Occupational Therapy Practice Framework: Domain and Process Fourth Edition
The fourth edition of the Occupational Therapy Practice Framework: Domain and Process (hereinafter referred to as the OTPF-4), is an official document of the American Occupational Therapy Association (AOTA). Intended for occupational therapy practitioners and students, other health care professionals, educators, researchers, payers, policymakers, and consumers, the OTPF-4 presents a summary of interrelated constructs that describe occupational therapy practice.
Within the OTPF-4, occupational therapy is defined as the therapeutic use of everyday life occupations with persons, groups, or populations (i.e., the client) for the purpose of enhancing or enabling participation. Occupational therapy practitioners use their knowledge of the transactional relationship among the client, the client’s engagement in valuable occupations, and the context to design occupation-based intervention plans. Occupational therapy services are provided for habilitation, rehabilitation, and promotion of health and wellness for clients with disability- and non-disability-related needs. These services include acquisition and preservation of occupational identity for clients who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction (AOTA, 2011; see the glossary in Appendix A for additional definitions).
When the term occupational therapy practitioners is used in this document, it refers to both occupational therapists and occupational therapy assistants (AOTA, 2015b). Occupational therapists are responsible for all aspects of occupational therapy service delivery and are accountable for the safety and effectiveness of the occupational therapy service delivery process. Occupational therapy assistants deliver occupational therapy services under the supervision of and in partnership with an occupational therapist (AOTA, 2020a).
The clients of occupational therapy are typically classified as persons (including those involved in care of a client), groups (collections of individuals having shared characteristics or a common or shared purpose; e.g., family members, workers, students, people with similar interests or occupational challenges), and populations (aggregates of people with common attributes such as contexts, characteristics, or concerns, including health risks; Scaffa & Reitz, 2014). People may also consider themselves as part of a community, such as the Deaf community or the disability community; a community is a collection of populations that is changeable and diverse and includes various people, groups, networks, and organizations (Scaffa, 2019; World Federation of Occupational Therapists [WFOT], 2019). It is important to consider the community or communities with which a client identifies throughout the occupational therapy process.
Whether the client is a person, group, or population, information about the client’s wants, needs, strengths, contexts, limitations, and occupational risks is gathered, synthesized, and framed from an occupational perspective. Throughout the OTPF-4, the term client is used broadly to refer to persons, groups, and populations unless otherwise specified. In the OTPF-4, “group” as a client is distinct from “group” as an intervention approach. For examples of clients, see Table 1 (all tables are placed together at the end of this document). The glossary in Appendix A provides definitions of other terms used in this document.
The founders emphasized the importance of establishing a therapeutic relationship with each client and designing a treatment plan based on knowledge about the client’s environment, values, goals, and desires (Meyer, 1922). They advocated for scientific practice based on systematic observation and treatment (Dunton, 1934). Paraphrased using today’s lexicon, the founders proposed a vision that was occupation based, client centered, contextual, and evidence based–the vision articulated in the OTPF-4.
The purpose of a framework is to provide a structure or base on which to build a system or a concept (“Framework,” 2020). The OTPF describes the central concepts that ground occupational therapy practice and builds a common understanding of the basic tenets and vision of the profession. The OTPF-4 does not serve as a taxonomy, theory, or model of occupational therapy. By design, the OTPF-4 must be used to guide occupational therapy practice in conjunction with the knowledge and evidence relevant to occupation and occupational therapy within the identified areas of practice and with the appropriate clients. In addition, the OTPF-4 is intended to be a valuable tool in the academic preparation of students, communication with the public and policymakers, and provision of language that can shape and be shaped by research.
“Achieving health, well-being, and participation in life through engagement in occupation” is the overarching statement that describes the domain and process of occupational therapy in its fullest sense. This statement acknowledges the profession’s belief that active engagement in occupation promotes, facilitates, supports, and maintains health and participation. These interrelated concepts include
* Health–“a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” (WHO, 2006, p. 1).
* Well-being–“a general term encompassing the total universe of human life domains, including physical, mental, and social aspects, that make up what can be called a ‘good life'” (WHO, 2006, p. 211).
* Participation–“involvement in a life situation” (WHO, 2008, p. 10). Participation occurs naturally when clients are actively involved in carrying out occupations or daily life activities they find purposeful and meaningful. More specific outcomes of occupational therapy intervention are multidimensional and support the end result of participation.
* Engagement in occupation–performance of occupations as the result of choice, motivation, and meaning within a supportive context (including environmental and personal factors). Engagement includes objective and subjective aspects of clients’ experiences and involves the transactional interaction of the mind, body, and spirit. Occupational therapy intervention focuses on creating or facilitating opportunities to engage in occupations that lead to participation in desired life situations (AOTA, 2008).
Although the domain and process are described separately, in actuality they are linked inextricably in a transactional relationship. The aspects that constitute the domain and those that constitute the process exist in constant interaction with one another during the delivery of occupational therapy services. Figure 1 represents aspects of the domain and process and the overarching goal of the profession as achieving health, well-being, and participation in life through engagement in occupation. Although the figure illustrates these two elements in distinct spaces, in reality the domain and process interact in complex and dynamic ways as described throughout this document. The nature of the interactions is impossible to capture in a static one-dimensional image.
Occupational participation can be considered independent whether it occurs individually or with others. It is important to acknowledge that clients can be independent in living regardless of the amount of assistance they receive while completing occupations. Clients may be considered independent even when they direct others (e.g., caregivers) in performing the actions necessary to participate, regardless of the amount or kind of assistance required, if clients are satisfied with their performance. In contrast to definitions of independence that imply direct physical interaction with the environment or objects within the environment, occupational therapy practitioners consider clients to be independent whether they perform the specific occupations by themselves, in an adapted or modified environment, with the use of various devices or alternative strategies, or while overseeing activity completion by others (AOTA, 2002b). For example, a person with spinal cord injury who directs a personal care assistant to assist them with ADLs is demonstrating independence in this essential aspect of their life.
It is also important to acknowledge that not all clients view success as independence. Interdependence, or co-occupational performance, can also be an indicator of personal success. How a client views success may be influenced by their client factors, including their culture.