CLIN ED 1 - Bottom Up Top Down
CLIN ED 1 - Bottom Up Top Down
Historical Perspective
In the early 19th century, the moral treatment movement was noted in several mental hospitals, influenced in part, by religious
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and political beliefs at the time. This movement, which encouraged patients to engage
in activities, is credited as the philosophical
roots of occupational therapy (Bockhoven,
1971). Adolph Meyer built on those principles with value placed on time, work, and
activities that promote self-fulfillment
(Christiansen & Baum, 1997). Occupations and later habit training embodied
the early philosophy of occupational therapy (Mosey, 1986). The popular societal
beliefs regarding the indelible connection
between a persons value and his or her
work as well as the danger of idle hands
likely supported or even shaped the early
philosophy of occupational therapy (Mosey,
1986, p. 25). This era can be described as
using a modified top-down approach,
where intervention focused primarily on
occupations, with remediation of performance skills being an occasional, but welcome by-product.
In the early 1900s, medicine focused
on treating acute conditions. After World
War I, immunological and surgical practices
advanced; however, the Depression overshadowed serious growth in the field of
rehabilitation (Mosey, 1986). Injuries suffered during World War II, followed by the
successful use of antibiotics presented a need
and supportive climate for the rehabilitative
professions. Intervention at this time
focused on physical components, as that was
what the medical team valued. Many occupational therapists embraced the reductionist medical model and to varying degrees
abandoned the holistic approach of occupations and activities (Christiansen & Baum,
1997; Mosey, 1986). This series of events
ushered in the use of a bottom-up approach.
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Supporting Evidence
Which Approach Works?
Therapists evaluate to obtain data necessary
for understanding the client and for planning appropriate interventions (Hinojosa
& Kramer, 1998). The way that a therapist
organizes and conducts an evaluation will
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Inherent Challenges
in Each Approach
The resurgence of occupations as a primary focus of the profession is significant and
positive. This very special and unique
aspect of occupational therapy has taken a
backseat for many years, much to our collective loss. However, top-down approaches centered in occupations do present
some challenges if not limitations.
Occupation-based practice does not
address time-based priorities such as a
burn, which requires immediate concentration on the injury even prior to assessment of occupations. In some cases, exclusive use of occupation-based practice can
be detrimental to the client.
Assessment of occupation-based intervention still has room for growth.
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Bottom-Up Approach
Models/Theories Incorporating Each Approach
(The following include some examples of the
given category. There are many other models not
included)
Top-Down Approach
Unique Strengths
Limitations
There have been difficulties noted in assessment and implementation of some models in
this approach (Law, 1998).
Some models in this approach embody basic
sciencenot readily applicable for use.
the spirit face imminent harm and hindering future engagement in occupations if not
addressed in the immediate present. This
initial screening is not top-down, bottomup or contextual, it is concerned with
understanding the client. Based on the
findings from this screening, the therapists
can determine what the best course of
action is. If the major concern is a health
problem, the therapist would begin with a
bottom-up approach. Examples include
aspiration, a newly repaired tendon, or a
patient with a fall risk. If the major concern
is the ability to participate in a life activity,
the therapist would begin with a top-down
approach. Examples include taking care of
ones personal self-care, participating in a
social group, or writing poetry. If the major
concern involves contextual concerns, the
therapist would begin evaluation by examining those factors.
Conclusion
We as a profession have come full circle.
Our approach to evaluation and treatment
is similar to that of our founders, albeit
evolved. At this juncture, a retrospective
awareness of how trends in our profession
have mirrored societal ones may prevent
our continued swaying with the tides of the
time. Introspection would surmise that it is
time to frame problems in a manner that
best serves our clients, instead of in a manner that best fosters the independence and
autonomy of the profession. In conclusion,
it is our position that primary use of only
one approach in problem framing can be
insufficient, and that the use of a screening
tool is indicated to ascertain the area warranting intervention, be it foundational,
contextual, or occupational.
Acknowledgments
Much appreciation to Dr. Mary Donohue
for planting seeds of curiosity about
approaches and occupational therapy. Her
comments on an earlier version of this paper
were very helpful. Many thanks to Dr. Ruth
Segal for her insightful comments on an
earlier version of this paper and her constant
support. Much gratitude to Ann Burkhardt
and Phyllis Mirenberg for their guidance in
the early stages of writing this paper.
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