Monday, May 16, 2011

A Client-Centred Outcome Measure for the Psychiatric Population

One of my favorite assessments is the Canadian Occupational Performance Measure (COPM), but it has not always been my favorite. At one point, I even stopped using it. I have found some challenges with using it with a psychiatric population, but have also found some ways of overcoming those challenges.

Here's the authors' description of it:

The Canadian Occupational Performance Measure (COPM)© is an individualized outcome measure designed for use by occupational therapists.  The measure is designed to detect change in a client's self-perception of occupational performance over time.

Basically, you meet with your client, and discuss the issues/barriers a person may be having in the different areas of occupational performance (activities of daily living). These are in the categories of self-care, productivity, and leisure, and have further sub-categories.

You use a 1-10 Likert scale to assist your client to determine the issues that are most important to him or her. Your client then uses a 1-10 Likert scale to rate performance, as well as satisfaction with performance in those areas.

After intervention, you assist your client to re-rate his or her satisfaction in the identified areas of occupational performance, to see if there is any change.

The COPM seems to have 3 uses:

1. Identification of the goals of therapy, and a reminder of them.
2. Measure of progress.
3. As a discharge tool.

It can be a great way of ensuring client-centred goal-setting. It is helpful when working with clients where you tend to get side-tracked, by giving you something to refer back to. It is great for helping both you and your client see if there has been any change. Often, when there has been significant improvement, it makes it easy for both you and your client to see that discharge is the next step.

Sounds pretty great, but what are the issues with it?

1. Many clients with severe and persistent mental illnesses such as schizophrenia have difficulty identifying what their issues are. For example, if you ask a person if he or she has trouble grocery shopping, the answer will likely be "no". However, if you ask more specific questions, such as, "Are you able to carry your groceries home from the store?", or "Do you have enough money to buy groceries?", or "Are you able to find the items you need at the grocery store?", the answer is often very different.

2. Many clients have difficulty with using a Likert scale as it is too abstract for them to understand. They are therefore unable to rate their occupational performance.

Due to clients not being able to independently identify their performance issues, I no longer use the COPM as an interview. I have my own initial interview that has very specific questions in each area of independent living. After going through a very comprehensive initial interview, I make a list of the areas that I feel the client is telling me that he or she is having issues in. I then review the list with the client to see if he or she agrees that those are issues, and to see if there are any issues I have missed.

In terms of the Likert scale being too abstract, I have found that a scale with happy/sad faces underneath can make it much more concrete. I use a sheet that shows a really sad face, a sort of sad face, a neutral face, a sort of happy face, and a really happy face, all with the numerical rating scale on a line above the faces. I only use it when my client is having difficulty understanding the scale. It will be included in my upcoming book: Daily Living Skills Worksheets.

I also sometimes vary from the standardized wording a little too. I know, I know, that's a big no no. However, this is not a norm-referenced assessment, so I figure I am not hurting anyone. It can sometimes make the difference between being able to use the scale or not being able to use it. Instead of asking how a person would rate his or her performance, I sometimes say, "How well are you able to...?" Instead of asking how satisfied a person is with his or her performance, I sometimes say, "How happy are you with your ability to...?"

These are little changes in the way I administer the COPM, but they have made a big difference in the usefulness of this assessment. I'm glad I gave the COPM another try.

To find out more about the COPM, check out their website by clicking here. The authors are: Mary Law, Sue Baptiste, Anne Carswell, Mary Ann McColl, Helene Polatajko, and Nancy Pollock.

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