Is it about the degrees of motion in your shoulder? That you can flex your wrist against gravity? Do you pronate or supinate to grasp and manipulate objects?
It’s Not About the Shoelaces: An Occupation as Site of Conflict
A young man with Cerebral Palsy, shortly to be transitioning into adulthood. He and his parents have one Occupational Therapy goal: for him to tie his shoelaces independently.
Functionally, he has all of the components: fine motor dexterity and requisite upper limb skills, cognitive skills, visual skills – with effort and concentration, he could do it. He could tie his tie, a half-windsor, with no problem. Bottom-up, there was no reason he could not tie his laces. Analysing his attempts, his sequencing was off, and he could not replicate my instructions. He had the component skills and the idea of making loops and tying knots. But, something else was going on…I needed to step back.
I am an OT in the community, I want to help people. I make things happen. I am important to these people’s lives, right?
Wrong. I am one of many faces and names who interact with these individuals monthly, weekly, daily. People like me are perceived as gatekeepers to knowledge, opportunities, and equipment, who are seemingly niggardly in how we dole out our apparently vast resources.
Wrong. Most of us are stumbling in the dark. We learn something and hope to be able to apply some of it to another situation.
One thing I have re-affirmed to me over and over is that I need to resist the desire to solve the problem – especially when I do not fully understand what the nature of the problem is. Instead, I must ask more questions.
By exploring the meaning of occupations, we come to understand how beliefs about strengths, weakness, values – and conflicts – influence our occupations and engagements.
I sat down with the family to explore the idea of shoelace tying – why was it important? Was it the act of tying the shoelaces independently, or was it what tied shoelaces would enable – getting out of the house to go to work or access the community (and in that case, was there a solution that would remove the need for shoelace entirely)?
This young man’s mother has a history of CP and is experiencing arthritis. Therefore, it falls to the father to tie shoelaces for several of the family members. While the father has tried to teach his son shoelace tying, the father’s technique was difficult for his son to learn, and both parties had gotten frustrated. There seemed to be an underlying dimension to their relationship – the son as both reliant on his father for basic care activities, whilst trying to assert a natural independence from his parents.
I whipped off my own shoe and began showing the family a very simple shoelace tying technique. After seeing this, the father acknowledged that his technique might be more complex, that we all needed to settle on one method to teach this young man. Importantly, the father acknowledged that trying to teach his son minutes before they were to leave for school in the morning might not be ideal.
Together, we drew up a plan, (gasp! a goal, a SMART one at that!) that involved specific actions with a timeframe, and outlined responsibilities for myself, the young man, and the father.
It’s Not About the Bottom Wiping: An Occupation as Meaningful Rehabilitation
A striking woman in a slinky dress, I first met her carrying cables and microphone leads with impressive competence, peeped at her from backstage as she gracefully played her slinky black violin to open the show, and hopped out of her way as she rushed to help her DJ girlfriend with a intimidating efficiency. Then we spoke.
A skiing accident, she said. Needing reconstruction to her skull, her left leg, and both arms.
Sometimes all you need is determination and a right leg.
She points to her girlfriend. “As far as anyone’s concerned, I don’t fart. I don’t piss. I don’t shit. I was not going to toilet in my bed”. While in hospital, she asked the nursing staff to assist her to the toilet, but no further. She spent an hour learning to wipe herself with her right foot.
Perhaps that was where her rehabilitation began – where the will leads, the body can follow.
A commanding woman in a slinky dress who taught me that bottom wiping might be the beginning of recovery. If I look carefully, I can see surgical scars
Occupations are about meaning. Occupations are about dignity. Occupations are about volition. Occupations are about values.
Occupations are symbolic.
Occupations can be a site of conflict – and therefore can be the site of therapy and transformation.