Achieving Best Practice: A Review of Evidence Linked to Occupation-Focused Practice Models

Jenica Lee, OTD, OTR/L

ABSTRACT. The aim of this paper is to identify and synthesize evidence concerning the most widely used contemporary occupation-focused models including Ecology of human performance; Model of human occupation; Occupational adaptation; and Personenvironmentoccupational performance. The paper characterizes the amount and type of evidence. Evidence found includes illustrations of how the models can be applied to understand and address a particular problem or population, basic studies that test or expand theoretical concepts, psychometric studies, studies that document therapy outcomes, and studies that examine clinical reasoning and/or practice based on the models. The four models differed widely in the amount and type of evidence available. KEYWORDS. Ecology of human performance, model of human occupation, occupation-based model, occupational adaptation, personenvironmentoccupational performance model

In the past two decades, leaders have encouraged occupational therapists to develop occupation-focused practice that reects the professions core (Christiansen, 1999; Clark, 1993; Fisher, 1998; Law, 1998; Townsend, 1997; Wilcock, 2001; Wood, 1998). To this end, occupation-based models have been developed to guide occupational therapy practice (Baum & Christiansen, 2005; Dunn, Brown, & McGuigan, 1994; Kielhofner, 2008; Schkade & Schultz, 1992). At the same time, therapists are challenged to implement occupation-focused practice; they are being called upon to assure that practice is evidence-based (Bennett & Bennett, 2000; Ilott, 2004; Taylor, 1997; Tickle-Degnen &
Jenica Lee is afliated with the Department of Occupational Therapy, University of Illinois at Chicago, Chicago, Illinois. Address correspondence to: Jenica Lee, Department of Occupational Therapy, University of Illinois at Chicago, 1919 W. Taylor (MC 811), Chicago, IL 60612 (E-mail: jenica.lee@gmail.com). A special thanks is given to the following individuals, Drs. Carolyn M. Baum, Christine Berg, Winnie Dunn, Gary Kielhofner, and Sally Schultz, who assisted in the identication and conrmation on the comprehensiveness of the literature list for the occupation-based models. Their expertise and input was invaluable in preparing this paper. This paper is supported by the National Institute on Disability and Rehabilitation Research (Grant #H133P060003). Occupational Therapy in Health Care, Vol. 24(3), 2010 Available online at http://informahealthcare.com/othc 2010 by Informa Healthcare USA, Inc. All rights reserved. doi: 10.3109/07380577.2010.483270

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Bedell, 2003). Evidence-based practice requires practitioners to systematically check their professional decisions against existing evidence. Occupational therapists make different levels of evidence-based decisions. Some are very specic, while others more global. The choice of models to be used in practice is one of the most consequential decisions that the practitioner makes. Models can inuence what client issues a practitioner addresses, how clients are assessed, how therapy is approached, and what kinds of services are offered (Crepeau, Cohn, & Schell, 2009; Kielhofner, 2009). Like other practice decisions, the choice of models should be guided by evidence. Contemporary literature on evidence-based practice has scant discussion of the evidence base of contemporary occupation-focused models. Rather, the literature tends to focus on using evidence to inform decisions about a specic practice approach or technique. Such decisions are important in practice. However, because the concepts one uses has a signicant inuence on practice (Guyatt, 2004; Law & MacDermid, 2008), occupational therapists also need some way to assess the evidence pertaining to proposed models. The aim of this paper is to identify and characterize what evidence exists concerning contemporary occupation-focused models. There is evidence that the most widely used models in American practice (National Board for Certication in Occupational Therapy (NBCOT) survey, 2004) are as follows: Ecology of human performance (EHP); Model of human occupation (MOHO); Occupational adaptation (OA); and Personenvironmentoccupational performance (PEOP). In addition, these models have been identied in the past two editions of Willard and Spackmans Occupational Therapy as the major occupation-focused models in the eld (Crepeau, Cohn, & Schell, 2003; Crepeau et al., 2009). Thus, this examination of evidence will focus on these models, which are briey characterized in Table 1.

METHODS As the aim of this paper is to identify and synthesize evidence related to contemporary occupation-focused models, the methods focused on identifying the scope of evidence for review, thoroughly and accurately identifying existing evidence, categorizing the types of evidence available to analyze what kinds of evidence exist about contemporary occupation-focused models, and comparing the evidence base across models to characterize the type and amount of evidence available for each model.

Identifying the Scope of Evidence for Review A wide range of evidence is relevant to the diverse kinds of decisions that practitioners must make (Tickle-Degnen & Bedell, 2003). Such decisions include what assessments should be used, what combination of services should be offered, and how should service delivery take place. Consequently, evidence can include ndings from a variety of basic and applied, qualitative and quantitative studies, descriptions of successful programs, and cases that reect clinical expertise and experience. Thus, for this review, evidence included all published studies that specically addressed a model.

TABLE 1. Original Publication Date, Focus, Emphasis, and Major Concepts of Four Occupation-Focused Models

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Focus of the Model Major Emphasis Major Concepts

Model

Date Originally Published

Ecology of human performance (EHP)

1994

The interaction between a person and the context affects human behavior and task performance.

Model of human occupation (MOHO)

1980

Occupational adaptation (OA)

1992

Personenvironment occupational performance (PEOP)

1991

Consists of four major constructs: the person Emphasizes the transactional natures of (skills, abilities, and experience), context person, task, performance, and context. (social, cultural, physical, and temporal), Understanding this will enable practitioners task, and performance. The interactions of to identify performance needs and develop these variables determine the persons strategies to enhance performance. performance range. Understanding occupation and problems of Provides a broad framework to Emphasizes circumstances both within the occupation occur in terms of its primary person and in the environment that explain how human concepts of volition (personal causation, contribute to the persons motivation, occupation is motivated, values, and interests); habituation patterns of behavior, and occupational patterned, and performed. (persons habits and roles); performance performance. MOHO provides a way of capacity (physical and mental abilities); thinking about peoples and environmental context (physical and adaptation and about the social). process of therapy. Occupational environments (as inuenced by Emphasizes the creation of a therapeutic The interaction between the physical, social, and cultural properties) climate, the use of occupational activity, person and the environment are as important as the patients and the importance of relative mastery. when the person is faced sensorimotor, cognitive, and psychosocial with an occupational functioning and the patients experience of challenge. personal limitations and potential is validated. The integration of these concepts drives the treatment process The PEOP model has four major Emphasizes practitioners use of A top-down approach to components: occupations (what people client-centered strategies that engage the emphasize the view of want or need to do in their daily lives); individual or group to develop or use performance as an performance (actual act of doing the resources that enable successful interaction between person occupation); person (physiological, occupational performance. and environment. psychological, neurobehavioral, cognitive, and spiritual factors), and environment (physical, natural, cultural, societal, social context in which occupations take place).

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Identifying Existing Evidence First, a web-based search using Google Scholar and CINAHL, which provided the most comprehensive coverage of occupational therapy literature, was conducted to locate published works related to each occupation-based model in the English language between 1980 and July 31, 2009. The title, abstract, and keyword elds indexed in these databases were searched for the following phrases: ecology of human performance, model of human occupation, occupational adaptation, and personenvironmentoccupational performance combined with any of these terms: occupational therapy and model. Reference lists and bibliographies were hand-searched from all retrieved articles to identify additional published works and textbooks, and chapters related to each model were also searched to identify case examples and programs that might not otherwise be identied through electronic search. Identied works were then examined to ensure that they actually provided evidence related to a model; those that did not were eliminated. Papers that simply referenced a model to support a point, but did not make a direct linkage between the purpose or content of the paper and the referenced model were excluded. Finally, experts who developed or contributed to each model were consulted to further identify existing research and evidence related to each model. They were provided the lists of works identied for their model and asked to help identify any missing works. In each instance, the expert conrmed the lists as including all relevant citations and no new works were further identied. Categorizing Evidence After all the published works were identied, they were rst categorized into one of the following types of publications: books, chapters, refereed articles, and nonrefereed articles. Subsequently, the evidence under each of these publication vehicles were reviewed and further sorted to characterize the nature of evidence corresponding to each publication type. Examination of the published works revealed that many types of evidence concerned the models theory and resources (e.g., assessments), their use in practice and the outcomes of therapy based on the model. These types of evidence were adopted as subcategories that characterize the content of the evidence. The number of published works corresponding to each category was then calculated as a whole and for each model to allow comparison of the available types of evidence across models. Finally, the evidence related to each model was examined as a whole. This examination sought to characterize the direction that evidence development has taken for this model. In addition, similarities and differences of how models were developing evidence were identied. FINDINGS A total of 503 published works were located. These included 12 related to the EHP, 433 related to the MOHO, 31 related to the OA, and 27 related to the PEOP models. The number of published works and the types of evidence found varied across each model. Table 2 shows the types and number of published works for each model.

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TABLE 2. Frequency of the Types of Publication Vehicles

Refereed Publications 6 390 19 17

Model EHP MOHO OA PEOP

a b

Textbook(s) 0 1b 1 0

Chaptersa 4 18 7 9

Non-Refereed Publications 2 24 4 1

Numbers of chapters do not include chapters published in books exclusively focused on a model. Four editions of the Model of Human Occupation: Theory and Application have been published in the search period; they were considered a single book.

Content Related to Publication Types Textbooks and chapters were the most common publications that presented the explanation of the theoretical concepts corresponding to each model. Both contained case examples of how each of the theories can be implemented in practice. However, the largest category of works was articles published in refereed journals. These publications included both research and non-research articles as shown in Tables 3 and 4. Research articles were those that utilized a method of inquiry (quantitative and qualitative group studies and single subject designs). The research articles included the following kinds of studies: (1) studies whose primary purpose was to test or expand a theory, (2) studies that examined applications of the model, (3) studies that aimed to develop or validate an assessment, and (4) outcome studies that examined the impact of service based on a model. Table 3 provides a breakdown of the numbers of each of these kinds of studies by model. Non-refereed articles and non-research refereed articles mainly focused on issues related to best practice, program descriptions, and other clinical applications related to a particular model. These articles included the following topics: (1) theoretical discussions and critiques, which elaborated on theoretical concepts, applied the concepts to create a better understanding of a particular phenomenon, or provided critical discussion of some concept(s); (2) program descriptions that presented a standardized service (e.g., standard approaches to assessment, goals setting and intervention) based on the model
TABLE 3. Frequency of Types of Studies Represented in Refereed Articles Reporting Research
EHP (n = 1) Basic studies that test or expand theory Studies that examine the application of the model or assessment (e.g., using the models concepts and/or instruments to identify client needs for services) Studies developing or validating an assessment Outcome studies examining the impact of interventions based on a model 0 0 MOHO (n = 245) 45 110 OA (n = 10) 0 3 PEOP (n = 13) 0 2

0 1

73 17

1 6

8 3

Lee TABLE 4. Refereed Journal Non-Research Articles

EHP (n = 5) Theoretical commentaries Program/intervention descriptions Case illustrations Discussion/clinical application of assessments and model 0 5 0 0 MOHO (n = 145) 37 10 28 70 OA (n = 9) 2 1 3 3 PEOP (n = 4) 0 0 0 4

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and designed for a particular population or for a specic problem. These publications report a structured program of services that was designed and implemented; (3) case examples that demonstrated application of a model to a particular client, and (4) general discussions of how model concepts and/or assessments can be used to understand and address a particular problem or population (e.g., persons with chronic pain, injured workers, immigrants, and victims of domestic violence). These papers do not present a standard program but rather an approach or strategy for delivering individualized services.

Characterization of Evidence Related to Each Model Ecology of Human Performance (EHP) The EHP model was developed by the faculty of the Occupational Therapy Education Department at the University of Kansas Medical Center in the early 1990s (Dunn et al., 1994). The framework was originally used to guide scholarly work and served as an organizing structure for the departments curriculum, research, and service activities. The EHP model was also used to facilitate collaboration among interdisciplinary colleagues. Subsequently, the EHP framework has been documented in both refereed and non-refereed journals and through book chapters. A total of six refereed articles (Brown, Rempfer, & Hamera, 2002; Dunn et al., 1994; Mellerd, Hall, & Parker, 2000; Myers, 2006; Stav, Justiss, Belchior, & Lanford, 2006; Teel, Dunn, Jackson, & Duncan, 1997) and two non-refereed articles (Bulgren et al., 1997; Dunn, Gilbert, & Parker, 1997) were published related to the EHP model. Most articles were descriptive in nature and illustrated the application of the EHP model in various settings. For example, several publications illustrate how the EHP framework was used to understand accommodations in education programs and thus better support college teaching (Bulgren et al., 1997; Dunn et al., 1997; Mellerd et al., 2000). Another explores how the model can be applied to interventions related to early childhood transitions (Myers, 2006). One study by Brown and colleagues (2002) provided evidence of the effectiveness of an EHP-based intervention in improving accuracy of grocery shopping skills of participants who were diagnosed with schizophrenia. In addition, book chapters related to the EHP model illustrate its application with different populations (children, families, adults receiving employment services, and adults with stroke (Brown, 2009; Dunn, 2007; Dunn, Brown, & Youngstrom, 2003; Rempfer, Hildenbrand, Parker, & Brown, 2003).

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Model of Human Occupation (MOHO) The MOHO was rst introduced in 1980, and the model grew out of the work of three practitioners efforts to articulate a theory to guide practice (Kielhofner & Burke, 1980). The MOHO was the rst model to present concepts related to occupation and to discuss occupation-focused therapy. The body of the literature on this model includes 390 refereed journal articles. Among them, 245 research that (a) test concepts and contribute to renement of the MOHO theory, (b) examine the dependability and utility of the MOHO assessments, (c) explore a continuum of questions that relates to application of the MOHO and its assessments and what happens during therapy, and (d) provide evidence concerning the outcomes of the MOHO-based programs and interventions. Twenty MOHO-based assessments have been developed that vary in purpose, format, and target groups. They include interviews, self-reports, observational assessments, and assessments that combine means of data collection (e.g., Kielhofner & Forsyth, 2001; Kramer, Kielhofner, Lee, Ashpole, & Castle, 2009; Sandqvist, Bjork, Gullberg, Henriksson, & Gerdle, 2009). About 30% of the MOHO-based research examines and contributes to development of these assessments. In addition, the non-research MOHO literature identies how these assessments are administered and how they are used in practice and for what populations they are appropriate (Du Toit, 2008; Ennals & Fossey, 2009; Harney & Kramer, 2007; Parkinson, Chester, Cratchley, & Rowbottom, 2008). Seventeen studies provided evidence of positive outcomes generated by the MOHObased programs and interventions for a variety of populations including persons with mental health problems, stroke, AIDS/HIV, caregivers of persons with dementia, adolescents in juvenile facilities, and older adults with Alzheimers (e.g., Corcoran & Gitlin, 2001; Gitlin et al., 2003; Graff et al., 2003; Ingvarsson & Theod rsd ttir, 2004; Kielo o hofner, Braveman, Fogg, & Levin, 2008; Kielhofner et al., 2004; Turner & Lydon, 2008). A number of studies have also examined how the MOHO is used in practice and how it inuences clinical reasoning. (e.g., Apte, Kielhofner, Paul-Ward, & Braveman, 2005; Durand, Vachon, Loisel, & Berthelette, 2003; Goldstein, Kielhofner, & PaulWard, 2004; Lee, Taylor, & Kielhofner, 2009; Tham & Kielhofner, 2003). There are a number of publications that describe how the MOHO is used to develop, implement, and monitor interventions with a range of client populations and in a variety of settings including hospitals, outpatient clinics, residential facilities, nursing homes, rehabilitation programs, work programs, prisons and correctional settings, and community-based organizations (e.g., Braveman, 2001; Kahlin & Haglund, 2009; Levin & Helfrich, 2004; Melton et al., 2008; Taylor & Kielhofner, 2003). Other evidence is published in the form of examples that are found in journals, chapters, and textbooks. Most of these case examples illustrate how the MOHO-based interventions are applied to and/or affect a specic client, diagnosis type, or context. Some focus on the use of particular assessments, typically discussing why the assessment was chosen, what it revealed about the client, and how it informed intervention. Occupational Adaptation (OA) The OA model was developed by the faculty at Texas Womans University in the late 1980s and was used as a framework to guide the occupational therapy curriculum and research focus for the PhD program (Schkade & Schultz, 2003b).

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A total of 31 published works have been identied related to the OA model. Among them, six publications report studies that document the effectiveness of OA-based interventions with clients following a cerebral vascular accident (CVA) (Dolecheck & Schkade, 1999; Gibson & Schkade, 1997; Johnson & Schkade, 2001), following a hip fracture (Buddenberg & Schkade, 1998; Jackson & Schkade, 2001), elderly clients with a variety of chronic illnesses (Spencer, Hersch, Eschenfelder, Fournet, & MurrayGerzik, 1999), and adolescents with limb deciencies (Pasek & Schkade, 1996). There are also a number of case examples that demonstrate the application of the OA model with different populations including children and adolescents with mental health problems (Bouteloup & Beltran, 2007), homeless persons (Johnson, 2006), persons with carpal tunnel syndrome (Martin, 2007), older workers (Moyers & Coleman, 1992), community-dwelling elders (Miller et al., 2002), forensic psychiatry (Stelter & Whisner, 2007), home health (Ford, 1995; Schultz & Schkade, 1994), and level II eldwork students (Coates & Crist, 2004; Garrett & Schkade, 1995; Schkade, 1999). In addition, the OA-related texts and chapters also illustrate OA application with a variety of contexts including school-based settings, eldwork education, and psychosocial rehabilitation (Ikiugu, 2007; Schkade & McClung, 2001; Schkade & Schultz, 1993, 2003a, 2003b; Schultz, 2000, 2009; Werner, 2007). One assessment tool related to the OA model, Relative Mastery Measurement Scale (RMMS), has been documented in the literature (George, Schkade, & Ishee, 2004) and one psychometric study related to this tool has been reported (George et al., 2004).

PersonEnvironmentOccupational Performance Model (PEOP) Development of the PEOP model began in 1985 and it was rst published in 1991 (Christiansen & Baum, 1991). Of 13 research articles, three were outcome studies that examined the effectiveness of the PEOP-guided interventions for adult stroke survivors (Hartman-Maeir, Soroker, Ring, Avni, & Katz, 2007; Hartman-Maeir et al., 2007) and children with development coordination disorder (Taylor, Fayed, & Mandich, 2007). The PEOP model does not provide any specic guidelines or intervention techniques. The PEOP constructs have not been directly translated into measures but have served as a general framework underlying the development and validation of several measures including the activity card sort (ACS), pediatric activity card sort (PACS), and the kitchen task assessment (KTA). Therefore, a majority of the published research is related to the psychometric development and the application of these measures to a range of clients including persons with Alzheimers, persons with stroke, adults with multiple sclerosis, community-dwelling older adults, caregivers, and children (Baum & Edwards, 1993; Chan, Chung, & Packer, 2006; Doney & Packer, 2008; Everard, 1999; Everard, Lach, Fisher, & Baum, 2000; Katz, Karpin, Lak, Furman, & Hartman-Maeir, 2003; Packer, Boshoff, & Dejonge, 2007; Sachs & Josman, 2003; Stoffel & Berg, 2008). Other evidence is published in the form of case examples that are found in chapters and non-refereed journals. These case examples depict the application of the PEOP framework and its related measures (Baum & Christiansen, 2005; Baum, Perlmutter, & Dunn, 2001; Christiansen & Baum, 1991, 1997; Law, Baum, & Baptiste, 2002; Law, Baum, & Dunn, 2001, 2005; Perlmutter, 2002).

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DISCUSSION This paper identied and examined the types of evidence that are available for four occupation-focused models. Importantly, characterizing the rigor of the studies was beyond the scope of this paper and although the quality of evidence is an important component of evidence-based practice (Law & MacDermid, 2008; Tickle-Degnen & Bedell, 2003), those who wish to more fully investigate the evidence related to a model should consider the rigor of studies. Similarities Across all four models, the types of evidence directly related to practice were identied: (a) evidence of how the model, its concepts, and/or assessments can be applied to understand and address a particular problem or population, (b) basic studies that test or expand theoretical concepts of the model, (c) psychometric studies that contribute to assessment development/validation, and (d) studies that document the outcomes of services based on the model. In addition to these types of evidence there are also publications that discuss or critique theory of the models, and studies that examine clinical reasoning and/or practice based on the models. Each of the models has provided a conceptualization of some aspect of occupation (Table 1). As these concepts shape the way that therapists view occupation, especially in practice, it would appear important that they are empirically scrutinized. All the models have published case examples that illustrate the application of their concepts in practice. The EHP model offers general guidelines for different intervention approaches (i.e., establish/restore; modify/adapt; alter/prevent; and create). The OA model has specied two types of interventions (i.e., occupational readiness and occupational activities) (Schkade & McClung, 2001). The MOHO has been translated into a large number of programs and standard approaches to care. The PEOP model has not offered any intervention approaches. There are no assessments designed specically to capture information on constructs from the EHP model. The OA model has one assessment of its concept of relative mastery. The PEOP model has no specic assessments to capture information on its constructs. However, it has served as a general framework for the development of some assessments and has generated a measurement model to help guide the process of assessing assets, decits, and past performance of the individual (Baum & Christiansen, 2005). The PEOP models research focuses on assessments developed within that general framework. Twenty assessments have been designed to capture information on the MOHO constructs and a large body of psychometric research has supported the development of these MOHO assessments. Research evidence concerning the effectiveness of intervention strategies is available for only the OA model (six studies) and the MOHO (17 studies). While other types of evidence (e.g., case studies) do provide some indication of outcomes that can be expected from services based on the models, this area of research is critical to understanding how useful these models are for achieving positive outcomes. Differences The MOHO is the only model with a body of research that has examined its theoretical concepts through research. Moreover, it is also the only model that has systematically

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developed measures of the range of constructs proposed by the model. These measures are important to being able to study the various concepts proposed by a model. The MOHO research includes both quantitative studies that test hypotheses derived from the MOHO theory and qualitative studies that examine phenomena related to the MOHO concepts and result in elaboration of these concepts. While space does not permit a complete discussion of the range of evidence generated on behalf of the MOHO concepts, the following examples related to one MOHO concept, volition, will give a sense of what this body of research has contributed to the understanding of occupation in the eld. According to the MOHO, volition includes a persons sense of capacity and efcacy, interests, and values (Kielhofner, 2008). It is argued that volition inuences how people anticipate, choose, experience, and interpret their occupations, as well as the extent to which they achieve satisfaction in their occupations. Several studies have demonstrated that volition and the occupational narrative that is closely related to volition are related to and predict future choices for occupation as well as patterns of occupational participation (Kielhofner et al., 2004; Levin, Kielhofner, Braveman, & Fogg, 2007; Neville-Jan, 1994; Peterson et al., 1999). Other studies have shown that volition inuences how clients make sense of their occupational life circumstances and interpret opportunities or barriers to participate in occupation (Helfrich, Kielhofner, & Mattingly, 1994; Jonsson, Josephsson, & Kielhofner, 2001). Studies have also shown that participation in volitionally relevant activities is related to life satisfaction (Elliott & Barris, 1987; Gregory, 1983; Smith, Kielhofner, & Watts, 1986). History of Progress in Research Studies When the models are compared, the MOHO has clearly been subjected to the most testing and has the largest research base. The MOHO was established about 1018 years longer than the other models; this, in part explains its substantially larger research base. However, an examination of the rates of published works for the past 5 years (see Figure 1) suggests that substantially more MOHO evidence is being generated each year. Thus, part of the reason for the larger evidence base is the ongoing rate of evidence-generation. Furthermore, the development of evidence appears closely related to the development of resources for application of these models. For instance, the development of assessments tends to be accompanied by psychometric studies. When programs and structured interventions are specied for models, studies of outcomes can be conducted. Usefulness of Published Research to Practitioners The area in which evidence is lacking is outcome of services. This nding suggests that this is the area most in need of development. The development of evidence related to models tends to proceed along the lines of rst developing case examples, programs, and standard interventions along with structured assessments. Once these elements are in place, then outcome studies can be conducted, as the interventions and measures are in place. The evidence available for models means that therapists do have some basis on which to make selection of models. For instance, when considering a program for a particular population, it is likely that one or more of the models will have an existing program designed for that particular population or a closely related population. Or when

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FIGURE 1. Rate of publications between 2004 and 2008. Note. Textbook, chapters, and refereed journal articles are included in the count.

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considering how to approach a particular client or problem, it is likely that there are case descriptions or discussions of standardized approaches that will be relevant. CONCLUSION This paper portrayed the evidence available for four contemporary occupationfocused models. A range of evidence was identied that provides support for using these occupation-based models. This evidence focuses on different aspects of practice such as selecting assessments, formulating treatment goals and strategies, addressing needs of particular populations or settings, and identication of outcomes. Thus, therapists who wish to use occupation-based approaches to practice will nd a substantial evidence base to guide decisions. There are clear differences in the amount of evidence available for each model and for different applications of models. This means that, when considering models for a particular practice application, therapists should carefully examine the evidence available relevant to that application in order to make an informed decision about which model is best suited. Declaration of interest: The author reports no conict of interest. The author alone is responsible for the content and writing of this paper. REFERENCES
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Received: 11/19/2009 Revised: 03/29/2010 Accepted: 04/01/2010

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