1. Perspectives on Recreational Therapy
David R. Austin, Ph.D., FDRT, FALS
Bryan P. McCormick, Ph.D., CTRS, FDRT. FALS

2. The Therapeutic Relationship
Chapter 1
The Therapeutic Relationship

3. Definition of Therapeutic Relationship:
The therapeutic relationship is “a trusting connection and rapport established between therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect.” (Cole & McLean (2003), p. 262)

4. Key Elements in Therapeutic Relationships:
Empathy
Caring
Having positive regard and respect for clients
Hope
Genuineness
Autonomy and Mutuality

5. Role Play Questions for Class (1st slide)
Did the RT display empathy?
Was the RT caring in his or her interactions with the client?
Was the RT warm and nonjudgmental?
Did the RT use touch appropriately?
Did the RT treat the client with dignity and respect?
Was the RT genuine with the client (not phony or hiding behind the role of serving as a therapist)?

6. Role Play Questions for Class (2nd slide)
Was the RT defensive?
Did the RT seem to be attentive, being engaged or involved with the client?
Did the RT seem to be accepting of the client? Treat the client with positive regard?
Was the relationship collaborative—a two-way relationship involving co- acceptance?
If the RT slipped up, did he or she attempt to repair any ruptures or tension or breakdown in establishing a collaborative relationship?

7. Questions for the “Client” in Role Play…
Did you feel the RT was honest and open with you?
Was the RT open to you speaking about things important to you?
Was the RT ever impatient with you?
Was the RT impersonal or cold toward you? Made you feel rejected?
Did the RT seem to like you no matter what you said?
Did the RT seem to understand your experiences and what they meant to you?
Did the RT seem to act in a superior way toward you or try to “keep you in your place” since he or she was the therapist and you were a client?
Did the RT try to impress you with his or her skill or knowledge?

8. Unique Elements in RT
The roles of RTs (Doing things with clients, not to them. RTs are active collaborators. Relationships for RTs are “client-partner”)
Offering clients warm, caring, supportive atmospheres (The warm, supportive, caring atmospheres frees clients to be themselves.)
Clients tend to like RTs (Clients tend to appreciate and value what RTs do for them and like the RTs for it.)
Place matters (In contrast sterile examining rooms or formal offices, RT takes place in positive recreation venues.)

9. Questions on Transtheoretical Model (TTM):
Do you agree with Prochaska and DeClemente that it is an important part of the therapist’s responsibilities to motivate clients or is it the clients’ responsibility to motivate themselves? Explain.
What are the stages within the Transtheoretical Model?
Describe each of the stages.

10. Stages of the TTM
Precontemplation
Contemplation
Preparation
Action
Maintenance

11. Description of the TTM Stages…
Precontemplation: Not planning any changes in foreseeable future.
Contemplation: Having acknowledged problem. Is considering change.
Preparation: Planning steps in the near future. May be starting to make small changes.
Action: Plans are put into action. Actively involved in changing. Engaging in new behaviors.
Maintenance: Working to maintain change over time. Preventing relapse, consolidating gains, integrating new behaviors into lifestyle.

12. Broadening the Concept of “Evidence” in Recreational Therapy Practice
Chapter 2
Broadening the Concept of “Evidence” in Recreational Therapy Practice

13. Questions on EBP:
a. What does EBP stand for? b. Why was EBP developed? What is its purpose? c. What are the three elements of EBP that are critical for the effective application of EBP? Have all three received the attention they deserve? Please explain. d. What are some challenges faced when RTs attempt to employ evidence-based practice? e. What are RCTs or Randomized Controlled Trails? What might they be considered to be the “gold standard” for clinical research?

14. Questions on EBP:
f. What types of evidence might RTs consider in addition to systematic reviews of research using RCTs? g. Should nonpropositional knowledge be seen as evidence for practice even though it is not research based? Please explain. h. Can you describe quasi-experimental designs, descriptive studies, or case studies? Should the results be of these studies be used as evidence? Please explain. i. Do you agree that it is essential to broaden the criteria for evidence to include diverse sources of evidence as being acceptable for EBP? Please explain.

15. International Classification of Functioning, Disability, and Health
Chapter 3
International Classification of Functioning, Disability, and Health

16. Lecture to Introduce the ICF…
International Classification of Functioning, Disability, and Health

17. An Introduction to ICF…
International Classification of Functioning, Disability, and Health

18. The ICF…
The International Classification of Functioning, Disability and Health (ICF) is a framework for describing and organizing information on functioning and disability.

19. History of ICF…
A disjointed approach historically existed in treating individuals with health conditions across differing countries and the fields of rehabilitation
To provide an international standard for describing and measuring health and disability, on May 22, 2001, the World Health Organization (WHO) adopted the ICF
Over 70 countries have adopted the ICF
ATRA strongly endorsed the ICF in 2005

20. Evolution of Disability Models
Medical Model: Emphasis on pathology (If the person can’t be “cured,” the individual must be abnormal or dysfunctional)
Social Model: Social and environmental barriers create disability. The model is centered on the foundation of equality and justice for all
Biopsychosocial Model: Pathology is important to functioning but so are social and environmental factors (ICF Model)

21. ICF and the medical model
Health and disability are viewed as a part of the universal experience under the ICF model
The ICF is much broader than the medical model
The ICF promotes the concept of disability as a result of assets or barriers found within the social and physical environments instead of a “problem”

22. Disabilities & Functioning under the ICF…
Disability is an umbrella term for the impairments, activity limitations, and participation restrictions. It denotes the negative aspects of the interaction between a person’s health condition(s) and that individual’s contextual factors (environment and personal factors).
Disability is thus not just a health problem. It is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives. Overcoming the difficulties faced by people with disabilities requires interventions to remove environmental and social barriers.
Functioning is an umbrella term for the body function, body structures, activities, and participation. It denotes the positive or neutral aspects of the interaction between a person’s health condition(s) and that individual’s contextual factors (environmental and personal factors).

23. Definitions of Components of the ICF:
Body functions–The physiological functions of body systems (including psychological functions).
Body structures – Anatomical parts of the body such as organs, limbs, and their components.
Impairments – Problems in a body function and structure such as significant deviation or loss.
Activity – The execution of a task or action by an individual.
Participation – Involvement in a life situation.
Activity limitations – Difficulties an individual may have in executing activities.
Participation restrictions – Problems an individual may experience in involvement in life situations.
Environmental factors – The physical, social, and attitudinal environment in which people live and conduct their lives. These are either barriers or facilitators to the person’s functioning.

24. Additional ICF components defined…

25. Health Condition…
The term health condition is the framework heading of the diagnosed condition or disease relevant to the person.
For example, an individual with a T12 spinal cord injury (SCI) would have SCI as his or her identified health condition within the ICF framework (Essentially, this is the diagnosis of the client).

26. Personal Factors…
The domain of personal factors has yet to be coded by the WHO as a result of the great number of possibilities for personal attributes to be considered within this area.
In the example with the client with T12 SCI, if the client has an adventurous and resilient personality as well as existing naturally athletic ability pre-injury, this will influence the client’s recovery as well as the approach taken by the RT.

27. The ICF & RT…
The ICF seems to be an ideal foundation to guide recreational therapy practice and research
The ICF, with its biopsychosocial and holistic approaches fits nicely within recreational therapy

28. Principles for ICF that translate well to RT…
Provides the care provider with more than a medical diagnosis.
The focus is on the functional capacity (rather than on the deficits) and the provision of optimal life experiences for the individual. It is strengths-based.
Reconceptualization of chronic illness and disability into the continuum of health and function help to remove the stigma and isolation seen in the past.

29. Quotes on ICF & RT from Dawson’s ICF chapter:
“The ICF is a strong fit for recreational therapy due to the use of environment and personal contextual domains as facilitators or barriers to participation in community life.”
“The ICF framework provides a clear clinical structure for the recreational therapist to both improve the activity and functioning domains while also mitigating barriers and capitalizing on strengths within contextual domains (environmental and personal) to improve overall participation in society.”

30. RT has embraced the ICF – as evidenced by the following examples of applying it in:
A family education and community reintegration program
A community-based program for people with disabilities
Within a program for veterans with disabilities
With youth with hearing impairments attending a camp

31. RT has produced literature on the ICF:
Porter & Van Puymbroeck (2007) provided a working overview of the ICF within RT practice
burlingame & Blaschko (2010) included the ICF as a theoretical foundation for RT assessment
Porter & burlingame (2006) authored a 770-page textbook on the ICF diagnoses and treatment within RT

32. In sum: RT & ICF… ICF is still relatively new within RT
ICF is being employed by RTs
Because of the endorsement of the ICF by ATRA and more and more literature on the ICF having become available, it is likely that ICF use will grow within RT

33. ICF Discussion Questions
What is the WHODAS 2.0? Describe it and explain how it may be useful to RTs.
What purpose may ICF codes serve for RTs?
Are resources available for RTs wishing to use the ICF codes? If so, identify two or more resources for RTs.
Within the case study provided in the chapter, do you believe the RT interventions listed are appropriate? Please support your answer.
With what you have learned about the ICF, do you believe it can be useful in practice within recreational therapy? Please explain.

34. Integrative Health Care
Chapter 4
Integrative Health Care

35. Class Discussion of Integrative Healthcare
Describe what is meant by integrative health care in your own words.
Explain what is meant by the term complementary approaches.
Explain what is meant by alternative approaches.
Identify complementary approaches typically used by RTs.
Explain if you believe your professional preparation will be adequate to meet the minimum requirements set forth in the report Health Education and Integrative Health Care/

36. Conceptual Models for Theory and Practice
Chapter 5
Conceptual Models for Theory and Practice

37. 3 rungs on the “Ladder of Abstraction” (shows the relationship between philosophy, theory, & practice)
Top rung = philosophy
Middle rung = theory
Lower rung = empirical
This “Ladder of Abstraction” provides an understanding of the relationships between philosophy, theory, and practice.
You can see philosophy on the top rung and theory on the middle rung, with the bottom rung being the empirical or practice level.
Philosophy affects theory, which in turn, affects practice.
(Smith, M., & Liehr, P.R. (eds.) (2008). Middle range theory for nursing (2nd ed). New York: Springer.)

38. RT Conceptual Models provide all three…
1.Philosophy (beliefs/values/philosophy provides major foundations for theories)
2.Theory (What we view our work and profession to be/our mission/purposes/principles)
3. Our practice level (What we actually do – which rests on our theory)

39. Major Elements in Philosophy
Basic philosophical beliefs about human nature (e.g., Human beings are social animals who need to interact with other individuals; All individuals have the capacity for change; All people possess a need to grow toward realizing their unique potentials)
Professional values (Valuing a strengths-based approach to health enhancement that perceives each client as someone possessing abilities and intact strengths; Valuing fun and enjoyment as motivators for clients; Valuing recreational therapy for being purposeful and goal-directed)

40. Theory
Theory is the lens though which practice is viewed. That lens then affects what those in the profession see. It colors how the discipline and clients are perceived.
read slide

41. Theory provides a basis for practice…
“Practice without theory becomes rote performance of activities based on tradition, common sense, and following orders” (McEwen & Wills, 2011, p. 377).

42. Rest on philosophical foundations and
RT Conceptual Models:
Rest on philosophical foundations
and
Provide our theory for practice or they inform practice.
So, in summary, our conceptual models in rec therapy rest on philosophical foundations – such as values and beliefs drawn from the humanistic perspective.
and
Our conceptual modes in rec therapy are where we get our theory for practice.

43. RT Conceptual Models: (Austin, 2002, p.4)
“…offer an image or visualization of the component parts that make up the discipline of recreation therapy, and then describe how these parts relate to one another. Conceptual models outline the purpose and scope of practice…”
(Austin, 2002, p.4)
Read slide….

44. All Conceptual Models provide:
A visual representation
A narrative that accompanies the visual representation

45. First, Conceptual Models Provide a Visualization
A diagram or
Visual representation
Read slide….

46. Here is a diagram of my HP/HP Model diagrammed here.
Have you seen it before? Are you familiar with it at all?
Quickly review major parts…along the bottom is the illness/wellness continuum…along the top are the 3 types of interventions….between these is shown how the client’s control increases and the RT’s control decreases as clients move along the illness/wellness continuum.

47. These narratives have a dual role of…
Secondly, Conceptual Models offer Narratives that Accompany the Diagrams
These narratives have a dual role of…
Read slide

48. Dual Roles of Narratives for Conceptual Models
Address the central phenomena that define a discipline – clarify the nature of the profession and its purpose…why we exist and what we do.
Guide practice – determining what information is obtained on clients, how to understand the dynamics affecting clients, how to approach clients, and determine the actions of practitioners delivering care.
(Allgood & Marrrier-Tomey, 1997)
Read slide…

49. Therefore RT Conceptual Models:
1. Define or distinguish our profession & 2. Determine the actions of RTs in their practice. Our Theory Base for what we do!
Read slide…

50. Concepts from Social Psychology
Chapter 6
Concepts from Social Psychology

51. Do you agree with Hendrick?
“…of all the disciplines concerned with ‘mental health,’ social psychology is the most relevant discipline for the development of effective psychotherapeutic interventions at individual and group levels, by the nature of its content.”
(Hendrick, 1983, p. 67)

52. Do you agree with Austin?
“…understandings from social psychology are not restricted to applications with clients dealing with mental health issues.”

53. Pop Quiz on Social Facilitation
The first social psychology experiment was on social facilitation. Briefly describe this study completed at Indiana University.
Explain the effects of the presence of others when performing tasks.
What ramifications might the social facilitation effect have within recreational therapy practice?

54. Pop Quiz on Self-Views
Explain the difference between self-concept and self-esteem.
What are two major sources of self-esteem?
Explain how holding high self-esteem or low self-esteem can impact on an individual.
What are approaches to helping clients raise low self-esteem?

55. Major Sources of Self-Efficacy
Performance
Vicarious experiences
Verbal persuasion
Physiological arousal

56. The Strengths-Based Approach in Recreational Therapy
Chapter 8
The Strengths-Based Approach in Recreational Therapy

57. Key Points on the Strengths-Based Approach
1. Strengths-based approaches value the capacity, skills, knowledge, connections, and potentials possessed by individuals. 2. Focusing on strengths does not mean ignoring challenges, or spinning struggles into strengths. 3. Practitioners using a strengths-based approach have to work in collaboration – helping people to do things for themselves. In this way, people can become co- produces of support, not passive consumers of support.

58. Chapter 9
Recreational Therapy Mental Health Theory and Practice: Emphasizing the Positive

59. Austin holds that recreational therapists:
(a) have responsibility for the entire mental health spectrum or the entire illness-wellness continuum that includes both clinical recovery and rehabilitation recovery. (b) don’t follow a medical model, do not devalue recreation and leisure but instead highly prize them, and do apply a strengths-based approach.

60. Chapter 10
Professionalism

61. Questions Related to Professionalism
What are markers of the professionalization of an occupational group?
How is professionalism defined?
What are elements associated with professionalism? Do any stand out as being most important to you?
What are means that will help RTs engage in professionalism?

62. How to Take and Pass Tests
Chapter 11
How to Take and Pass Tests

63. Effective Study Skills Discussion Items (Discuss if you agree with the tips given under each item and which tips seem to be most important)
Ways to schedule yourself for taking tests (e.g., Not waiting until the night before to study. Knowing when tests are listed on the course syllabus.)
Devoting time each week to study for a course and scheduling that time (Determining needed hours for study and scheduling them)
Taking part in class (e.g., Attending, taking notes)
Reading assignments (e.g., Reading assignments more than once)
Additional suggestions (e.g., Inquiring with your professor about tests and test content. Using study groups. Attending pretest review sessions)

64. Chapter 13
On Healthy Caring

65. Student Self-Care Recommendations
Make friends with others in the program.
Do not procrastinate with assignments.
Take time for yourself to do something active each day.
Just make time for yourself – for whatever you need.
Learn assertive communication skills to meet your needs and resolve conflicts with others.
Make self-care a priority.
Learn to say “no.”
Take time each day to be mindful – enjoy little things and little moments.
Take school one day at a time and one assignment at a time.

66. Certification and Licensure
Chapter 15
Certification and Licensure

67. Terms Defined
Registration: The process by which a professional has his or her name placed on an official list following verification that he or she possesses specific qualifications such as a degree and professional experience in the area of practice.
Certification: Certification indicates holding a minimum degree of knowledge and skills required to protect the health, safety, and welfare of the public. In RT, certification requires completing a college degree with a specified set of courses, successfully completing an internship under a CTRS, and passing the NCTRC exam.
Licensure: Licensure is a process in which state government provides permission to individuals meeting specified requirements to practice. Typically, NCTRC certification is one of the specific requirements.

68. Chapter 16
Professional Ethics

69. Ethical Principles
Beneficence: Promoting well-being; promoting well-being of clients
Nonmaleficence: Obligation not to harm others or protecting from harm
Fidelity: Faithfulness; keeping promises
Veracity: Being truthful and honest
Justice: Being fair and equitable in distributing services

70. Three Important Principles for RTs
The RT must be familiar with and understand the code of ethics for the profession.
(2) Ethical reasoning flourishes in an environment that promotes open and honest communication.
(3) When faced with an ethical dilemma consult in a professional and confidential manner with your clinical supervisor.

71. Historical Development of Recreational Therapy
Chapter 19
Historical Development of Recreational Therapy

72. “History of Therapeutic Recreation”
Program 1: Precursors of Therapeutic Recreation
Program 2: The First Revolution in Therapeutic Recreation: The Great Acceleration and the Beginnings of Professionalization (starts 10 minutes and 15 seconds into the video)
Program 3: The Professionalization of Therapeutic Recreation (starts at 24 minutes and 5 seconds into the video)

73. Professional Preparation
Chapter 20
Professional Preparation

74. Research on RT Curricula
RT curricula require 7.2 recreational therapy courses totaling almost 24 semester credit hours of coursework.
Universities also universally offered four courses: 1. An introductory course; 2. A techniques/methods/processes course; 3. A course in assessment/programming/evaluation; and 4. A course covering disability groups.
The vast majority also had a course in administration/supervision/operations and an issues/problems/trends course.