are organized within the
text.

Psychological Dimension
The psychological dimension, the first dimension, “is the ability to process informa-
tion from past events and information currently available … to view one’s self, others, and
one’s life situation realistically. The psychological dimension is influenced by and derived
from the emotions and feelings of the human experience” (Krishnagiri, 2000). Krishnagiri
(2000) would include the cognitive aspects of the human in this dimension, but this author
prefers to include it in the learning dimension. This is an arbitrary division and only
serves to describe testing procedures. In the psychological dimension, Azima and Azima
(1959), Fidler (1982), and Mosey (1996) have proposed testing procedures. To support the
assessment tool theoretically, theories of Freud (1976), Jung (1954), Maslow (1954), and
Rogers (1951) are utilized.
Mosey (1996) coined the term object relations to describe a person’s relationship to
people and occupation—the person’s ego function. This part of the patient’s psyche helps
therapists identify patient needs and body image and to gain insight. Other psychological
functions, such as reality contact, intrinsic gratification, body concept, decision making,
 Assessment in Occupational Therapy 9

problem solving, and social relationships, are evaluated. The most effective methods for
evaluating these occupational performances are with projective media, such as painting
or pencil drawings. The occupational performances in the psychological dimensions can
be measured with projective media. The focus is on completion of a task, not on analyz-
ing symbolic content. Although the patient is able to project his or her unconscious needs
into symbolic images, it is the responsibility of the therapist to observe the manner in
which the task is completed. Viewing the patient in action is valuable when observing
how patients express their innermost needs, feelings, and emotions onto the environment.
Projective assessments were developed previously by Azima and Azima (1959), Fidler
(1982), Shoemyen (1982), and Hemphill-Pearson (1999), but little has been done to advance
their use. Other assessments are the Goodman Battery (Evaskus, 1982), Lerner’s (1982)
Collage Scoring System, and Build a City (Clark, 1999).
Frequently, the use of projective media will facilitate the expression of religious con-
tent. Allowing the patient to express his or her faith tradition is a means by which the
therapist can assess the patient’s level of spiritual development and his or her concerns
about the relationship between his or her disability and faith tradition. In evaluating a
mentally ill patient where religious content is presented, it is important for the therapist to
distinguish between a mystical experience and religious delusions. Mystics describe their
experience as ecstatic and joyful. When they express their experience, the words serenity,
wholeness, transcendence, and love are used. Persons with psychosis are often confused and
frightened by the religious hallucinations, which are distressing and often accompanied
by an angry God. Both mystics and persons with psychosis experience what appears to
be a break from reality. For mystics, this period of withdraw is welcomed. However, when
the period ends, they return to normal activity. For the person with psychosis, the with-
drawal from reality is involuntary. Delusions can last for years and result in driving the
individual into deeper distress. Mystics are often respected members of the community
(Newberg, D’Aquili, & Rause, 2002). Another difference is in how each interprets his or
her religious experience. Persons with psychosis may have feelings of religious grandios-
ity and an inflated egotistical importance. They may think they have messages from God
or have some spiritual powers. In contrast, mystics experience a state of calm, a loss of
pride, and the emptying of the self.

Behavioral Dimension
The second dimension is the behavioral dimension. It draws on the theories of cogni-
tive, behavioral, social, and learning sciences. Techniques such as reinforcement, model-
ing, token economies, desensitization, biofeedback, and stress management are used as
treatment principles. The body of knowledge from occupational therapy literature comes
from the writings of Fidler and Velde (1999), Kielhofner (1999), Mosey (1996), and Reilly
(1962). In the behavioral dimension, the therapist is concerned with the role the environ-
ment plays in the acquisition of behavior for occupational performance. It is important in
this dimension to consider the patient’s behavior in the context of the environment.
The patient’s environment (life space) and the patient’s lifestyle are analyzed (Chapter
29). The patient’s life space includes the expected environment. For example, it is impor-
tant to know if the patient is homeless, comes from the inner city, a rural area, or a
middle-class neighborhood. The patient’s lifestyle (race, ethnic background, value system)
influences the assessment process. Combined, the patient’s lifestyle and life space can
influence the acquisition of behavior. For example, an assessment that is culturally biased
will not give a true picture of the patient’s disabilities or abilities.
 10 Chapter 1

Social interaction process, based on the principle that socialization is a developmental

process that results from classical conditioning, is assessed in the behavioral dimension.
In this dimension, socialization is not a skill but rather an occupation that an individual
acquires through interaction with the environment. The occupations of communication
and group interaction are attributes evaluated in this dimension. It is important to iden-
tify any environmental barriers that are prohibiting the performance of the activity.
The assessment is generally done by taking a patient’s history using interviewing
techniques and checklists. Assessments such as the Interest Checklist (Matsutsuyu, 1983),
Occupational Role History (Florey & Michelman, 1982), Life Style Performance Profile
(Fidler, 1982), Activity Configuration (Spahn, 1965), Adolescent Role Assessment (Black,
1976), History Interview (Henry & Mallinson, 1999), and The Barth Time Construction
(Barth, 1988) are used to assess the behavioral dimension. The assessments based on
the Model of Human Occupation are included in this dimension. Included in this text
are chapters on “The Assessment of Occupational Functioning–Collaborative Version”
(Chapter 17) and three summary chapters: “Assessment Used Within the Model of
Human Occupation” (Chapter 16), “Role Assessments Used in Mental Health” (Chapter
18), and “Work-Related Assessments: The Worker Role Interview, Work Environment
Impact Scale, and Assessment of Work Performance” (Chapter 24).
The behaviors that express the patient’s spirituality are included in this dimension.
Occupational performances such as religious attendance, praying, reading spiritual mate-
rial, attending spiritual groups, volunteering, and engaging in activities that have deep
spiritual meaning are expressions of a patient’s spirituality. Chapter 28, “The OT-QUEST:
The Occupational Therapy Quality of Experience and Spirituality Assessment Tool,”
assesses the spiritual performance of patients.

Learning Dimension
There are two differences between the behavioral and the learning dimension (the
third dimension). The first difference is the method of administration. Behavioral assess-
ments are administered by interview only or by interview and task performance. The
therapist is interested in learning what is hindering the patient from performing the
activity. Learning assessments are administered by task only. The therapist is interested
in the performance of a skill. It is important to actually observe the skill in context and
determine what is preventing the patient from performing the skill. The second difference
is the method of assessment. Learning assessments use scales or some other form of mea-
surement to compare scores, whereas behavioral assessments generally do not.
There are two factors that the therapist must be concerned with when using a learn-
ing assessment: the patient’s cognitive function and the patient’s level of skill develop-
ment. Cognitive functions have a direct impact on the patient’s performance—the ability
to learn. However, the therapist is interested in the performance of a skill, not how the
patient acquired the skill. Assessments that measure skill do not measure cognitive func-
tion; cognitive function is a biological dimension, not a skill function. Finally, the patient’s
developmental level must be related to the assessment or the task being performed. The
therapist cannot ask a 2-year-old to tie his or her shoe when the child is not developmen-
tally ready.
Functions that are assessed in the learning dimension are work skills, activities of
daily living, leisure, and social skills. It is most important that the assessment involve a
task that simulates a life skill. This is what distinguishes a learning assessment from all
other occupational therapy assessments. Even though the same functions appear to be
 Assessment in Occupational Therapy 11

assessed in the behavioral dimension, learning assessments are used by actually perform-
ing or simulating the skill. “The Performance Assessment of Self-Care Skills” (Chapter 20),
“The Comprehensive Occupational Therapy Evaluation” (Chapter 21), “The Independent
Living Scales” (Chapter 22), “Kohlman Evaluation of Living Skills” (Chapter 23), and
“The Test of Grocery Shopping Skills” (Chapter 25) are included in this dimension.
In the area of spirituality, the therapist needs to know the patient’s faith tradition to
understand the problems that might arise when teaching an occupational performance
that is influenced by that faith, such as dressing. For example, in some Amish traditions,
buttons are not used on clothing. Teaching a person who does not have buttons on his or
her clothing how to button would require some creative maneuvering.

Biological Dimension
The fourth dimension is the biological dimension. This area of assessment has
received the most attention and research. Its concepts can easily be observed and mea-
sured. In the psychological literature, it is referred to as the biomedical model. It asserts that
abnormality is an illness of the body. The Allen Cognitive Level Screen–5 in Chapter 11 is
an assessment that examines the level of cognition with the use of a leather-lacing project.
It has been rigorously examined to determine its reliability and validity.
There has been a series of research reporting a connection between spirituality and
the mind. The brain is a collection of “physical structures that gather and process sensory,
cognitive, and emotional data: the mind is the phenomenon of thoughts, memories, and
emotions that arise from the perceptual processes of the brain” (Newberg et al., 2002,
p. 33). The brain makes the mind. “Science cannot demonstrate a way for the mind to
occur except as a result of the neurological functioning of the brain” (Newberg et al., 2002,
p. 33). All that is meaningful in human experience and spirituality happens in the mind.
Studies have indicated that the limbic system is integral to religious and spiritual experi-
ence. It is the association between areas of the brain that is essential if the individual is
going to have a meaningful and spiritual life.
The association areas of the brain are structures that gather together or associate
neural information from various parts of the brain. The association areas eventually tap
into memory and emotional centers to allow the person to organize and respond to the
exterior world. For example, it has been suggested that the visual association area is active
in individuals who use images to help facilitate meditation or prayer. There are several
association areas in the cerebral cortex: visual, orientation, attention, and verbal. These
four association areas are extremely important in patient assessment. They relate to each
other and can affect the patient’s sense of self, emotional response to activity, and the abil-
ity to express religious beliefs. If an area of the brain is affected by trauma, stroke, depres-
sion, alcoholism, or drugs, the therapist needs to know the relationship to the patient’s
faith tradition.
For example, if a patient has a strong religious tradition that believes in using images
in worship, such as during communion, and the patient has an injury in the visual associa-
tion area, he or she will have difficulty relating to these images in recovery. These patients
will have trouble praying and using meditation. Damage in the orientation area will cause
trouble relating to mystical and religious experiences. The verbal association will make it
difficult for the patient to express his or her religious beliefs. This dimension within the
text is addressed in a chapter on “Spiritual Assessments in Mental Health Occupational
Therapy” (Chapter 27) as well as the “The OT-QUEST: The Occupational Therapy Quality
of Experience and Spirituality Assessment Tool” (Chapter 28).
 12 Chapter 1

Summary
In developing a client’s profile, the therapist gathers information from a wide variety
of sources. This includes information obtained from the client, the family, and his or her
medical, spiritual, and cultural history. This information can be obtained through stan-
dard and nonstandard testing, by interviewing the client, and from his or her environ-
ment. This chapter presented four dimensions that may be used to gather and integrate
information about patients in order to develop a profile. The integrative approach to
develop a client’s profile is based on a holistic triad—mind, body, and spirit. In an attempt
to present a holistic approach to assessments, spirituality was added to the discussion.
There is a suggestion that more than one assessment from competing frames of reference
can be used to achieve a holistic approach. Therefore, the integrative approach to patient
assessment draws on the concepts and philosophy of occupational therapy. The prin-
ciples in the Framework developed by the AOTA (2014) are the guidelines used during the
assessment process, and this chapter utilizes the Framework and integrates the language
of applying assessments to the evaluative process. Many of the assessments are currently
being developed, and it cannot be overemphasized that ongoing assessment development
and research in mental health is desirable.

References
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and
process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48.
American Occupational Therapy Association. (2015). Occupational therapy code of ethics. American Journal of
Occupational Therapy, 69(Suppl. 3).
American Occupational Therapy Association. (2017). New occupational therapy evaluation coding overview.
Retrieved from https://www.aota.org/~/media/Corporate/Files/Advocacy/Federal/Evaluation-Codes-
Overview-2016.pdf
Asher, I. E. (2014). Occupational therapy assessment tools (4th ed.). Bethesda, MD: AOTA Press.
Azima, H., & Azima, F. (1959). Outline of a dynamic theory of occupational therapy. American Journal of
Occupational Therapy, 8, 215.
Barth, T. (1988). Barth time construction. In B. Hemphill (Ed.), Mental health assessment in occupational therapy: An
integrative approach to the evaluative process (pp. 115-129). Thorofare, NJ: SLACK Incorporated.
Black, M. (1976). Adolescent role assessment. American Journal of Occupational Therapy, 30, 73-79.
Clark, E. (1999). Build a City. In B. Hemphill-Pearson (Ed.), Assessments in occupational therapy mental health: An
integrative approach (pp. 155-170). Thorofare, NJ: SLACK Incorporated.
Evaskus, M. (1982). The Goodman Battery. In B. Hemphill (Ed.), The evaluative process in occupational therapy (pp.
85-125). Thorofare, NJ: SLACK Incorporated.
Fidler, G. (1982). The lifestyle performance profile: An organizational frame. In B. Hemphill (Ed.), The evaluative
process in psychiatric occupational therapy (pp. 43-47). Thorofare NJ: SLACK Incorporated.
Fidler, G., & Velde, B. (1999). Activities: Reality and symbol. Thorofare, NJ: SLACK Incorporated.
Florey, L. L., & Michelman, S. M. (1982). Occupational role history: A screening tool for psychiatric occupational
therapy. American Journal of Occupational Therapy, 36, 301-308.
Freud, S. (1976). Psychical (or mental) treatment. In J. Starchey (Ed.), The complete psychological work. New York,
NY: W. W. Norton & Company.
Hemphill, B. J. (1982). The evaluative process in psychiatric occupational therapy. Thorofare, NJ: SLACK Incorporated.
Hemphill-Pearson, B. (1999). How to use the B.H. Battery. In B. Hemphill-Pearson (Ed.), Assessments in occupa-
tional therapy mental health: An integrative approach (pp. 139-152). Thorofare, NJ: SLACK Incorporated.
Henry, A., & Mallinson, T. (1999). The occupational performance history interview. In B. Hemphill-Pearson
(Ed.), Assessments in occupational therapy mental health: An integrative approach (pp. 59-70). Thorofare, NJ:
SLACK Incorporated.
Jung, C. (1954). Man and his symbols. Garden City, NY: Harper and Row.
Kielhofner, G. (1999). A model of human occupation: Theory and application (2nd ed.). Baltimore, MD: Williams &
Wilkins.
 Assessment in Occupational Therapy 13

Krishnagiri, S. (2000). Occupations and their dimensions. In J. Hinojosa & M. Blount (Eds.), The texture of life:
Purposeful activities in occupational therapy. Bethesda, MD: AOTA Press.
Leland, N. E., Crum, K., Phipps, S., Roberts, P., & Gage, B. (2015). Advancing the value and quality of occupa-
tional therapy in health service delivery. American Journal of Occupational Therapy, 69(1), 1-7.
Lerner, C. (1982). The magazine picture collage. In B. Hemphill (Ed.), The evaluative process in occupational therapy
(pp. 139-154). Thorofare, NJ: SLACK Incorporated.
Maslow, A. H. (1954). Motivation and personality. New York, NY: Harper and Row.
Matsutsuyu, J. (1983). The Interest Checklist. American Journal of Occupational Therapy, 23, 323-328.
Mosey, A. C. (1996). Psychosocial components of occupational therapy. New York, NY: Raven Press.
Newberg, A., D’Aquili, E., & Rause, V. (2002). Why God won’t go away. New York, NY: Ballantine Books.
Padilla, R., & Griffiths, Y. (Eds.). (2017). The Eleanor Clarke Slagle Lectures in occupational therapy 1955-2016: A
professional legacy centennial edition. Bethesda, MD: AOTA Press.
Reilly, M. (1962). Occupational therapy can be one of the great ideas of the 20th century medicine. American
Journal of Occupational Therapy, 16, 1-9.
Rogers, C. (1951). Client-centered therapy. Boston, MA: Houghton-Mifflin.
Shoemyen, C. (1982). The Shoemyen Battery. In B. Hemphill (Ed.), The evaluative process in psychiatric occupational
therapy (pp. 63-83). Thorofare, NJ: SLACK Incorporated.
Spahn, R. (1965). The patient gets busy: Change or process. Paper presented at the meeting of the American
Orthopsychiatric Society, New York, NY.
 2

Evidence-Based
Practice and Assessment in
Occupational Therapy
Christine K. Urish, PhD, OTR/L, BCMH, FAOTA

The conscientious, explicit and judicious use of current best evidence is

making decisions about the care of individual patients.
(Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p. 312)

During the 2000 Eleanor Clarke Slagle Lecture, lecturer Margo B. Holm directed
occupational therapy practitioners toward a mandate of becoming evidence-based prac-
titioners (Holm, 2000): “The fact that patient outcomes are improved with occupational
therapy services is no longer sufficient to justify our services, unless we can also explain
what we do and how we do it so that others can replicate our interventions and achieve
similar outcomes with comparable patients with like needs, wants, and expectations”
(Holm, 2000, p. 576). Although it has been nearly 2 decades since this lecture was given,
occupational therapists are continuing to address the importance of utilizing best evi-
dence to move the profession forward in research, education, and clinical practice. When
engaging in clinical decision making within clinical practice, occupational therapy prac-
titioners must consider their experience, the external scientific evidence available, and
the client’s situations and values (Brown, 2017). A study conducted in 2016 found that
occupational therapists practicing in mental health settings had a positive attitude toward
evidence-based practice (EBP); however, individuals with more clinical experience were
less positive in their attitudes toward EBP (Hitch, 2016). Hitch (2016) stated that advanced
qualifications (experience) may exert a more positive impact upon attitudes, but further
research was suggested.
Several official documents exist within the profession of occupational therapy that
illuminate the necessity for EBP. The Standards of Continuing Competence, developed by
the Commission on Continuing Competence and Professional Development, state that
occupational therapy practitioners are responsible for the integration of relevant evidence

Hemphill, B. J., & Urish, C. K. (Eds.). Assessments in

Occupational Therapy Mental Health: An Integrative Approach,
Fourth Edition (pp. 15-35). © 2020 SLACK Incorporated.
 16 Chapter 2

for the patient populations they serve and should demonstrate the ability to meet clients’
needs, as well as the demands of a dynamic profession (American Occupational Therapy
Association [AOTA], 2015b). The Standards of Continuing Competence further indicate that
practitioners are responsible for the synthesis and application of evidence from a variety
of sources, including collaboration with the patient in making clinical decisions (AOTA,
2015b). Lastly, the Standards of Continuing Competence directs practitioners to continually
update their performance based on the most current research and evidence available
(AOTA, 2015b).
The AOTA’s (2015a) Occupational Therapy Code of Ethics affirms the importance of EBP
in providing the best care possible to the client related to the concept of beneficence (i.e.,
to do good). Further, the Occupational Therapy Practice Framework: Domain and Process,
Third Edition (AOTA, 2014) directs practitioners to conduct analysis of occupational per-
formance as an evaluative step within the occupational therapy process. During this
phase of the occupational therapy process, the patient’s assets, problems, or potential
problems are identified. Performance skills, performance patterns, context or contexts,
activity demands, and patient factors are taken into consideration, and the practitioner
chooses areas of assessment based on these aspects. Specific patient outcomes are identi-
fied. On completion of the analysis of occupational performance, an intervention plan is
developed. Intervention is implemented and a review of the intervention is conducted
to ascertain progress toward targeted outcomes (AOTA, 2014). Therefore, assessment in
the occupational therapy process is a mechanism to identify patient functional limita-
tions and facilitate the development of an effective intervention plan, as well as to deter-
mine whether the intervention that was implemented was effective in the facilitation of
improved function and change in occupational performance. During this process, prac-
titioners are directed to use all available evidence from scientific, narrative, pragmatic,
and ethical aspects of clinical reasoning to facilitate the selection of assessments and the
gathering of evaluation data (AOTA, 2014). Assessments that are utilized during the evalu-
ation process should be valid and reliable and should illuminate the areas of occupational
performance in which the patient has limitations. Upon completion of assessment, inter-
vention approaches are chosen based on best practice and evidence. The intervention plan
is to be developed in collaboration with the patient, which is another aspect of the use of
EBP in occupational therapy. In intervention review, the intervention plan is reexamined,
and patient outcomes are considered to determine whether the plan should be modified
and intervention should be continued or whether occupational therapy services should be
discontinued or the patient referred elsewhere (AOTA, 2014).

What Is Evidence-Based Practice?

EBP in health care service delivery has been identified as an important consideration
in psychiatric occupational therapy that should be strengthened (Tsang, 2002). Further,
it has been suggested that occupational therapists speak up about their profession and
voice the positive outcomes and evidence that exist within the profession (Dickinson,
2003). Through presentation of evidence-based information about the profession of occu-
pational therapy, decision makers and patients may come to attach an increased value
for the services occupational therapy practitioners provide (Dickinson, 2003). EBP has
been defined within medicine by Sackett et al. (1996); however, the definition of EBP
within occupational therapy differs somewhat from the definition proposed by Sackett
et al. An evidence-based occupational therapy practice uses research evidence combined
with clinical knowledge and reasoning to facilitate clinical decision making regarding
 Evidence-Based Practice and Assessment in Occupational Therapy 17

what interventions are effective for specific clients (Law, Baum, & Dunn, 2017). The need
for EBP has come from an increased demand for accountability combined with ongoing
restraint in health care spending. These needs have facilitated an increased interest in the
use of research evidence within the practice of occupational therapy.
The desire for documented outcomes in health care is not a new concept (Foto,
1996; Fuller, 2011). Payers and policy makers continue to demand objective evidence of
treatment efficacy and cost effectiveness of occupational therapy services. Through the
utilization of EBP in occupational therapy, assessment of patient outcomes can provide
information regarding the outcomes of a variety of interventions and meet the needs of
payers and policy makers (Foto, 1996). Occupational therapy practitioners have a respon-
sibility to utilize an evidence-based perspective. Patients expect this kind of practice,
and, as a profession, we have an obligation to ensure we are providing the best practice;
furthermore, we need to demonstrate our ability to provide quality services that are of
value and provide the best outcomes at minimum cost (Law et al., 2017). The goal of EBP in
occupational therapy is to provide improved intervention to the patient that is supported
by assessments that are based upon solid evidence (Brown, 2017). Occupational therapy
outcomes in psychiatric occupational therapy need to be documented through research by
professionals outside of the discipline (Tsang, 2002). The benefit of research-based EBP is
that the knowledge obtained from critical review of research can facilitate change that has
the potential to expand the body of occupational therapy knowledge (Brown & Rodger,
1999). EBP in occupational therapy focuses on therapeutic practice that is valid and that
considers safety and value. EBP is not based solely on opinion, past clinical practice, or
precedent (Brown & Rodger, 1999).

What Is Not Evidence-Based Practice?

One problem in this area is that EBP has not been well-defined from a universal per-
spective. As a result, confusion may be present among researchers, practitioners, and pay-
ers (LaGrossa, 2003). Different individuals may feel strongly about one aspect or another
from an evidence-based perspective, and, as a result, subtle variations of terminology and
how terminology is utilized are present within the health care arena (LaGrossa, 2003).
EBP in occupational therapy does not mean that the practitioner sets aside his or her own
professional knowledge or expertise. Rather, EBP means that the practitioner focuses on
the integration and utilization of research knowledge in conjunction with clinical judg-
ment, expertise, and patient choice (Law et al., 2017). EBP does not mean that all patients
who come to receive occupational therapy services with similar occupational performance
concerns will be provided with the same assessment and intervention (Lim, Frater, &
Samaras, 2014). Another myth about EBP is that it is based entirely on research and fails
to take into consideration the occupational therapy practitioner’s knowledge, clinical judg-
ment, or expertise. EBP relies on the clinical knowledge and judgment of the practitioner
as one piece of the evidence in making clinical decisions (Lim et al., 2014). Research and
patient contributions are the other essential elements. The goal of EBP is to provide the
best care to the patient through thoughtful consideration and evaluation of all of the evi-
dence available and does not deny the clinical judgment and expertise of the occupational
therapy practitioner (Lim et al., 2014).
 18 Chapter 2

Goal of Evidence-Based
Assessment in Mental Health
The goal of EBP is to include the best evidence available for the assessment, interven-
tion planning, intervention implementation, and outcomes monitoring for each patient
who receives occupational therapy services. Ultimately, the goal is to provide patients
with the most appropriate intervention (Gutman, 2011). Improved function may follow
when the occupational therapy practitioner uses evidence to choose appropriate areas to
assess in each patient he or she is serving, plans interventions based on the outcomes of
the assessment, and considers the patient’s values, needs, and goals, along with the best
evidence available. Occupational therapy practitioners who work in the adult mental
health discipline were reported to be challenged integrating standardized assessment
measures to document effectiveness of occupational therapy services within daily prac-
tice (Fuller, 2011). One study found that 68.4% of Canadian occupational therapists used
one standardized assessment measure when working with individuals diagnosed with
depression and schizophrenia while providing inpatient and community-based care
(Rouleau, Dion, & Korner-Bitensky, 2015); this study also reported that the Canadian
Occupational Performance Measure (Chapter 4) was utilized most frequently across clini-
cal settings and diagnoses studied.

Improving Intervention Outcomes

Through Assessment/Intervention
When assessments are selected that have proven to be valid and reliable and are used
to facilitate the planning of intervention that has been proven to be effective, ongoing
evidence can be generated and added to the body of knowledge within the profession of
occupational therapy. This procedure would be described as best practice, and occupa-
tional therapy practitioners have an obligation to provide therapeutic intervention accord-
ing to best practice (Law et al., 2017).

Best Practice in Measurement

One of the most essential considerations with regard to EBP in occupational therapy is
the consistent use of outcome measures to evaluate services (Law et al., 2017). Information
from outcome measures facilitates decision making as to which programs and services are
most effective and adds to the body of knowledge, which builds evidence to support the
ongoing provision of occupational therapy interventions. Occupational therapy practitio-
ners are directed to “mine the gold” in considering what researchers in other disciplines
have found regarding how individuals interact with their environment to perform tasks.
This action can further the profession of occupational therapy through the development
of advanced thinking and clinical practices based on the critical review and analysis of
available research literature (Law et al., 2017).
Occupational therapy practitioners are directed to become systematic in the choice
and utilization of measures that formalize observation and interview data collected
within occupational therapy practice. Creating a systematic plan can assist other profes-
sionals in viewing the importance and necessity of occupational therapy services. When
others cannot understand the how and why of occupational therapy assessment and
 Evidence-Based Practice and Assessment in Occupational Therapy 19

intervention, our professional practice may be challenged as possibly unscientific or lack-

ing evidence rather than viewed from a formal professional evidence-based perspective
(Law et al., 2017).
The use of evidence in practice is essential due to the changes in service delivery,
funding mechanisms, and increased pressure to demonstrate service efficacy (Law et
al., 2017). Individuals who consume occupational therapy services are more informed
regarding their choices through the use of the internet and various media. This raises the
occupational therapy practitioner’s need to be knowledgeable of and provide evidence-
based assessment and intervention. Use of EBP provides a means for the occupational
therapy practitioner to stay current with regard to what is known about specific condi-
tions and problems. EBP offers the practitioner the opportunity to critique and apply
relevant research knowledge to clinical practice. Further, the use of EBP can facilitate
critical discussion with the service recipient and the patient’s care provider with regard
to various interventions. Through this action, the potential risks and benefits of various
intervention choices can be discussed and analyzed. Effectiveness of interventions can
be considered to determine whether changes should be instituted during the course of
therapy (Law et al., 2017).
When occupational therapy practitioners utilize measures that were developed by or
used within other disciplines, they must be extremely mindful of the need to articulate
how occupational therapy views problems or solutions differently than the other disci-
plines that may utilize these measures (Law et al., 2017). When occupational therapy prac-
titioners use measures that other professionals use but do not make explicit the significant
contribution of occupational therapy from an occupation-focused perspective, others
will be unaware of the important contribution that occupational therapists can make.
An example would be when considering the context of environment. Social workers may
consider environment but may be more concerned with addressing the social or cultural
concerns within the environment, whereas from an occupational therapy perspective, the
concern may be the physical and temporal features present within the environment that
may facilitate or hinder an individual’s performance (Law et al., 2017).
It is essential in the context of measurement that we practice from a patient-centered
perspective (Law et al., 2017). What this means in terms of assessment is that occupational
therapy practitioners need to identify assessments that illuminate the problems experi-
enced by the patient. Occupational therapy practitioners need to direct their resources
toward addressing specific concerns regarding the occupational performance raised by
the patient and the patient’s priorities. The assessments that occupational therapy prac-
titioners choose need to facilitate this process (Law et al., 2017). In considering possible
assessments to use, practitioners should first critique the measure in terms of its focus,
sensitivity to change, standardization, reliability, validity, strengths, and weaknesses, as
well as the overall relevance of the assessment to the problems the therapist wishes to
address with the patient.
Assessment from an EBP perspective provides a means for the occupational therapy
practitioner to provide information to the patient about what is known and what is not
known about the effectiveness of assessments and interventions. Rapport can be facilitat-
ed through this use of EBP. The therapist is in active dialogue with the patient concerning
the outcomes of an assessment and the appropriate interventions to be selected (Law et
al., 2017). Utilization of EBP facilitates a change in the role of the occupational therapist.
Occupational therapy practitioners are considered experts in their area of professional
knowledge; however, patients need to be considered because the individual who lives
the experience of functional limitation has an increased perspective and should not be
discounted from the process (Law et al., 2017). When including the patient in the EBP
 20 Chapter 2

process, information needs to be provided in a manner that the patient can easily under-
stand. Extensive use of professional terminology or jargon is not suggested. When using
an evidence-based approach, occupational therapy practitioners need to embrace the fact
that interventions may evolve from dialogue with the patient. This differs from previous
practice, which may not have included the patient in this discussion and in which the
therapist selected interventions in advance and in isolation from the patient’s input (Law
et al., 2017).

Searching and Evaluating the

Evidence in Assessment
Developing an effective search and evaluation strategy is an essential component
of the utilization of EBP (Tickle-Degnen, 1998). Further, being able to understand and
interpret different types of reviews (e.g., mixed methods review, systematic review, meta-
analysis review, rapid review, scoping review) are important skills for the occupational
therapy practitioner to possess (Unsworth, 2017).

How to Search for Best Evidence

The amount of professional literature available each month to occupational therapy
practitioners can make it seem daunting to try to stay current (Law et al., 2017). Colleges
or universities may offer assistance to clinicians by providing access to medical and
health literature resources, including print journals, online journals, and computerized
databases. Many resources exist on the internet to assist the occupational therapy practi-
tioner in the development of effective searching strategies (Bennett, 2017). To manage the
volume of resources available in the medical literature, occupational therapy practitioners
should consider establishing a surveillance strategy (Hall-Flavin, 2005). This means that
the practitioner chooses a small number of journals whose focus is central to his or her
daily clinical practice and reviews a limited number of more general health-related areas
(Hall-Flavin, 2005). Alternatively, if there are several therapists in a clinic who have an
interest in different areas of clinical practice, but who wish to stay as current as possible
with evidence-based literature, they could form a journal club. Using a journal club, occu-
pational therapy practitioners would report on the findings from their own reviews of the
literature and professional discussion could occur regarding the information obtained.
Through the use of this mechanism, therapists may be able to better manage the plethora
of information they are confronted with in their desire to seek out and consume research
information to facilitate EBP.
Collaboration is key to EBP (Coster, 2004), and occupational therapy practitioners
must collaborate. When a practitioner discovers a resource or new technique or procedure,
the practitioner has a professional duty to share this information with colleagues. Active
collaboration and sharing in this manner saves time and makes it so no one person feels
as if he or she is reinventing the wheel (Coster, 2004). One suggestion for the sharing of
knowledge is to develop an EBP tips sheet. When an individual identifies new information
that could be shared with others, he or she could record it on a sheet or form and then this
form is duplicated to share with all staff members.
Several EBP databases should be considered by occupational therapy practitioners
when searching for best evidence regarding potential assessments and interventions
 Evidence-Based Practice and Assessment in Occupational Therapy 21

Table 2-1
Available Websites and Databases for
Accessing Evidence-Based Research Literature
Name URL
American Occupational Therapy Association https://www.aota.org/Practice/Researchers/
Evidence Briefs Series practice-guidelines.aspx
(must be an AOTA member to access)
OTseeker (Occupational Therapy http://www.otseeker.com
Systematic Evaluation of Evidence)
PubMed https://www.ncbi.nlm.nih.gov/pubmed/
University of York http://www.york.ac.uk/inst/crd/crddatabases.
Centre for Reviews and Dissemination htm#DARE
Cochrane http://www.cochrane.org/index.htm
Bandolier http://www.bandolier.org.uk
National Guideline Clearinghouse https://www.thecommunityguide.org/resources/
national-guideline-clearinghouse
Open Access Peer-Reviewed Journals http://scholarworks.wmich.edu/ojot
(The Open Journal of Occupational Therapy; https://www.omicsonline.org/physicaltherapy-
Physical Therapy and Rehabilitation Journals) rehabilitation-journals.php
American Occupational Therapy Association https://www.aota.org/Practice/Researchers.aspx
Guidelines for Critically Appraised Paper

HighWire http://highwire.stanford.edu/lists/browse.dtl

they may use with patients. These databases are divided into two basic categories—
unscreened (unfiltered) and screened (filtered; Table 2-1). Unscreened databases contain
articles from journals that have not been screened according to a predetermined qual-
ity standard. Each journal has a peer-review process, and these reviews provide a pri-
mary quality check. MEDLINE and the Cumulative Index to Nursing and Allied Health
Literature (CINAHL) are databases that would fit into this category. Journal articles that
are accessed through these sources should be scrutinized by the practitioner to determine
the quality of the evidence contained within the article (Wong, Barr, Farina, & Lusardi,
2000). Screened databases are prefiltered, and articles are selectively chosen for inclusion
based on a minimum rating on a scoring system that addresses the scientific rigor of the
research. The Cochrane Library is an example of a screened database. Other databases
provide a synthesis and/or summarization of evidence and provide recommendations
related to clinical practice; OTseeker is an example. Clinical guidelines provide the occu-
pational therapy practitioner with recommendations that can be used to assist in clinical
decision making. Guidelines are developed by experts within any given field (Wong et al.,
2000). Systematic reviews and randomized controlled trials are important sources of data
utilized in the development of clinical guidelines. The Agency for Healthcare Research
and Quality has developed clinical guidelines in a variety of clinical areas. EBP reports in
psychiatry exist for mental health conditions and substance abuse (Agency for Healthcare
 22 Chapter 2

Research and Quality, 2017). When entering the phrase “occupational therapy and mental
health” into the National Guidelines Clearinghouse database, 73 related items were identi-
fied (National Clearinghouse Guidelines, 2017). Advantages and disadvantages to the use
of clinical guidelines exist (Roberts & Barber, 2001).
The usefulness of clinical practice guidelines in ongoing clinical practice should be
critiqued by occupational therapy practitioners (Stergiou-Kita, 2010). Clinical practice
guidelines may be easier to use with some areas of practice than with others. Guidelines
are just that; they may not provide the specific, straightforward solution that the practitio-
ner desires (Roberts & Barber, 2001). Most of the developed guidelines for medicine and
nursing are for specific conditions. However, when providing intervention for individuals
who present with complex and multiple disabilities, the use of clinical practice guidelines
may not be as straightforward as the practitioner would like (Roberts & Barber, 2001).

Evaluating the Evidence

Once studies have been obtained or guidelines secured, occupational therapy practi-
tioners are directed to ask specific questions that can facilitate the review and evaluation
of information obtained (Tickle-Degnen, 1998). When researching the literature, if meta-
analysis is available, one should attempt to secure research articles of this nature. A meta-
analysis can potentially save time because it summarizes the statistical findings from a
large number of individual research studies. Research participants in the studies selected
for review need to be critically examined to determine whether they are similar to the
patient for whom the occupational therapy practitioner will be assessing and providing
intervention (Tickle-Degnen, 1998). Next, the assessment or intervention presented in the
article needs to be considered. Would it address the functional concerns of the patient in
the area of assessment or the needs and attributes of the patient in the area of interven-
tion? Then, the assessment or intervention should be considered for practicality. Is the
assessment practical to administer in the practitioner’s setting in terms of resources of
time, funding, personnel, and equipment? Does it possess good reliability and validity?
Lastly, is the outcome obtained from the intervention one that the occupational therapy
practitioner intends to work toward with the patient for whom he or she is providing
intervention (Law et al., 2017)? In considering all of these areas, the occupational therapy
practitioner must also consider the level of evidence provided by the research.
Because occupational therapy practitioners were concerned about the application of
Sackett et al.’s (1996) levels of evidence related to occupational therapy research evidence,
the AOTA developed a classification system to address these concerns. The classifica-
tion system being used by the AOTA within the evidence-based literature review proj-
ect includes a level of evidence coding format that takes into consideration the design,
sample size, internal validity, and external validity of a study to assign a level of evidence
(Liberman & Scheer, 2002). Level of evidence for research design is coded as follows:
• Randomized controlled trial is considered level of evidence I.
• Nonrandomized controlled trial with two groups is level of evidence II.
• Nonrandomized controlled trial with one group addressing one treatment condition,
with a pre-test and post-test, is considered level of evidence III.
• A research study with a single subject design is level of evidence IV.
• Narratives and case studies are identified as NA in the level of evidence for the
research design (Liberman & Scheer, 2002).
 Evidence-Based Practice and Assessment in Occupational Therapy 23

The sample size of a study also receives a rating. Studies with greater than 20 par-
ticipants per condition (experimental and control) receive a level of evidence rating of A.
Studies with fewer than 20 participants per condition receive a level of evidence rating of
B. A 3-point system has been identified for rating internal validity within a study. Level I
is assigned to studies with high internal validity that demonstrated no alternative expla-
nation for the outcomes obtained within the study. Level II is assigned to studies with
moderate internal validity in which the study attempted to control for a lack of random-
ization. Level III is assigned to studies that demonstrated low internal validity, as when
two or more serious alternative explanations could be provided for the outcome obtained
within the study (Liberman & Scheer, 2002).
External validity is evaluated as well. Studies that present a high level of external
validity, in which participants represent the populations and interventions were represen-
tative of current practice, receive a level of evidence rating of a. Moderate external validity
in a study is assigned a level of evidence rating of b. Low external validity rating, in which
the sample was heterogeneous and one is not able to ascertain whether the outcomes pre-
sented within the study were similar for all diagnoses or the intervention provided does
not reflect current practice, receives a level of evidence rating of c (Liberman & Scheer,
2002).
Therefore, a study with a level of evidence rating IA2a would be a randomized con-
trolled trial with greater than 20 participants per conditions with a moderate level of
internal validity and a high level of external validity. Although disagreements exist from a
variety of different disciplines regarding levels of evidence, there are interventions being
utilized widely within clinical practice in psychiatry that have not been supported by
research (Torrey et al., 2001).

Process of Evidence-Based Practice

The ability to obtain research information to facilitate EBP can be developed through
the formation of partnerships with patients, service providers, researchers, payers, and
policy makers, as well as in the educational curriculum (Moyers & Finch-Guthrie, 2016;
Stube & Jedlicka, 2007). The changing nature of mental health services places occupa-
tional therapy practitioners at a crossroads, needing to be able to clearly demonstrate
the effectiveness of the services being provided. As a result, it is increasingly important
for occupational therapists to know how to engage in the process of searching for best
evidence to assist them in selecting and implementing the most effective interventions
in practice (Lloyd, Bassett, & King, 2004). There are five steps to utilizing an evidence-
based approach in occupational therapy practice. These steps, in conjunction with patient
collaboration and the practitioner’s clinical reasoning skills, form the basis for evidence-
based occupational therapy practice (Bennett & Bennett, 2000; Brown, 2017):
1. Formulating clinical questions
2. Searching the literature and sorting the evidence
3. Critically reviewing and appraising the evidence
4. Applying applicable findings to practice
5. Evaluating the effect/outcomes: Reassessing the evidence-based practice process
 24 Chapter 2

Formulating Clinical Questions

Questions that arise from everyday clinical practice related to therapy, prevention,
etiology and harm, diagnosis, prognosis, and economic analysis can become the basis of
a clinical question. The key to effective searching of electronic evidence available on the
internet and through electronic databases is the formulation of a clear question (Bennett
& Bennett, 2000; Brown, 2017). Questions can relate to assessments or to intervention
effectiveness or can be descriptive to the gathering of more information about patients
with specific occupational performance limitations (e.g., what is the effectiveness of occu-
pational therapy in the context of recovery model in the areas of community integration
for adults with severe and persistent mental illness; AOTA, 2011). Another example ques-
tion is “Do older adult women in the community with depression experience a difference
in activity participation from those who are not diagnosed with depression?” (Tickle-
Degnen, 2000). The occupational therapy practitioner may wish to gain information on a
variety of different types of evidence in addition to the usefulness of an assessment. Other
questions may include those related to the efficacy of an intervention, the description of a
condition, the clinical outcome prediction, and the individual lived experience of a client
(Brown, 2017). An effective method for the development of a clinical question is the use
of patient/problem/population, intervention, comparison of intervention, and outcome
(PICO). Examples of questions are:
P: How could a practitioner describe a group of patients similar to the patient I am
interested in securing information about?
I: What intervention am I considering for use?
C: What is the alternative to the intervention I have identified, or what is another
intervention for which I would like to make a comparison?
O: What is the outcome I would like to measure? What improvement is desired
(UIC: University Library, 2017)?
An example of an intervention effectiveness question could be the following: “What
are the most effective interventions for increasing participation in satisfying daily life
activities among elderly women with depression who live in the community?” (Tickle-
Degnen, 2000, p. 103). Another approach is a PICOTT (Medical University of South
Carolina, 2017). The TT added at the end of PICO are acronyms for the type of question
(i.e., diagnosis, therapy, prognosis, etiology/harm, prevention) and for the type of study
design (e.g., randomized controlled trial, cohort study, case series). Therefore, instead of
stopping at PICO, some occupational therapy practitioners may choose to be more specific
with PICOTT.

Searching the Literature and Sorting the Evidence

Searching the literature was addressed earlier in this chapter. Planning a search
strategy through development of a PICO or PICOTT and then keeping a record of the
databases searched and the terms utilized is an effective strategy. If occupational therapy
practitioners do not have access to medical and health databases through their place of
employment, making connections with colleges and universities may yield access to these
resources. Some colleges and universities may welcome partnering with practitioners
(Moyers & Finch-Guthrie, 2016). Students enrolled in educational programs need to learn
research strategies and may be available as a resource to access the resources desired and
present their findings.
 Evidence-Based Practice and Assessment in Occupational Therapy 25

Considering the level of evidence and the type of research findings that relate to the
PICO or PICOTT question posed is key. The occupational therapy practitioner needs to
be able to effectively rank the research evidence that was available and the ability of the
research to answer the PICO or PICOTT question. Secondary evidence through systematic
reviews and meta-analysis studies can provide the practitioner with a good deal of infor-
mation that has been summarized and possibly simplified to provide a trustworthy pre-
sentation of previously conducted research in a specific area of interest (Unsworth, 2017).

Critically Reviewing and Appraising the Evidence

To effectively critique the evidence obtained, occupational therapy practitioners may
need to update their research knowledge. Understanding various research designs, meth-
odologies, and statistics will facilitate the effective review and appraisal of available evi-
dence. In appraising the available evidence, the power of a research study, randomization,
and clinical significance need to be considered. To determine whether an intervention was
effective, one must consider whether the number of participants who participated in the
study was sufficient to determine statistical significance or the power to detect change
(Bennett & Bennett, 2000; Brown, 2017). Random assignment is an important consider-
ation when examining the causal relationship between the intervention and the outcome
obtained. Statistical significance is most commonly established such that a 95% likelihood
exists that the effects obtained were due to the intervention, with a 5% likelihood that
the results were due to chance. Clinical significance assists the therapist in examining
the results from a different perspective and may seem more practical to the occupational
therapy practitioner. Results that do not indicate statistical significance may be deemed
clinically significant if some change, but not a statistically significant change, occurred.
Some occupational therapy practitioners have expressed concern with regard to the inter-
pretation of statistics contained within research papers. The internet is a helpful resource,
containing statistical tutorials. Journal articles such as “How to Read and Understand
a Scientific Paper: A Step-by-Step Guide for Non-Scientists” (Raff, 2014), “How to Read
a Paper: Statistics for the Non-Statistician I: Different Data Need Different Statistical
Tests” (Greenhaigh, 1997a), and “How to Read a Paper: Statistics for the Non-Statistician
II: Significance, Relations and Their Pitfalls” (Greenhaigh, 1997b) could be of great assis-
tance. Critical examination of the rigor of the study design, outcome measures chosen to
examine the variable of interest, level of evidence, sample size, and internal and external
validity need to be considered when reviewing the evidence (Brown, 2017).
Occupational therapy practitioners can also ask themselves the following questions to
facilitate review of literature (Bennett & Bennett, 2000; Tickle-Degnen, 1998):
• Were the participants in the research similar to the patient or patients for whom infor-
mation is being reviewed?
• Did the intervention presented in the study meet the needs of the therapist and the
patient?
• Was the intervention in the study practical to implement in terms of time, money,
equipment, and required personnel in comparison to other intervention options?
• Was the outcome that was measured an outcome that was identified as important and
desired by the patient?
 26 Chapter 2

Applying Applicable Findings to Practice

It is important that occupational therapy practitioners collaborate to collect and share
research evidence and strategies that have proven successful to change practice. Success
in this area will assist in ensuring good quality and effective services to patients (Roberts
& Barber, 2001). Once research findings have been obtained and reviewed, application of
these findings depends on patient factors and problems, practitioner clinical reasoning
and expertise, and institutional factors (Brown, 2017). During this step of the process,
ongoing and effective communication with the patient is significant. Information needs
to relate to the patient’s needs and concerns and be presented in a clear manner (Tickle-
Degnen, 1998).

Evaluating the Effect/Outcomes:

Reassessing the Evidence-Based Practice Process
The last step of the process is the evaluation of the entire process. Examination of
the procedures undertaken and reflection on the effectiveness or ineffectiveness of the
process can facilitate changes and improvements that could be implemented (Bennett &
Bennett, 2000).
It was reported that education-based approaches that incorporated methods to
improve the clinician’s knowledge and skills, in addition to an organizational approach
that facilitated collaboration, teamwork, and effective leadership, were effective for imple-
menting EBP (Stube & Jedlicka, 2007). In considering professional development and to
begin incorporating EBP into one’s clinical repertoire, one should allocate time for reflec-
tion on the patients and current practice. Keeping a notebook of the clinical questions
that arise during assessment and intervention can be one method of facilitating reflection
regarding clinical practice. Ongoing search of the literature for information on trends in
evidence for occupational therapy in mental health can be helpful and provide insight
and significant overview for the future direction of the occupational therapy practitioner
(Hitch, Pepin, & Stagnitti, 2015).
Collaboration with colleagues on setting clinic priorities and working with one
another to share knowledge and research resources is a good suggestion to foster collabo-
ration and interprofessional EBP (Finch-Guthrie, 2016). Practitioners are directed to access
quality information and use their skills to critically appraise the information obtained.
Some practitioners may need to attend continuing education courses to increase their
knowledge of research design and bias to increase their ability to determine the quality
of the information available.
Practitioners should identify their current practice and compare this practice with a
benchmark (Menon, Korner-Bitensky, Kastner, McKinnon, & Straus, 2009). In consider-
ing where their practice is and where they would like it to be, practitioners are directed
to develop an improvement plan that is reasonable and doable. In consideration of their
plan for change, practitioners must identify barriers to making the change and determine
how these barriers can be overcome. Development of a plan for ongoing education can
include taking continuing education courses, participating in a clinic-based journal club,
completing critically appraised topics on the most recently published research literature,
and reviewing critically appraised topics and disseminating this information to clinic
colleagues. Practitioners are encouraged to consistently and continually reassess their
progress (Menon et al., 2009). Are the assessments chosen yielding valid and reliable
results? Are the interventions planned and implemented proving to be effective based on
outcomes data?
 Evidence-Based Practice and Assessment in Occupational Therapy 27

Evaluating Evidence Using the

Canadian Occupational Performance Measure
Research for literature assessing the Canadian Occupational Performance Measure
(COPM; Chapter 4) was conducted online via PubMed and CINAHL. This research
yielded a clinical review of the instrument published in 2004 (Carswell, McColl, Baptiste,
Law, Polatajko, & Pollock). In addition, a manual search was conducted to secure articles
that addressed the COPM that were not included within the database. Articles were con-
sidered for this review if the COPM was identified in the article title or abstract and if the
article addressed one of the following: (1) the psychometric properties, (2) contribution
to research outcomes, or (3) contribution to occupational therapy practice. This review
yielded 88 articles, of which 76 could be placed into one of the three categories previously
mentioned (Carswell et al., 2004).
If this review were not available, the occupational therapy practitioner could access
similar information regarding the COPM assessment by conducting individual searches
using CINAHL or PubMed by entering the term “Canadian Occupational Performance
Measure” and other descriptive terms, such as a population of individuals with whom
they are working (i.e., patients with mental health concerns or homeless individuals;
Carswell et al., 2004).
The review included articles on the use of the COPM published in 35 different jour-
nals (Carswell et al., 2004). In considering the psychometric properties of the COPM, 19
articles examined the reliability, validity, and responsiveness of the instrument. The stud-
ies reviewed indicated strong test-retest reliability. In general, the studies reviewed indi-
cated the COPM was a valid measure of occupational performance. One study challenged
the concurrent validity of the COPM relative to other functional measures. One would
anticipate a low correlation with an objective functional measure because the COPM
may not address functional items that would be considered within typical functional
measures. The review found the COPM to be sensitive to changes in patient outcomes
over time in the areas of perceived performance and satisfaction when examining other
functional measures, such as the Health Assessment Questionnaire and the Short Form-36
(Carswell et al., 2004).
In considering occupational therapy research outcomes and the use of the COPM,
articles presented in this review identified the use of the COPM as an outcome measure
(Carswell et al., 2004). These studies included 6 randomized controlled trials, 16 quasi-
experimental designs, 10 case studies, and 2 patient surveys. The studies found the COPM
to be useful as an outcome measure when examining new therapeutic interventions or
specific therapeutic devices. There was most often agreement that the use of the COPM
was an effective method for engaging patients in the therapeutic process and setting goals.
The review also provided information on the negative aspects or limitations of the COPM.
Despite the limitations, the literature presented in this review indicated that the COPM
has been utilized in a successful fashion with a variety of patients, from homeless indi-
viduals to outpatients, patients with mental health needs, patients in a neurorehabilitation
unit, and older adults residing in a care facility. Thirty-three articles were reviewed and
identified that described the use of the COPM in the provision of patient-centered occu-
pational therapy services from an EBP perspective (Carswell et al., 2004).
Overall, this review suggested that the measurement properties of the COPM were
repeatedly identified as satisfactory to excellent (Carswell et al., 2004). The review identi-
fied that interrater reliability is not testable, as each patient determines specific problems
and assigns scores for the patient’s own situation. Therefore, consistency of the responses
Random documents with unrelated
content Scribd suggests to you:
The Project Gutenberg eBook of Handy Mandy
in Oz
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
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you are located before using this eBook.

Title: Handy Mandy in Oz

Author: Ruth Plumly Thompson

Illustrator: John R. Neill

Other: L. Frank Baum

Release date: November 29, 2017 [eBook #56079]

Most recently updated: October 23, 2024

Language: English

Credits: Produced by Greg Weeks, Mary Meehan and the Online

Distributed Proofreading Team at http://www.pgdp.net

*** START OF THE PROJECT GUTENBERG EBOOK HANDY MANDY

IN OZ ***
 HANDY MANDY IN OZ

By
RUTH PLUMLY THOMPSON
Founded on and continuing the Famous Oz Stories

By
L. FRANK BAUM
"Royal Historian of Oz"

Illustrated by
JOHN R. NEILL

The Reilly & Lee Co.

CHICAGO
 COPYRIGHT 1937

By
THE REILLY & LEE Co.

ALL RIGHTS RESERVED

Printed in the u. s. a.

[Transcriber's Note: Extensive research did not uncover any

evidence that the U.S. copyright on this publication was
renewed.]
Hello there!
Another spring, another book and another old Wizard in Oz!
Imagine! And with Ruggedo mixed up in the story there's bound to
be fun and excitement.
Now I do hope you like Handy Mandy and Nox. I'm very fond of the
Royal Ox, myself. He rather reminds me of Kabumpo, while Kerry is
as nice a young King as I've met in an Oz age. But tell me what YOU
think. No one, not even Ozma, receives as fine letters as you all
write me, and I can hardly wait to hear all this year's news and
those interesting Ozzy suggestions. My news comes from the palace
of the Red Jinn, today. It seems that he and Kabumpo are really
going to pay that long-promised visit to Randy in Regalia. My—y, I'll
have to look into this. Meanwhile, best and merriest wishes and a
high old happy-go-lucky year to you!

RUTH PLUMLY THOMPSON.

254 S. Farragut Terrace,

West Philadelphia, Pa.
This book is lovingly dedicated to all
the boys and girls who have written
me letters! Yes, here's to YOU and
cheers to you!

RUTH PLUMLY THOMPSON

April, 1937
 Handy Mandy in Oz
On many a day had Handy, the Goat Girl of Mern, pursued her goats
up and down the rocky eminences of her native mountain. And
never—NEVER—in her fourteen or so years' experience had she been
blown up by a mountain spring. But there comes, in every one's
experience a day which is unlike every other day, and so it was with
the Goat Girl. As she was pursuing What-a-butter, her favorite goat,
there was a sudden crash, a whish, and up flew the slab of rock on
which she was standing, up and away.
The adventures into which she was carried by this simple though
awefull beginning take a whole book to relate. How she met Nox the
Royal Ox of Keretaria, how together they went in search of little King
Kerry, how at last they rescued him and found themselves feted
guests of Ozma of Oz, all these things you must read for yourselves.
Read what the University of Washington Chapbooks have to say
about the famous Oz series. They have taught American children to
look for the elements of wonder in the life around them, to realize
that even smoke and machinery may be transformed into fairy lore if
only we have sufficient energy and vision to penetrate to their
significance and transform them to our use.... Some day we may
have better fairytales but that will not be until America is a better
country. (Edward Wagenknecht.)
 CONTENTS
1 Mandy Leaves the Mountain
2 The End of the Ride
3 The King of Keretaria
4 The Message in the Horn
5 Out of Keretaria!
6 Turn Town!
7 A Horn of Plenty
8 Handy Mandy Learns about Oz!
9 The Magic Hammer
10 The King of the Silver Mountain
11 Down to the Prisoners' Pit!
12 Prisoners of the Wizard
13 In the Emerald City of Oz
14 The Robbery Is Discovered
15 The Pilgrim Returns to the Mountain
16 The Wizard's Bargain!
17 Out of the Prison Pit
18 Wutz and the Gnome King Leave for the Capital!
19 At the Bottom of the Mountain!
20 Just in Time!
21 The Hammer Elf Explains
 CHAPTER 1
Mandy Leaves the Mountain

"What-a-BUTTER! What-a-BUTTER!" High and clear above the peaks

of Mt. Mern floated the voice of the Goat Girl calling the finest,
fattest but most troublesome of her flock. All the other goats were
winding obediently down toward the village that perched
precariously on the edge of the mountain. But of What-a-butter
there was not a single sign nor whisker.
"Serves me right for spoiling the contrary creature," panted Mandy,
pushing back her thick yellow braids with her second best hand.
"Always wants her own way, that goat—so she does. What-a-butter,
I say WHAT-A-BUTTER—come down here this instant." But only the
tantalizing tinkle of the goat's silver bell came to answer her, for
What-a-butter was climbing up, not down, and there was nothing for
Mandy to do but go after her.
Muttering dire threats which she was much too soft hearted ever to
carry out, the rosy cheeked mountain lass scrambled over crags and
stones, pulling herself up steep precipices, the goat always
managing to keep a few jumps ahead, till soon they were almost at
the top of the mountain!
Here, stopping on a jutting rock to catch her breath and remove the
burrs from her stockings, Mandy heard a dreadful roar and felt an
ominous rumbling beneath her feet. What-a-butter on a narrow
ledge just above heard it too, and cocked her head anxiously on one
side. Perhaps she had best jump down to Mandy. After all, the great
silly girl did feed and pet her, and from the sound of things a storm
was brewing. If there was one thing the goat feared more than
another, it was a thunder-storm, so, rolling her eyes as innocently as
if she had not dragged Mandy all over the mountain she stretched
her nose down toward her weary mistress.
"Bah—ah-ah-ahhhhhhhhhh!" bleated What-a-butter affectionately.
"Oh 'Bah' yourself!" fumed Mandy, making an angry snatch for the
Nanny Goat's beard. "Pets and children are all alike—never
appreciate a body till they have a stomach ache, or a thunder-storm
is coming. Now then, m'lass, be quick with you!"
Holding out her strong arms, Mandy made ready to catch the goat
as it jumped off the ledge. But before What-a-butter could stir, there
was a perfectly awful crash and explosion and up shot the slab of
rock on which Mandy was standing, up—UP and out of sight entirely.
Where the mountain girl had been, a crystal column of water
spurted viciously into the air, so high the bulging eyes of the goat
could see no end to it. Rearing up on her hind legs, What-a-butter
turned round and round in a frantic effort to catch a glimpse of her
vanishing Mistress. Then thinking suddenly what would happen
should the torrent turn and fall upon her, the goat sprang off the
ledge and ran madly down the mountain, bleating like a whole herd
of Banshees.
And Mandy, as you can well believe, was as frightened as What-a-
butter and with twice as much reason. The first upheaval, as the
rock left the earth, flung her flat on her nose. Grasping the edges of
the slab with all hands, Mandy hung on for dear life and as a
stinging shower of icy water sprayed her from head to foot,
wondered what under the earth was happening to her. Thorns and
thistles! Could the thunder-storm really have come UP instead of
down? Certainly it was raining up, and what ever was carrying her
aloft with such terrible force and relentlessness?
How could the Goat Girl know that a turbulent spring pent up for
thousands of years in the center of Mt. Mern had suddenly burst its
way to freedom! And you have no idea of the tremendous power in
a mountain spring once it uncoils and lets itself go. Mandy's rock
might just as well have been shot into the air by a magic cannon.
First it tore upward as if it meant to knock a hole in the sky, then,
still travelling at incalculable speed, began to arch and take a
horizontal course over the mountains, hills and valleys west of Mern.
All poor Mandy knew was that she was hurtling through space at
break-neck speed with nothing to save or stop her. The long yellow
braids of the Goat Girl streamed out like pennants, while her striped
skirt and voluminous petticoats snapped and fluttered like banners in
the wind.
"What-a-butter! Oh What-a-butter!" moaned Mandy, gazing wildly
over the edge of the rock. But pshaw, what was the use of calling?
What-a-butter, even if she heard, could not fly after her through the
air, and when she herself came down not even her own goat would
recognize her. At this depressing thought, Mandy dropped her head
on her arms and began to weep bitterly, for she was quite sure she
would never see her friends—her home—or her goats again.
But the rough and frugal life on Mt. Mern had made the Goat Girl
both brave and resourceful, so she soon dried her tears and as the
rock still showed no signs of slowing up nor dashing down, she
began to take heart and even a desperate sort of interest in her
experience. Slowly and cautiously she pulled herself to a sitting
position and still clutching the edges of the rock, dared to look down
at the countries and towns flashing away below.

"After all," sniffed the reckless maiden, "nothing very dreadful has
happened yet. I've always wanted to travel and now I AM travelling.
Not many people have flown through the air on a rock—why it's
really a rocket!" decided Mandy, with a nervous giggle. "And that, I
suppose, makes me the first rocket rider in the country, and the
LAST, too," she finished soberly as she measured with her eye the
distance she would plunge when her rock started earthward. "Now if
we'd just come down in that blue lake, below, I might have a
chance. Perhaps I should jump?"
But by the time Mandy made up her mind to jump the lake was far
behind and nothing but a great desert of smoking sand stretched
beneath her.
 CHAPTER 2
The End of the Ride

The sky, from the rosy pink of late afternoon, had faded to a
depressing grey, and Mandy could not help thinking longingly of the
appetizing little supper she had set out for herself before going up to
call the goats. Who would eat it now or even know she was flying
through the air like a comet? No one, she concluded drearily, for
Mandy was an orphan and lived all by herself in a small cottage on
Mt. Mern, high above the village of Fistikins. In a day or two, some
of her friends in the village might search the cottage and find her
gone, but NOW, now there was nothing to do but sit tight and hope
for the best.
Mandy's next glance down was more encouraging. Instead of the
dangerous looking desert, she was sailing over misty blue hills and
valleys dotted with many small towns and villages. High as she was,
she could even hear the church bells tolling the hour, and this made
Mandy feel more lost and lonely than ever. All these people below
were safely at home and about to eat their suppers while she was
flying high and far from everything she knew and loved best.
Hungrily the Goat Girl cast her eyes over the rock she was riding,
thinking to find a small sprig of mountain berries or even a blade of
grass to nibble. At first glance, the rock seemed bare and barren,
then sticking up out of a narrow crevice Mandy spied a tiny blue
flower. "Poor little posy, it's as far from home as I am," murmured
the Goat Girl, and carefully breaking the stem, she lifted the blue
flower to her nose. Its faint fragrance was vaguely comforting and
Mandy had just begun to count the petals, when the rock gave a
sickening lurch and started to pitch down so fast Mandy's braids
snapped like jumping ropes and her skirts bellied out like a
parachute in a gale.
"NOW for it," gasped the Goat Girl closing her eyes and clenching
her teeth. "OH! My poor little shins!" Mandy's shins were both stout
and sturdy, but even so we cannot blame Mandy for pitying them.
Stouter shins than hers would have splintered at such a fall. Hardly
knowing what she was doing, Mandy began to pull the petals from
the blue flower, calling in an agonized voice as she pulled each one
the names of her goats and friends. She had just come to Speckle,
the smallest member of her flock, when the end came.
Kimmeny Jimmeny! Was this ALL? Opening one eye, the Goat Girl
looked fearfully about her. She was sitting on top of a haystack, no,
not a haystack, but a heap of soft blue flower petals as soft as
down. Opening the other eye she saw the rock, on which she had
travelled so far, bump over a golden fence and fall with a satisfied
splash into a shimmering lake. But what lay beyond the lake made
Mandy forget all her troubles and fairly moan with surprise and
pleasure.
"A CASTLE!" exulted the Goat Girl, putting one hand above her
heart. "Oh! I've always wanted to see a castle and now I AM." And
this castle, let me tell you, was well worth anyone's seeing, a castle
of lacy blue marble carved, and decorated with precious stones, in a
way to astonish the eyes of a simple mountain lass. From the tallest
tower, a silken pennant floated lazily in the evening breeze.
"K-E-R-E-T-A-R-I-A," Mandy spelled out slowly. Sliding off the heap of
flower petals she stood for a long delicious moment lost in
admiration. Then, giving herself a businesslike shake to be sure she
was not broken or bent by her amazing flight and tumble, Mandy
turned to examine the rest of her surroundings.
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