PROFESSIONAL TRENDS IN ASIA

The Ayurvedic Model of Human Occupation
Venthan J. MAILOO, BSc(Hons), MCSP, CertMgmt1
1Band 5 Rotational Occupational Therapist. Barnet Primary Care Trust, Finchley

Memorial Hospital

Abstract: Ayurveda is an Eastern system of medicine that has been practised for over
5000 years. The relationship between occupations and health is a fundamental aspect of
the ayurvedic health model. It could contribute a strong spiritual element to modern
occupational therapy practice and may be more culturally appropriate for people withstrong Hindu/Buddhist beliefs than modern occupational therapy models. The aim of thispaper is therefore to introduce the ayurvedic model to occupational therapists that are
unfamiliar with it. It describes assumptions underlying the ayurvedic model and related
frames of reference that are relevant to occupational therapy. Yoga is the main
occupational therapy intervention advocated by the model. The branches of yoga aredescribed. Other traditional interventions are summarised but not described in detail.
Sanskrit terminology has mostly been removed and concepts have been simplified for theease of a general readership.
Key words: Ayurveda, yoga, Tantra, spirituality(Asian J Occup Ther 6: 1–13, 2007)

Introduction
In the British Journal of Occupational
Therapy Ilott et al. (2006, p.39) recently suggested“ E n gl is h is t he l a n gua ge f or s c i e nce a nd
occupational therapy”. Their statement arguably
imposes occupational injustice on occupational
therapists and researchers for whom English is not
the first language. That it slipped though thereview process of the British journal may be anindication of a cultural insensitivity or lack of
cultural awareness pervading the profession in
Received: May 31, 2007, Accepted: September 16, 2007
Corresponding to: Venthan J. Mailoo, Band 5 Rotational
Occupational Therapist. Barnet Primary Care Trust,Finchley Memorial Hospital, UK
phone: 447811251624 fax: 4420 8349 7504
e-mail: servantofvishnu@gmail.com

Britain. Occupational therapy was practised indifferent forms by various cultures worldwide
long before the term ‘occupational therapy’ wasformally applied (Wilcock, 2001), and healthmodels incorporating occupation existed before
the English language. Two closely related(Frawley & Lad, 1988) examples of this are
traditional Chinese medicine (Williams, 1999) and
Ayurveda (ancient Indian medicine). Both ofthese feature occupational regulation for the
maintenance of good health.
Modern Western occupational therapy haslargely failed to embrace traditional Easternconcepts and could arguably be improved if it did
so. Relatively recent advances in modern Westernscience, such as quantum physics Vicente et al.
(2005) and psychoneuroimmunology (Mailoo,
2006b) are steadily bridging the gap between
modern Western and traditional Eastern

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AYURVEDIC MODEL OF HUMAN OCCUPATION

philosophies. Healthcare provisions based onthese advances have exploited advantages theoccupational therapy profession is largely yet toembrace. An example of this is Reverse Therapy(Eaton, 2006), a modern successful chronic fatigue
treatment approach that parallels a much older
Tantric frame of reference (a component of
Ayurveda). As communication construction isculturally determined (Venth, 2007), if theoccupational therapy profession imposes modern
Western constructs onto traditional health systems
when determining their quality as models, its
understanding and growth may be adversely
restricted. It would arguably be better to researchestablished health models fully with an open mind,
and understand them fully before judging them.
This article is therefore intended to introduce one
Eastern model to occupational therapists that are
unfamiliar with it. The model is Ayurveda.
The term ‘ayurveda’ is derived from the
Sanskrit words ‘ayu’ that means ‘daily living’ and‘veda’ that means ‘knowing’. Ayurveda has beenpractised for over 5000 years (Lad, 1985). The
relationship between occupations and health is afundamental aspect of the ayurvedic health model.
It is comprised of three key frames of reference.
These are the Three Humours, the Three Natures
and the Tantric frame of reference.
Yoga is the main occupational therapyrelevant ayurvedic intervention. Mailoo (2005)
provided a very brief introduction to yoga but
Grieve (2006) suggested that if components ofyoga are used without a proper understanding of
their context, their value might be significantly
diminished. One could compare this to a personwith no knowledge of haemo-dynamics using a
sphygmomanometer on a patient and then giving
advice on salt consumption. This paper therefore
covers the assumptions underlying the ayurvedic
model, its three main frames of reference and theumbrella of yogic techniques. A thoroughunderstanding of yoga or ayurveda would require asignificant volume of reading with experiential
learning and is beyond the scope of a journal
article. This article does not therefore provide any
technical information on diagnostic or therapeutictechniques; it merely describes the underlying
framework to enable a contextual understandingthat learning can be built upon. This could becompared to reading about anatomy andphysiology before trying to use asphygmomanometer. Appendix recommends
specific further reading and opportunities forexperiential learning for occupational therapists
interested in taking the ayurvedic model further.
Sanskrit terminology has mostly been removed
and concepts have been simplified for the ease of ageneral readership.

Assumptions
Assumptions about the universe
Everything is believed to have developed
from a unified field termed ‘Brahman’. This could
be considered the collective consciousness ofeverything in the Universe (Sharma & Clark,
1998). The energy of this field generates matter.
Everything the human mind can perceive istherefore just transient forms of energy. Nothingcan exist forever in material form, but theunderlying energy has always existed and always
will exist. An example of this transience is birthand death. After death the outer-most material
manifestations of humans (the material bodies)
decay, but the underlying energy invariably remanifests elsewhere (Jinpa et al., 2006). The
nature of re-manifestation depends entirely on theenergy’s reactions to its previous experiences.
This may be interpreted as re-incarnation, heavenor hell.
A common belief in cultures following thisphilosophy is that material existence is a mistake
resulting from misperception of the Universe andan illusion of individuality (Dalai Lama, 2006).
The body and mind are seen as burdens to escapefrom. Many of the techniques used for escape fallunder the umbrella term ‘yoga’. Various schoolsof yoga are based on austerity, control of thesenses and withdrawal from material experience,with the ultimate aim of returning to a state ofunity with the Universe. The austerity usually
involves abstinence from sexual activity, meateating and alcohol consumption. This approach to
wellbeing is unlikely to be culturally appropriate
outside ascetic sub-cultures and has therefore been
excluded from this article.

Asian J Occup Ther 6: 1–13, 2007

Mailoo VJ

3

Table 1. The psyche (Adapted from True World Order, 2000).
Energy aspect

Experiences

BlissIntellectual
MentalVital
Physicalbliss, joy calmness, peace
higher reasoning, discrimination and decision making, individualism (ego)sensations of sight, sound, smell, taste and touch, emotions, basic thought, memories
hunger, thirst, heat, cold
Birth, growth, decay and death

Ayurvedic psychology
According to ayurveda, on the deepest level
each person is believed to be eternal andunchangeable (a fragment of Brahman). This is
the true (spiritual) self. It is indistinguishable fromthe Universe and is in a constant state of bliss. In
its pure inactive form it is unable to experiencematerial existence. It manifests more superficial
energies for this purpose. During gestation the
superficial energies develop a body and mind incircumstances designed to meet the desires of theself (Redfield, 1994).
The self is unable to experience distress. The
mind and body are simple tools for its use. Theego (in the intellectual aspect) can experience
distress when it becomes active and identifies withthe mind and body as an individual. “This sense of
self is simply a mental construct, a mere label
given to this cluster of dependently arising mental
and physical events in dependence on theircontinuity” (Dalai Lama, 2006, p xvi). This typeof identification leads to suffering, which indicatesthat the mind is not being used appropriately as atool. Various Eastern religions are therefore based
upon looking inwards to find the bliss aspect bytranscending the ego, to escape from suffering.
Ayurveda identifies three broad performancecomponents of thinking. These are sensate
thinking, feeling and reasoning (Frawley, 1994).
The sensate mind creates instinctive emotions
such as desire, fear and anger and harbours likes,
dislikes and personal opinions. It works throughfrom the physical to intellectual aspects of thepsyche but has no direct interaction with the bliss
aspect. It is essential for survival of the material
body. The feeling mind enables intuitive knowing
and the reasoning mind discriminates between
reality and illusion. The feeling mind generates

Table 2. The three humours
Sanskrit terminology

Metaphoricalterminology

Vata
Prana

Wind / air

Pitta
Tejas

Fire

Kapha
Ojas

Earth / water

the human will to live. The reasoning mind creates
the ego but also ultimately guides it towards
spiritual development. The feeling and reasoning
components of the mind work through all fiveaspects of the manifest self from the physical tobliss aspects (Frawley, 1994). They are tools to
guide the material body to fulfil the desires of theself.

Ayurvedic physiology
Ayurveda draws no clear distinctions
between mind and body or physical and mental
illness. These beliefs are congruent with those ofChinese medicine (Williams, 1999), modern
advances in psychoneuroimmunology (Mailoo,
2006b) and some developing Western alternative
therapy techniques (Gordon, 1999). The mind is
not thought to reside in the brain, but in the energythat permeates the entire body. Health is believed
to depend on a constant flow of that energy
through the body. The energy flows according toconsciousness through a complex system ofchannels and centres partially described by Sir
Donald Woodruff when he translated original
Sanskrit accounts in 1918 (Avalon, 1974).

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AYURVEDIC MODEL OF HUMAN OCCUPATION

Table 3. Earth symptoms and treatments (Lad, 1984, Frawley, 1994).
Signs of excessive earth

Treatment

Lack of drive, greed, attachment (hoarding
behavior), envy, slow to learn but with good longterm memory, lethargy, obesity.

Breathing exercises, physical exercise, travel,stimulating leisure activities.

Signs of inadequate earth

Left nostril breathing, rest, meditation, control ofsexual energy, regular routine, environmental
adaptation (housing), facilitation of: acquisition ofnecessities, household tasks, economic life,
religious devotion or faith occupations, informal
and formal associations and relationships, love,
intimate relationships

Emotional lability, fear, anxiety, restlessness,
insomnia, nervous exhaustion, immunosuppression, infertility.

Table 4. Wind symptoms and treatments (Lad, 1984, Frawley, 1994).
Signs of excessive wind

Treatment

Mental instability, rapid thought with good shortterm but poor long-term memory, rapid speech,
recklessness, indecisiveness, poor financial
management due to compulsive spending, loss ofconfidence, anxiety, hyperventilation, insomnia,
neurological weakness, intolerance of cold
conditions, fatigue, emaciation, cracked tongue,
brittle nails.

Rest, meditation, regular routine, environmental
adaptation (housing), facilitation of householdtasks and economic life.

Signs of inadequate wind

Breathing exercises, meditation, physical exercise,travel, music.

Lethargy, apathy

Detailed knowledge of the energy channels is not
required for occupational therapy, but energies are
the basis of two frames of reference underlying the
ayurvedic model. These are ‘the Three Humours’and ‘the Three Natures’. The main energies
considered in ayurvedic physiology are vata, pitta,
kapha, prana, tejas and ojas (Frawley, 1994).
Subtle differences between them are important forthe medicinal aspects of ayurveda but they can bematched into pairs by occupational characteristics.
For simplicity therefore, occupational therapists
need only remember them as earth, wind and fire.

Frames of Reference
The three humours
This frame of reference works on 3 humoursthat permeate the human being, metaphoricallytermed earth, wind and fire. For ideal health thethree humours must be in perfect balance. They
are influenced by diet, thoughts, habits and theenvironment. Of these, only the latter 3 are
relevant to occupational therapy. Earth isnecessary for functioning of the sensate mind.
Table 3 shows symptoms of and treatments forearth imbalance.
Wind balance is essential for intuition. Table
4 shows symptoms of and treatments for wind
imbalance.
Fire is essential for the functioning of thereasoning mind. It is associated with will power.
Table 5 shows symptoms of and treatments for fire
imbalance.
Diagnostic techniques for the three humoursAsian J Occup Ther 6: 1–13, 2007

Mailoo VJ

5

Table 5. Fire symptoms and treatments (Lad, 1984, Frawley, 1994).
Signs of excessive fire

Treatment

Overly critical mind, dominating personality,
paranoia, irritability, anger, hatred, burning
headaches, food cravings for sweet and bitter tastes,moles and freckles, intolerance of heat or sunlight,
excessive perspiration.

Conflict resolution, environmental adaptation.

Signs of inadequate fire

Right nostril breathing, clear honest
communication, silence (avoiding unnecessarycommunication), yoga (for spiritual development),
housing, environmental adaptation, stimulating
leisure activities.

Cloudy perception, irrational judgement, confused
speech, uncritical acceptance, passivity.

Table 6. The three natures.
NatureHuman characteristic

Problems (if excessive)

essence

Purity: serenity, mental clarity.

Naivety, loss of libido, unsustainable self-sacrifice,obsessive-compulsive disorder, death.

activity

Passion: ambition and drive, attachment.

Lust, frustration, anger, hatred, violence, mania.

inertia

Ignorance: laziness, withdrawal.

Selfishness, loss of libido, depression, lethargy.

are beyond the scope of this article but were
described in detail by Lad (1984).

The three natures
The material universe is characterised bythree natures: essence, activity and inertia (Sharma& Clark, 1998). Essence is pure in nature and is
the closest of the three to Brahman. In humans it
is responsible for altruistic motivation, tolerance
and compassion. Activity is the nature of passion.
This nature underlies the drives that keep thematerial body alive and ambition for material
achievement. Inertia is the nature of ignorance.
All three natures are required for human life.
Table 6 illustrates disorders caused by imbalanceo f t h e n a t u r e s . A s m at e r i a l e x i st e n c e i simpermanent and the ego is an illusion ofindividuality that hides a constant state of bliss,many have argued that life is pointless and weshould try to escape from it. Inertia enables
humans to suspend their disbelief and remain
involved in life. Without it there would be no

motivation for life. Passion (activity) is required
to motivate any achievement in the material world.
Through the practice of yoga it is possible to leave
the inertia and activity behind to reach constantawareness of the underlying bliss. This stage of
yoga practice is termed ‘Turiya’. Once Turiya has
been achieved, the human body can only survive
for three days as the yogi has no motivation tomaintain it (True World Order, 2000). Without
essence the ego is motivated by activity and inertia
alone. When this happens people are totallyvulnerable to societal influences and act in ways
incongruent with their inner selves. As the energyof material being originates from the self, it
progressively weakens if it becomes incongruent
with the self. This predisposes people to all
manors of diseases and leads to the decay of thehuman mind and body.
Disorders of the Three Natures are selfperpetuating. A depressed person for example,
may withdraw from activity (NICE, 2007) andview everything from a negative perspective

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AYURVEDIC MODEL OF HUMAN OCCUPATION

Table 7. The tantric frame of reference (Adapted from Kapke 2000)
Consciousness

Occupational needs

Examples of need fulfilling occupations.

Universal

Altruism

Heroism, charity, environmental conservation, passive being,
dying.

Self

Following intuition

Reflection, meditation, action based on intuition.

Creative

Creative and communicative
occupations.

Honest expression, information gathering, art.

Compassionate

Social occupations.

Building and maintaining social circles and family dynamics,
pet care.

Egotistical

Vocational occupations andpersonal development.

Education, vocational skills and employment, social statusbuilding.

BodilyComfort and pleasure seeking
occupations, sexual occupations,leisure.

Grooming, feeding (for pleasure), sexual activity andexpression, exercise and relaxation, leisure.

Material

Survival occupations

Sleep, feeding, hygiene activities, dressing, essential
housework and laundry, shopping, financial management,
security occupations.

(Griffin & Tyrell, 1999), thus increasing his or her
depression, while an angry person is likely tocreate conflict that provokes anger. Suchdisorders must therefore be treated with facilitatedoccupational change.

The tantric frame of reference
Tantra is a branch of yoga that values material
existence (Isaacs, 2006). Its origins have been
shrouded by politics (Lysebeth, 1995), but it haspermeated through both the Hindu and Buddhist
religions. Sexual intercourse, meat eating andalcohol consumption feature as spiritual practices
in some aspects of Tantra (Frawley, 1994). The
body and mind are seen as tools for spiritualdevelopment. For this reason, great care is takenof them. This is reflected by the popular saying“my body is a temple”. As the body and mind
were designed specifically to achieve the needs ofthe self, they suffer undue stress if they follow any
path not conducive to fulfilling those desires.
Such stress renders one vulnerable to disease.
Consciousness is a continuum but for
convenience this frame of reference divides it into
7 domains. A balance of consciousness between
all 7 domains is essential for survival of the humanmind and body. People may sacrifice their needs
for honest communication in order to maintain asense of power (Revill, 2003; Page, 2006) thoughmaterial success and hedonism if unbalanced are
not protective of mental health (Stack, 1987; Read
& Purse, 2006; Vaughn, 2007). This is likely tohappen if intuition is not permitted to guide one tothe altruistic motives of the self. Ultimate successwith Tantra depends on this altruistic motivation(Dalai Lama et al., 2005). At the other extreme
advanced yogis may become incapable of survival
due to excessive altruism, or may neglect their
physical bodies in favour of spiritual pursuits. One
aspect of Tantra utilises sexual energy to reachbliss consciousness (Gyatso, 1995), but this haspoor generalisability and so will not be describedin this paper.
It is important to remember that thesignificance of any occupation depends on
individual interpretation (Paley et al., 2006).
Taking military bravery as an example, one soldier
may undertake acts of courage to build social
status for egotistical reasons. Another may
undertake similar acts for altruistic reasons tosatisfy universal consciousness.

Asian J Occup Ther 6: 1–13, 2007

Intervention Modalities
Ayurvedic concepts traditionally influenced
government and societal rules, environmental
planning and personal occupational routines.
Yoga is the main occupational therapy-relevant
ayurvedic intervention. Western occupational
therapists have used yoga for mental health(Anderson & Winterbone, 1979; Eakin, 1979;
Giles, 1985; Kluge, 2004), health services forolder people (Batcheller, 2005), paediatrics(Behar, 2005; Bowen-Irish, 2005), neurology(Volz, 2002), occupational health (Taylor, 2001),
and general physical rehabilitation (Cooney, 2005)
specifically to treat autism (Behar, 2005) attention
deficit disorder, Down syndrome and cerebral
palsy (Klimas, 2003), multiple sclerosis (Volz,
2002), anxiety and respiratory disorders (Sabel &Gallagher, 2004), osteoarthritis and polio(Batcheller, 2005), reduced exercise tolerance(Bowen-Irish, 2005) and work-related injuries(Taylor, 2001). Reported benefits have included
decreased anxiety (Sabel & Gallagher, 2004),
improved digestion (Cantu, 2005), muscle tone,
strength, flexibility (Bowen-Irish, 2005), lateralthinking and social integration (Batcheller, 2005),
respiratory function (Proctor, 2004), joint control
and posture (Volz, 2002). Yoga is a system ofoccupational regulation. It can be broken down
into different branches, each more or lessapplicable to specific occupational domains andtreatment approaches.

Karma yoga
Karma yoga is altruistic work (True World
Order, 2000). This is the vocational rehabilitation
element of the ayurvedic system and should beconsidered when the Tantric frame of reference
reveals lacking altruistic occupations causing alack of meaning in life. As the self is continuouswith the Universe a sense of lasting fulfilment isunlikely unless one is contributing to the Universe
in some way. Karma yoga can be used to reduce
inertia and depending on the type of work chosen
may reduce the earth humour. Excessive work candeplete earth and fire leading to excessive wind.
Work-life balance should therefore be maintained
ensuring that all of the seven domains of

Mailoo VJ

7

consciousness specified in the Tantric frame ofreference are occupationally satisfied. The type ofwork chosen should be according to anindividual’s intuition. Many people remain in jobs
that make them unhappy due to social pressure.
Adverse social pressures are remedied with Jnana
Yoga.

Bhakti yoga
Bhakti yoga is any devotional religious
activity (True World Order, 2000). It increases theearth humour but is only applicable to thoseindividuals who feel it is important. People thatvalue this area of occupation should be encouraged
to keep protected time for it during their everyday
routines as well as during convalescence. Peopleof no religion may also practise bhakti with theirown personal methods if they are devoted to ahigher power.

Raja yoga
Raja yoga is a structured m ethod forfacilitating psychological and physicaldevelopment. It consists of simple rules for ethicalsocial conduct, postural exercises, breathing
exercises and meditation (Taylor, 2003). The
social conduct rules are: non-violence, nonstealing, non-lying, non-attachment andmoderation of the senses (Cirone, 2005). These
strengthen social congruence by increasing trust.
Non-attachment prevents greed and envy, andmoderation of the senses subdues the sensate mind
thereby increasing clarity of intuition. This
redu ces the possibi lity of addicti ons andmaladaptive changes that may lead to secondaryanti-social behaviour.
Suppression or repression of any impulses ordesires is believed to be harmful (Lad, 1984). For
this reason moderation of the senses using will
power alone is not advised. Breathing exercises
and meditation used in yoga slow the sensate mind
to a stop. As the physical body and sensate mind
manifest from the self, deep meditation on any
thoughts or desires from the sensate mind
ultimately leads back to the self that is constantly
content (Osho, 1998). This naturally dulls lust andthe effects of society’s influences on the mind.
There are several breathing exercises and8

AYURVEDIC MODEL OF HUMAN OCCUPATION

meditation techniques used in yoga. Some of thesework on specific humours and domains ofconsciousness. Description of the techniques isbeyond the scope of this article. The breathing
exercises were described in detail by Swami
Vishnu-devananda (1988) and have been thesubject of literature reviews (Shannahoff-Khalsa,
2001; Mailoo, 2006a). One-hundred and twelve
simple meditations were described by Osho (1998)
and more complex ones by the Dalai Lama et al.
(2005).
Steady postures are used in raja yoga to
improve concentration and maintain physicalfitness. Particular postures are used to increase or
reduce the influence of particular humours but thismodality falls into the domain of physiotherapy(Tayl or & Majm un dar, 20 00) rath er t han
occupational therapy.

Jnana yoga
Jnana yoga is the process of study and criticalanalysis to determine the truth of all things (TrueWorld Order, 2000). This is the cognitivebehavioural element of ayurveda. Jnana yoga isused to discriminate between a person’s true desire
and the desires of the sensate mind that arise due tosocietal influences. Products of Jnana yoga
include emotional release, detachment andpreparation for death.
Emotional Release: Society exerts pressure
on individuals to repress their natural drives
though fear, guilt, and shame (Kapke, 2000).
These feelings are processed by the ego.
Identifying the impermanence of society, the ego
and the feelings it generates and comparing it to
the permanence of the self liberates one from theserestraints.
Detachment: Society and the ego create
psychological attachments that may make the willof the self impractical. Examples of these
attachments may include addictions, interpersonal relationships (such as marriage), religious
beliefs or material possessions (such as amortgage). Attachment to financial debt due toconsumerist behaviour has become a Western
norm (Fincher, 1999; Healey, 2007). Once theimpermanence of the material world is recognised
and accepted, distressing attachments seem

illogical and are more easily left aside. Material
experiences that are stressful with attachment canbe enjoyed blissfully in the absence of attachment.
This was illustrated well by Mendes (1999) with
the narrative of a man who was very unhappyliving a normal secure middle-class North
American lifestyle but was able to find bliss (evenin death) by detachment.
Dying: Many fear dying is a passive process.
Death is a taboo subject in many cultures and no
preparation is made for it. Jnana yoga identifies
the impermanence of material existence and theinevitability of death. Death may be lessdevastating for individuals and families who areprepared for it. People who reflect on theinevitability of death may have preferences as to
how it happens. This is not an indication for
suicide, as Tantra views the human body as asacred vehicle to be cared for, but when people aredying their experiences may feel less traumatic if
their wishes are followed. Reflection on thecertainty of death increases the appreciation of life
and the motivation to live it well (Jinpa et al.,2006). According to ayurveda ones desires at theend of life shape ones next incarnation. For thisreason a main aim of yoga is attainment of a puredesire-less state of mind before death. This may
require fulfilment of all desires during life or yearsof meditation.

Environmental interventions
Inner peace is difficult to find in cities due toimbalance between human and plant life (Redfield1994) that leads to depletion of the wind humour(Frawley, 1994). For this reason serious yogis
usually move to remote areas. This could be
avoided if planning of cities accounted for better
harmony with and tolerance of nature (Fig. 1).
Ayurvedic planning as carried out according
to a process named ‘vastu’. This takes into
account the directions of sunlight and natural
magnetic fields. Vastu is complex and beyond thescope of this article. A detailed explanation can befound in Sharma & Rao (2005). The adaptations
used by modern Western occupational therapists
to allow physically impaired people freedom of
occupation can be applied using the Tantric frameof reference. Bathing and toileting equipment forAsian J Occup Ther 6: 1–13, 2007

Destructive planning.
Fig. 1. Nature in city planning.

Mailoo VJ

9Conservative planning.

Figure 1 illustrates how planning to preserve the balance of the wind humour (right) would compare to thecurrent planning (left) of a main road in Greater London (England). The functionality of road andamenities remains unaffected, but the psychological impact of their appearance is altered by coexistencewith plant-life.

example may be needed to satisfy the material
consciousness’ need for hygiene occupations.

Political and social intervention
Societal pressures can discourage people
from acting according to their own occupational
needs (Wilcock, 2001), and social norms can cloud
intuition, preventing people from identifying
lifestyle changes that would benefit them (Vicente
et al., 2005). Internalised societal values may
inspire unnatural occupational efforts. Common
examples in modern societies are dieting orexcessive exercise to compensate for body image
dissatisfaction (Foltz-Gray, 2006). Occupational
alienation may occur due to societal values or
prejudice. Young people in the United Kingdom
for example are alienated by the behaviour ofadults (Redfield, 1994) and legislation restricting
their engagement in paid employment and sexual
activity. This limits their opportunities foroccupations motivated by bodily and egotisticalconsciousness (Table 7). Homework given byschools teaches children to disregard occupationalbalance from an early age (Brown, 2007).
Mismatches between occupational needs andopportunities may lead to maladaptive antisocial
behaviour at individual (Johnson, 2006) or group(Balasingham, 2000) levels. In some Eastern

societi es peo ple trad itio nally en gaged in
productive and family roles at the ages when these
instincts emerged rather than at artificially sociallydetermined ages (Rasamandala, 1994; Osho,2001). Another cause of occupational alienationin the United Kingdom is the over-standardised
education system in which children are expected tolearn- and are tested on an array of subjects
regardless of personal interest. This can alienate
people who might experience greater success withmore vocational schemes. In Vedic culture yogis
were responsible for advising politicians andteaching the youth. Modern occupational
therapists may have to adopt similar roles in the
future.

Limitations of this Paper
A thorough understanding of yoga or
ayurveda would require several weeks of full-time
study and is therefore beyond the scope of thisjournal article. The concepts presented here havebeen highly simplified and described without theauthentic Sanskrit terminology. The terminology
used in this paper is not suitable for professional
communication with practitioners of authentica y u r v e d a , o r s e r v i c e -u se r s f r o m c u l t u r a l
backgrounds familiar with these concepts.

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AYURVEDIC MODEL OF HUMAN OCCUPATION

Fig. 2. Bath-seat.
Figure 2 shows a stool used by Swami Prabhupada for simple environmental adaptation at Bhaktivedanta
Manor, Letchmore Heath, England. Swami Prabhupada was the founder of the International Society for
Krishna Consciousness (ISKCon: http://www.iskcon.com/). ISKCon teaches bhakti yoga, karma yoga andjnana yoga free of charge worldwide.

Aspects of the yoga, ayurveda and Tantra thatcannot be easily generalised or applied to modern
societies have been omitted, as they may not be
relevant outside their historical context. This
article is broad and lacks specific detail for eacharea of the subject matter covered. It was written
this way to substantially reduce the time and effort
required by occupational therapists to gain acontextual understanding of ayurveda and yoga.
Appendix therefore provides recommended
reading and networking opportunities foroccupational therapists wishing to deepen theirunderstanding of the concepts presented.

Acknowledgements
This paper does not represent the policies orpractices of any National Health Service Trust.
This work was completed in respectful
memory of Mailoo Jeyaratnam LL.B., M.Sc.,
M.I.F.S.T., M.I.Mgt., C.Chem., F.R.S.C.,
Homeopath, LLFCH 27/6/1929-29/6/2004
The author wishes to thank the Asian Journalof Occupational Therapy’s anonymous
reviewer(s) for their constructive feedback.

References
Anderson, F., Winterbone, A. (1979). Yoga in a shortstay psychiatric unit. Br J Occup Ther. 42(8),191–
193.
Avalon, A. (1974). The Serpent Power. The secretsof Tantric and shaktic yoga. (7th edition),
Mineola: Dover Publications.
Balasingham, A. (2000). The Politics of Duplicity.
Mitcham: Fairmax Publishing Ltd.
Batcheller, L.J. (2005). The sitting mountain series.
Advance for Occupational Therapy Practitioners.
21(6), 46.
Behar, M. (2005). Using yoga to treat autism.
Advance for Occupational Therapy Practitioners.
21(12), 27.
Bowen-Irish, T. (2005). Bringing yoga into theclassroom. Advance for Occupational Therapy
Practitioners. 21(8), 43.
Brown, J. (2007, February 14). Damning verdict on
the ordeal of growing up in Britain today. The
Independent. 2–3.
Cantu, C. (2005). We need evidence for yoga inpediatrics. Retrieved April 13, 2006 from http://
occupational-therapy.advanceweb.com/common/
EditorialSearch/printerfriendly.aspx?CC=48544
Cirone, M.W. (2005). Yoga philosophy in yoga
therapy: teaching the yamas and niyamas toAsian J Occup Ther 6: 1–13, 2007

women with cancer. Retrieved June 11, 2006 fromhttp://www.iayt.org/publications/ytip/sep05/
woodscirone.htm
Cooney, D. (2005). Poses for all people. Advance for
Occupational Therapy Practitioners. 19(14), 22.
Dalai Lama (2006). Introductory commentary. In:
Jinpa T., Coleman G., Dorje G. The Tibetan Bookof the Dead. (pp.xv-xxix) London: Penguin
Books.
Dalai Lama, Dzong-ka-ba, Hopkins J. (2005). Yoga
Tantra. Paths to Magical Feats. Ithaca: Snow
Lion.
Eakin, P. (1979). Yoga (letter). Br J Occup Ther.
42(11), 295–296.
Eaton, J. (2006). M.E., Chronic Fatigue Syndrome &Fibromyalgia. The Reverse Therapy Approach.
Authors Online: Hertford.
Fincher, D. (1999). Fight Club. London: TwentiethCentury Fox.
Foltz-Gray, D. (2006, June). Happy in your own
skin. Yoga Journal. 76–81, 127–128.
Frawley, D. (1994). Tantric Yoga and the Wisdom
Goddesses. Delhi: Motilal Banarsidass.
Frawley, D., Lad, V. (1988). The Yoga of Herbs.
Twin Lakes: Lotus press.
Giles, G.M. (1985). Anorexia nervosa and bulimia:
an activity-oriented approach. Amer J Occup Ther.
39(8), 510–517.
Gordon, R. (1999). Quantum-Touch: The Power toHeal. Berkeley: North Atlantic Books.
Grieve, C. (2006). Yoga [Letter to the editor] Br J
Occup Ther. 69(2), 93.
Griffin, J., Tyrell, I. (1999). Psychotherapy and the
Human Givens. Hailsham: The European Therapy
Studies Institute.
Gyatso, K. (1995). Tantric Grounds and Paths. (2ndimpression), Ulverston: Tharpa Publications.
Healey, R. (2007, May). How to find freedom.
Mensa Magazine. 8–10.
Ilott, I., Taylor, M.C., Bolanos, C. (2006). Evidencebased occupational therapy: it’s time to take aglobal approach. Br J Occup Ther. 69(1), 38–41.
Isaacs, N. (2006, June). Tantra rising. Yoga Journal.
73–74, 122–126.
Jinpa, T., Coleman, G., Dorje, G. (2006). The
Tibetan Book of the Dead. London: Penguin
Books.
Johnson, A. (2006, March 5). Lost boys of the black
country. Night & Day Live. 16–20.
Kapke, B. (2000). Energy medicine. Wheels of light:
clearing, balancing & connecting chakras.
Massage & Bodywork. 15(6), 132–135.

Mailoo VJ

11Klimas, N. (2003). Yoga for youngsters. RetrievedApril 13, 2006 from http://occupationaltherapy.advanceweb.com/common/
EditorialSearch/printerfriendly.aspx?CC=6568
Kluge, J. (2004). Yoga therapy. An integrative
approach. OT Practice. 9(17), 22–24.
Lad, V. (1984). Ayurveda: The Science of SelfHealing. A practical guide. Wilmot: Lotus Press.
Lysebeth, A. V. (1995). Tantra: The Cult of the
Feminine. Boston: Weiser Books.
Mailoo, V.J. (2005). Yoga: an ancient occupational
therapy? Br J Occup Ther. 68(12), 574–577.
Mailoo, V.J. (2006a). Pranayama: potential tools toenhance occupational performance. Asian J Occup
Ther. 5, 1–10.
Mailoo, V.J. (2006b). Psychoneuroimmunology andoccupational therapy for inflammatory disorders.
Int J Ther Rehabil. 13(11), 503–510.
Mendez, S. (1999). American Beauty. Universal
City: DreamWorks SKG.
NICE (National Institute for Health and ClinicalExcellence) (2007) Clinical Guideline 23(amended) Depression: Management ofdepression in primary and secondary care.
National Institute for Health and ClinicalExcellence: London.
Osho (1998). The Book of Secrets: 112 Keys to the
Mystery Within. New York: St. Martin’s Griffin.
Osho (2001). Autobiography of a Spiritually
Incorrect Mystic. New York: St. Martin’s Press.
Page, B. (2006, May). Fighting for justice. Mensa
Magazine. 8–11.
Paley, J., Eva, G., Duncan, E.A.S. (2006). In-order-to
analysis: an alternative to classifying different
levels of occupational activity. Br J Occup Ther.
69(4), 161–168.
Proctor, S. (2004). Open up and say ‘om’. RetrievedApril 13, 2006 from http://occupationaltherapy.advanceweb.com/common/
EditorialSearch/printerfriendly.aspx?CC=39929
Rasamandala dasa (1994). The Westerneducationalists’ perspective on the Vedic
tradition. ISKCon Communications Journal. 2(2)Retrieved June 12, 2006 from http://
www.iskcon.com/icj/2_2/rasamandala.html
Read, K., Purse, M. (2006). Celebrities with bipolar
disorder: A few words of introduction. Retrieved
September 3, 2007 from http://bipolar.about.com/
od/celebrities/a/celebrities.htm
Redfield, J. (1994). The Celestine Prophecy.
London: Bantam.
Revill, J. (2003, May 11). Hospitals faking cuts in12

AYURVEDIC MODEL OF HUMAN OCCUPATION

casualty wait times. The Observer. 1.
Sabel, R., Gallagher, B. (2004). Restorative yoga.
Advance for Occupational Therapy Practitioners.
20(21), 50.
Shannahoff-Khalsa, D.S. (2001). Unilateral forced
nostril breathing: Basic science, clinical trials, andselected advanced techniques. Subtle Energies &Energy Medicine. 12(2),79–106.
Sharma, H., Clark, C. (1998). Contemporary
Ayurveda: Medicine and Research in Maharishi
Ayur-Veda. New York: Churchill Livingstone.
Sharma, G., Rao, D.P. (2005). Teach Yourself
Vaastu. New Delhi: Lotus Press.
Stack, S. (1987). Celebrities and suicide: A
taxonomy and analysis, 1948–1983. American
Sociological Review. 52(3), 401–412.
Taylor, M.J. (2003). Yoga therapeutics: An ancient
dynamic systems theory. Techniques in
Orthopaedics. 18(1), 115–125.
Taylor, M.J. Majmundar, M. (2000). Incorporating
yoga therapeutics into orthopedic physicaltherapy. Orthopedic Physical Therapy Clinics ofNorth America. 9(3), 341–360.
Taylor, S. (2001). Introducing a yoga group in anacute inpatient psychiatric facility. OT Practice.
6(6), 22–23.
True World Or der, ( 2000). Sivananda Yoga
Teachers’ Training Manual. Val Morin: True
World Order.
Vaughn, C. (2007). Celebrities and disorders.
Retrieved September 3, 2007 from http://
www.bellaonline.com/articles/art21256.asp
Venth (2007, August 21). Lost in translation: thetroubled dependence of occupational therapy on
narrative evidence. Retrieved September 3, 2007
from http://www.metaot.com/blogs/venth
Vicente, M., Chasse, B., Arntz, W (2005). What The
Bleep Do We Know!? London: RevolverEntertainment.
Vishnu-devananda (1988). The Complete Illustrated
Book of Yoga. New York: Three Rivers Press.
Volz, D. (2002). Yoga for multiple sclerosis.
Retrieved April 14, 2006 from http://occupationaltherapy.advanceweb.com/common/
EditorialSearch/printerfriendly.aspx?CC=7109
Wilcock, A.A. (2001). Occupation For HealthVolume 1. A journey from self health toprescription. London: BAOT COT.
Williams, T. (1999). Complete Chinese Medicine.
Bath: Mustard.

Appendix: Recommended Learning
Resources
1. Vedic Perspectives of the Universe:
Vicente M., Chasse B., Arntz W (2005). What The
Bleep Do We Know!? (DVD) London: RevolverEntertainment.
2. Vedic Psychology:
Basic: The three bodies, pages 8–9 in: Sivananda
Yoga Vedanta Centre (1999) Yoga Mind & Body.
London: Covent Garden Books.
Intermediate: Astral body, the mystery of mind,
and extrasensory perception, Chapter 9, pages
256–285 in: Vishnu-devananda (1988) The
Complete Illustrated Book of Yoga. New York:
Three Rivers Press.
3. Vedic Physiology:
Basic: Ayurveda and yoga, pages 9–24 in:Frawley D., Kozak S.S. (2001) Yoga for Your
Type. Twin Lakes: Lotus.
Intermediate: The absolute and evolution ofPrakriti, Chapter 10, pages 286–299 in: Vishnudevananda (1988) The Complete Illustrated Bookof Yoga. New York: Three Rivers Press.
Advanced: Avalon A. (1974) The Serpent Power.
The secrets of Tantric and Shaktic yoga. 7 thedition, Mineola: Dover Publications.
4. The Three Natures (frame of reference):
Mental type according to the gunas, pages 15–18
in: Frawley D., Kozak S.S. (2001) Yoga for Your
Type. Twin Lakes: Lotus.
5. The Tantric Frame of Reference:
Basic: Chopra D. (2006) Kama Sutra. London:
Virgin Books.
Intermediate: Mailoo V., Wickham J., Bannigan
K. (2006) OT and the tantric frame of reference.
Therapy Weekly 33(3): 8–10.
Advanced: Kapke B. (2000) Energy medicine.
Wheels of light: clearing, balancing & connecting
chakras. Massage & Bodywork. 15(6): 132–135.
6. Assessment and Diagnostics:
Tantric: http://www.eclecticenergies.com/chakras/
chakratest.php
General: Lad V. (1984) Ayurveda: The Science of
Self-Healing. A practical guide. Wilmot: Lotus
Press.
7. Raja Yoga:
Basic: Sivananda Yoga Vedanta Centre (1999)
Yoga Mind & Body. London: Covent Garden
Books.
Advanced: Vishnu-devananda (1988) The
Complete Illustrated Book of Yoga. New York:Asian J Occup Ther 6: 1–13, 2007

Three Rivers Press.
8. Meditation:
Basic: Osho (1998). The Book of Secrets: 112
Keys to the Mystery Within. New York: St.
Martin’s Griffin.
Advanced: Gyatso K. (1995). Tantric Grounds
and Paths. 2 nd impression, Ulverston: Tharpa
Publications.
or Dalai Lama, Dzong-ka-ba, Hopkins J. (2005).
Yoga Tantra. Paths to Magical Feats. Ithaca:
Snow Lion.
9. Detachment:
Basic: Mendez S. (2000). American Beauty.
(DVD) Universal City: Dreamworks HomeEntertainment.
Intermediate: Eaton J. (2006) M.E., Chronic
Fatigue Syndrome & Fibromyalgia. The Reverse
Therapy Approach. Authors Online, Hertford.
Advanced: Osho (1998). The Book of Secrets: 112
Keys to the Mystery Within. New York: St.
Martin’s Griffin.

Mailoo VJ

13

10. Active Dying:
Basic: http://death-and-dying.org/
Intermediate: Conquest of death, Chapter 12,
pages 308–323 in: Vishnu-devananda (1988) The
Complete Illustrated Book of Yoga. New York:
Three Rivers Press.
Advanced: Jinpa T., Coleman G., Dorje G. The
Tibetan Book of the Dead. London: Penguin
Books.
11. Vastu:
Sharma G., Rao D.P. (2005). Teach Yourself
Vaastu. New Delhi: Lotus Press.
12. Practical Learning:
It is not the author’s intention to endorse any
educational establishment. Readers may discusstraining opportunities with occupational therapists
experienced in yoga at these internet web-pages:
http://www.dynamicsystemsrehab.com//
directory.php
http://www.facebook.com/
group.php?gid=2352527880

ORIGINAL ARTICLE

Effects of Swallowing Posture Maneuvers
on Swallowing Functions
Misako HIGASHIJIMA, PhD., OTR.1
1Department of Health Sciences, Graduate School of Biomedical Sciences, Nagasaki

University

Abstract: Occupational therapists managing subjects with feeding or swallowing
problems must determine appropriate swallowing postures for feeding, while consideringrisks and swallowing function. Few reports have addressed associations between trunk
position and swallowing function, so this study aimed to provide basic data on such
associations for practical use. Noninvasive procedures were used to assess the effects ofdifferent trunk positions on swallowing functions during voluntary swallowing in 17
healthy adult women. Water bolus transport was not recognized in the laryngeal
movement latency of oral phases, and was recognized in the duration of laryngeal
movement of pharyngeal phases. Significant differences were recognized only forduration of laryngeal movement between the 90° and 30° trunk positions. Swallowing
saliva appears to be influenced by preceding water swallowing, in addition to visual input.
Decisions regarding swallowing postures the subject should take during swallowing
require integrated general data, including swallowing function status of laryngeal
movements, consistency, gravity and internal pressures.
Key words: swallowing posture, swallowing function, swallowing water, healthy adults(Asian J Occup Ther 6: 15–21, 2007)

Introduction
A major role of occupational therapists (OTs)
in managing subjects with feeding or swallowing
problems includes providing support in holding
food and feeding these patients. Moreover,following improvements in swallowing function
with training, patients need to take an appropriate
Received: June 15, 2006, Accepted: April 20, 2007
Corresponding to: Misako Higashijima; Department of
Health Sciences, Graduate School of Biomedical Sciences,
Nagasaki University, 1–7–1 Sakamoto, Nagasaki 8528520, Japan
phone: 81-95-849-7939 fax: 81-95-849-7996
e-mail: higajima@net.Nagasaki-u.ac.jp

swallowing posture for feeding. Such swallowing
postures may help to prevent aspiration in thesepatients. Determination of optimum swallowing
posture must be made considering cervical andtrunk positions. Cervical position angles of 45°(Buckley, 1976) and 20° flexion (Zimmermann,
1981) have been advocated, while trunk positionsof 30° inclination (Fujishima, 1995) and 90° (i.e.,
upright seated position) (Zimmermann, 1981)
have been described. Some reports haveadvocated a case-by-case approach in deciding
trunk positions (Logemann, 1983). However, few
studies have depicted the effects of different trunk
positions on swallowing. To evaluate swallowing
functions and examine treatment outcomes, we

16

RELATION TO SWALLOWING FUNCTIONS AND SWALLOWING POSTURE

attempted further investigation of a non-invasive
method we recently established, for which thereliability and validity have already been reported(Higashijima, 2002).
Our aim was to provide basic data forpractical use regarding appropriate swallowing
posture for deglutition in subjects with feeding or
swallowing problems. The present study used ournoninvasive method to investigate the effects ofdifferent trunk positions on swallowing functions
during voluntary swallowing in healthy adults.

Literature Review
Postural maneuvering for swallowing is acompensatory technique employed during feeding
training. After 3 weeks of applying compensatory
methods, the need for functional training is reevaluated (Logemann, 1983). Swallowing
postural maneuvering is for patients who display
trouble transporting a bolus. In other words,
swallowing postural maneuvering is appropriate
for patients experiencing difficulty during the oral
phase of swallowing. Such methods use gravity toovercome difficulties in transporting the bolus. In
a p hy s i ol o g i c a l s e n s e , t h is o r a l p h a s e o fswallowing involves a voluntary first half and areflexive second half, continuous with thereflexive (involuntary) pharyngeal phase. An
appropriate swallowing posture is determinedbased on swallowing function, physiologicalmechanisms and anatomical characteristics. We
examined different cervical position angles andangles of trunk position to determine appropriate
swallowing postures. General consensus agrees
that cervical position angle should display slightflexion (Ekbeng, 1986; Saitou, 1987; Fujishima,1995), but many opinions seem to suggest thattrunk positions should be decided on a case-bycase basis (Zimmenman, 1981; Fujishima, 1995;
Logemann, 1983). This could explain the paucityof evidence-based studies addressing variations intrunk positions in relation to swallowing functions.

MethodSubjects
Students in the third year of an Occupational

Therapy course at Kawasaki Medical Welfare
University were given background information on
the proposed study, and were then allowed toapply to be a subject in the study. The study
protocol was explained verbally to all participants
and written documentation was provided.
Informed consent was then obtained from 17
healthy Japanese women with a mean age of 22.4
± 2.2 years (range, 21–24 years). Subjects did nothave a past history of swallowing disorders
associated with respiratory or neuromusculardisease.

Apparatus
Subjects were familiarized with theexperiment protocol, after which 3 sensors wereattached. Furthermore, the subject took a pre-test
swallowing of water.
The TR-751T respiration pickup sensor(Nihon Kohden, Tokyo, Japan) was placed tomonitor respiratory movements of the chest wall.
An MP100 transducer (AD Instruments, USA)was attached at the thyroid cartilage to record
back-and-forth movements of the thyroid cartilage
during swallowing. A TR-762 thermistor
respiration pickup sensor (Nihon Kohden) was
placed in the left nasal cavity of each subject tomonitor nasal airflow and temperature differences
between inspired and expired air. Three sensors
were used to identify organic movement change
and movement persistence while not determining
amplitude.
Subjects with the 3 sensors attached were
instructed to sit on an extension-type reclining
wheelchair for which trunk positions could be
adjusted. Cervical position angle was always kept
at a constant 20° flexion (Fig. 1).

Procedure
To limit assessment to swallowing function
during the oral and pharyngeal phases while
excluding masticatory function during the
preparatory phase, subjects were instructed toswallow water. To investigate differences inswallowing function with and without water,
subjects were also instructed to swallow air.
The procedure was performed in a room at aconstant temperature of 23°C, and involved

Asian J Occup Ther 6: 15–21, 2007

Higashijima M

17

Fig. 1. 3 sensors attached to subject

injection of 10 ml of water at 10°C into the oralcavity of each subject. Subjects were instructed tokeep this liquid in the mouth until a red lamp
signal (trigger) was seen. When the chart recorderindicated the end of an expiratory phase of
respiratory movement, the red lamp signal was
given to the subject to completely swallow thewater bolus. After this, resumption before a
trigger of respiratory movement wave on the chart
recorder was confirmed. After confirmation, since
two-wave respiratory movement was over on thechart recorder, a signal to swallow air (saliva) was
given when subject indicated the end of the
expiratory phase again. Water swallowing was
performed 3 times. This experimental procedure
was repeated with different trunk positions of 90°(seated upright), 60°, and 30° flexion. The subject
rested for 15 min with every change of trunk
position.

Data analysis
Data were recorded during the procedureusing both a chart recorder and a digital audio taperecorder (sampling rate, 100 mm/s). At a later
date, these data were read by a computer using aPower Lab data analysis system (AD Instruments,
USA), and analyzed using Chart version 4.0
software (AD Instruments). During water bolus
and air bolus swallowing, 4 parameters werecompared between trunk positions (Fig. 2): timeinterval from red lamp signal (trigger) to start ofthyroid cartilage movement (laryngeal movement
latency; Fig. 2a); duration of thyroid cartilage
movement (duration of laryngeal movement; Fig.
2b); duration from lamp signal (trigger) to end of
air ventilation (apnea latency; Fig. 2c); andduration of apnea (Fig. 2d). Analysis was
performed using one-way analysis of variance(ANOVA) followed by post hoc Tukey test. The
level of statistical significance was set at P<0.05
unless otherwise noted.

Results
Swallowing of water bolus
Mean values (± standard deviation) of the 4parameters recorded during swallowing of thewater bolus for the 3 trunk positions are shown in
Fig. 3.
Significant differences in duration oflaryngeal movement were recognized only
between the 90° (2.21 ± 0.57 s) and 30° (1.72 ±0.41 s) trunk positions (F=3.877, P<0.05).

Swallowing of air (saliva)
Mean values (± standard deviation) of the 4parameters recorded during swallowing of saliva
in the 3 trunk positions are shown in Fig. 4.
Significant differences in duration oflaryngeal movement were recognized between the
90° (2.16 ± 0.58 s) and 30° (1.61 ± 0.47 s) trunk
positions and between the 90° (2.16 ± 0.58 s) and18

RELATION TO SWALLOWING FUNCTIONS AND SWALLOWING POSTURE

Fig. 2. Parameter and instrumentation range
Laryngeal movement latency: Interval from trigger to start of thyroid cartilage movement, Duration of laryngeal movement:
Duration of thyroid cartilage movement, Apnea latency: Interval from trigger to end of air ventilation.

60° (1.69 ± 0.41 s) trunk positions (F=6.128,
P<0.05).

Discussion
Swallowing of water bolus
Water bolus transport was not recognized in
the laryngeal movement latency of oral phases,
and was recognized in the duration of laryngeal
movement of pharyngeal phases. Significant
differences were recognized only for duration oflaryngeal movement between 90° and 30° trunk
positions.
In the past, bolus transport has been viewed
as a function of the oral phase (Ekbeng, 1986;
Saitou, 1987; Fujishima, 1995; Zimmenman,
1981; Logemann, 1983). However, the results
were reflected in duration of laryngeal movement,
not laryngeal movement latency (Fig. 2). As
suggested by Saitou (1987) and Logemann (1983),
this could be because the bolus taken comprised of
non-viscous water. Dodds et al. (1989) reported

that when subjects were instructed to hold food intheir mouth and swallow on a signal, somesubjects held food at the bottom of the oral cavity(dipper type), while others held food on the tongue(tipper type). In this study, subjects were
instructed to hold food in the mouth and swallow
on a signal. Differences in laryngeal movement
latency may thus have resulted from subjects
holding the water in a different place to where theyheld food. Furthermore, apnea latency was
shortened for the 30° trunk position compared tothe 90° trunk position. Some water may thus haveflowed down the pharynx while the subject waited
for a signal. Water bolus transport was thus notrecognized in the laryngeal movement latency oforal phases.
Significant differences were recognized only
for duration of laryngeal movement between 90°
and 30° trunk positions.
Yamada (2001) reported that in terms ofbolus transport, negative pressure caused byrelaxation of the inferior constrictor muscles of theAsian J Occup Ther 6: 15–21, 2007

Higashijima M

19

Fig. 3. Water (4 parameters from 3 postures)

Fig. 4. Saliva (4 parameters from 3 postures)

pharynx draws the bolus from the large pharyngeal
entrance to the small pharyngeal exit facilitatingtransport through the esophagus. Fujishima(1995) reported the influence of gravity ontransport. Both pharyngeal and esophageal phases
receive equal influence with 90°C trunk posture,
but the pharyngeal phase was accelerated in the
30°C trunk position and the esophageal phase was
unaffected. Kogoe (1995) examined swallowing

posture using ultrasonography, finding that alowered trunk position during swallowing
facilitates bolus transport through the pharynx andincreases length of the soft palate, but increases therisk of aspiration.
In future, decisions regarding whichswallowing postures a subject should take during
swallowing will require integration of generaldata, including functional status of the pharynx,

20

RELATION TO SWALLOWING FUNCTIONS AND SWALLOWING POSTURE

organic position, gravity, internal pressure,consistency and volume of the food bolus.

Swallowing of saliva
Similar results were recognized for laryngeal
movement during water swallowing. Swallowingof saliva in this study appears to have been
influenced by activity of the earlier deglutition of
the water bolus.
Leopold (1983) stated that this early phaseallows determination of safe bolus volume andprogramming of the swallowing reflex based on
previous feeding experiences. Ekberg (1986)
reported greater activity in the limbic system andcerebral cortex during this early phase ofswallowing as compared to other stages. Sumi
(1972) stated that reverberating circuits are formed
between the reticular formation and cerebrum, anddiverse sensory information is processed andrelayed to the cerebrum, resulting in activation. In
that study, subjects were instructed to swallow
water and then air. Given the above-mentioned
reasons, the study was influenced by the following
3 systems: a stereotypical organoleptic limbic
system informing the body that swallowing is safe
under the same conditions as swallowing 10 ml ofwater (certain shape swallowing movements thatwere induced by sensory input, and this partiallyoverlaps the brainstem system); a sensory-motor
field neocortical system based on cognitive
behaviors for external stimuli (swallowing
movements based on discriminating behaviors forsensory stimuli); and a brainstem system forming
the basic reflexive circuit for eating behaviors(Michael, 1996). In addition, Bach-y-Rita (1980)
used a sensory-motor field neocortical system as
described by Michael (1996) and similarly
reported that while some neurologicalmechanisms, such as respiration, are reflexive anddo not require much learning or experience, otherneurological mechanisms, such as swallowing
during the oral and laryngeal phases, are designed
to incorporate new programming in the short term.
Since subjects in the present study were healthy
individuals, this theory may have played somerole. Furthermore, an explanation for
discrepancies between water and air swallowing
between the present study and previous

investigations could be that visual information
regarding “no food presence” plays a dominantrole.
The first reason for setting a swallowing
posture in clinical situations is to allow consistentcomparison of bolus swallowing parameters withreference to trunk angle. The second reason is in
c o n si d e r a t i o n o f t h e d e g r e e s o f o r a l a n dpharyngeal dysfunctions. Appropriate evaluationof swallowing function and swallowing posturesettings on the basis of test results will help toprevent aspiration in clinical situations.

Conclusions
Using non-invasive investigative methods,
we analyzed the effects of different body postureson swallowing functions during swallowing in
healthy adults. Water bolus transport did notaffect laryngeal movement latency of oral phases,
but did affect duration of laryngeal movement ofpharyngeal phases. Significant differences wererecognized only for duration of laryngeal
movement between 90° and 30° trunk positions.
Swallowing of saliva seems to be influenced bypreceding swallowing dynamics and informationfrom visual input. Decisions on trunk position
during swallowing should be made on the basis ofswallowing function, bolus consistency andgravity. In future, we would like to investigate
relationships between body position and bolus
consistency using the same parameters used in thisstudy.

References
Bach-y-Rita, P. (1980). Recovery of Function:
Theoretical Considerations for Brain Injury
Rehabilitation. Baltimore: University Park.
Buckley, J., Addicks, C., Maniglia, J. (1976).
Feeding patients with dysphagia. Nursing Forum.
15, 69–85.
Dodds, W.J. (1989). Tipper and dipper types of oral
swallows. American Journal of Roentgenology.
153, 1197–1199.
Ekberg, O. (1986). Posture of the head andpharyngeal swallowing. Acta Radiologica
Diagnosis. 27, 691–697.
Fujishima, I. (1995). Rehabilitation for SwallowingAsian J Occup Ther 6: 15–21, 2007

Disorders associated with Stroke. Tokyo:
Ishiyaku, Publishers (in Japanese).
Higashijima, M., Tubahara, A., Koga, T., Kobashi,
M. (2002). Establishment of non-invasive method
procedure of a swallowing pattern and study about
correlation with electrogastrogram. Grant-in-Aid
for Scientific Research reports (in Japanese).
Kogoe, C., Saito, H. (1995). Effect of Position on
swallowing. Journal of Japanese Association of
Occupational Therapists.14, 216–223 (inJapanese).
Logemann, J. (1983). Evaluation and Treatment of
Swallowing Disorders. Austin, Texas: Pro Ed.
Leopold, N.A., Kagel, M.C. (1983). Swallowing
ingestion and dysphagia. Arch Phys Med Rehabili.
64, 371–373.
Michael, E.G., Fujishima, I. (1996). Dysphagia
Diagnosis and Management. Tokyo: Ishiyaku,

Higashijima M

21

Publishers (in Japanese).
Saito, E. (1987). About dysphagia and posture andcorrelation of food configuration. Monthly
Nursing. 7, 1244–1246 (in Japanese).
Sumi, T. (1972). Role of the pontine reticularformation in the neural organization of
deglutition. Japanese Journal of Physiology. 22,
295–314 (in Japanese).
Steefel, S.J. (1981). Dysphagia Rehabilitation for
Neurologically Impaired Adults. Charles C:
Thomas, Publishers.
Yamada, Y. (2001). The understanding of oral andswallowing function. Tokyo: Ishiyaku, Publishers(in Japanese).
Zimmerman, J.E. (1981). Swallowing dysfunction inacutely ill patients. Physical Therapy. 61, 1755–
1763.

ORIGINAL ARTICLE

Self-Efficacy and Outcome Expectancy:
Analysis of Theory and Measurement in
Occupational Therapy
Kayoko TAKAHASHI, MS, OT1
ScD Candidate in Doctoral Program in Rehabilitation Sciences, Sargent College of Healthand Rehabilitation Sciences, Boston University

Abstract: Occupational therapy seeks to effectively change clients’ behavior to result inbetter quality of life by both focusing on tasks that clients find purposeful and meaningful
and by enhancing clients’ sense of competence. Self-regulatory system theory similarly
demonstrates that behaviors are best predicted by the combined influence of one’s
competence to perform a task (self-efficacy) and the purposefulness and meaningfulnessof a task (outcome expectancy). In this paper, twenty-four scales for self-efficacy andoutcome expectancy for older adults were reviewed. However, these scales were found
not to be validly following the theoretical framework. Furthermore, in clinical contexts,
therapists rarely evaluate clients’ states using scales; rather they observe clients’nonverbal and verbal behavior. This observational assessment is not only found to bereliable but also helps to develop a strong working alliance and better rehabilitation
outcome. Research is currently underway to develop a systematic method to identify
which of the clients’ cues are valid and reliable expressions of self-efficacy and outcome
expectancy.
Key words: measurement, outcome expectancy, self-efficacy, self-regulatory system,
theory(Asian J Occup Ther 6: 23–34, 2007)

Introduction
Occupational therapists focus on tasks that
their clients find personally purposeful andmeaningful and for which the clients have positive
Received: August 24, 2007, Accepted: October 30, 2007
Corresponding to: Kayoko Takahashi, ScD Candidate in
Doctoral Program in Rehabilitation Sciences, Sargent
College of Health and Rehabilitation Sciences, Boston
University, 635 Commonwealth Ave. # 553 Boston, MA
02215 U.S.A.
Phone: 1-617-627-4591 fax: 1-617-627-4824
e-mail: kayo@bu.edu

expectations related to potential outcomes of thetasks. The philosophical assumptions that drive
rehabilitation practice include the link between
task performance and sense of competence (Gage& Polatajko, 1994): Successful completion of atask that a person finds purposeful and meaningful
can lead to an increase in the person’s sense ofcompetence and in the person’s willingness toengage in other tasks. Research in occupational
therapy has been done to support thisphilosophical assumption (Bakshi, Bhambhani, &Madill, 1991; Dickerson & Fisher, 1997; Ferguson& Trombly, 1997; Kircher, 1984; Miller &24

SELF-EFFICACY AND OUTCOME EXPECTANCY

Nelson, 1987; Morton, Barnett, & Hale, 1992;
Murphy, Trombly, Tickle-Degnen, & Jacobs,
1999; Riccio, Nelson, & Bush, 1990; Takahashi,
2002; Thibodeaux & Ludwig, 1988; Trombly,
1993, 1995, 2002; Yoder, Nelson, & Smith, 1989).
In order to facilitate task performance,
occupational therapists not only choose a task thatclients find purposeful and meaningful, but also
set a goal to increase the client’s sense ofcompetence (Christiansen, 1991; McAuly, 1993;
Trombly, 1993). Enhancing the client’s sense ofcompetence has been an important focus ofoccupational therapy from its early days. Adolph
Meyer (1922), a founder of occupational therapy,
described the value of feeling the satisfaction andachievement that is associated with successful
completion of a project. Robert White (1971), a
scholar of motivation and human behavior,
stressed that occupational therapists need to beaware of a client’s sense of competence. By bothfocusing on the task that clients find purposefuland meaningful and enhancing the client’s sense ofcompetence, occupational therapy seeks toeffectively change a client’s behavior to result in abetter quality of life.
However, occupational therapy does not havea specific theoretical framework to support thisphilosophical assumption. Putting clinicalphenomena into a theoretical framework helps
practice in two ways. First, it helps in a
retrospective way, to systematically understandthe condition of a client. Second, it helps in aprospective way, to systematically guide effective
treatment planning for the client. One theoreticalframew ork that i s hig hly co nsisten t wi th
occupational therapy practice is the self-regulatory
system model (Bandura, 1977, 1986, 1991, 1997)
demonstrating the conditional relationshipbetween cognition and behavior involved inhuman actions.
Moreover, only a few measurement tools
used in healthcare fields precisely follow atheoretical framework. Having a measure is not
only the first step for a therapist to understandclient’s condition, but also to see the outcome of
the intervention so that a therapist can provide a
better and more effective intervention for eachclient.

The purpose of this paper is first to analyze
one of the theories by Bandura about people’s
behavioral change via a self-regulatory system,with a specific focus on measurements derived
from the theory that have been used inrehabilitation research with older adults. A
discussion will then go further into a clinicalapplication of how occupational therapists canassess the theorized factors to better understandbehavioral change.

The Self-regulatory System as a
Theoretical Framework
According to Bandura’s framework, humanaction is a self-regulatory system, in which selfregulation is defined as self-directed change
influenced by the environment. Bandura (1977,
1986, 1991, 1995, 1997) states that behavior andself-regulation processes are best predicted by the
combined influence of one’s belief in the ability toperform a task (self-efficacy) and the results one
anticipates from having performed these tasks(outcome expectancy). Both self-efficacy andoutcome expectancy are part of the cognitive
process prior to one’s action, because self-efficacy
is a perception of oneself capably performing abehavior and outcome expectancy is a perceptionof the purposefulness and meaningfulness of doingthat behavior. These two types of cognitive
perception then influence the person’s actual
behavior of doing a task. Self-efficacy influences
the choices people make, their aspirations, howmuch effort they put into achieving the task, andhow long they persevere in the face of difficulties(Bandura & Adams, 1977). Outcome expectancy
influences the amount of effort they put into
achieving the task, but also influences the amountof satisfaction they feel in achieving the task andeagerness to move on to a similar or more difficulttask.
To apply Bandura’s framework, Fig. 1
presents an example of an occupational therapy
client and how self-efficacy and outcome
expectancy enter into her own motivation to do atask. Mrs. Sato is a 67-year-old homemaker with
Parkinson’s disease. She lived with her 45-yearold daughter who was a busy lawyer, and threeAsian J Occup Ther 6: 22–33, 2007

Takahashi K

25

Fig. 1. Self-regulatory system. The conditional relationship of self-efficacy andoutcome expectancy to an actual behavior

grandchildren (10-year-old girl, 14-year-old boy,and 17-year-old boy). She was in charge of theentire household and cares for the grandchildren.
In the first session of occupational therapy, she
was depressed that she could not perform her role
as a homemaker, given a severe tremor. Following
the philosophical assumption of occupational
therapy that performing tasks clients findmeaningful will increase their motivation andpositive rehabilitation outcomes, the therapist
decided to work on a task related to householdchores. Therefore, the therapist showed her how
to pare an apple controlling for a tremor, and withthis guidance she did so successfully. Her eyes
sparkled and she smiled, saying “I did it! I neverthought I could, but I did it! I am not thatworthless, am I?” After this successful experience,
she became eager to try cooking using strategies tocontrol a tremor, and to move on to more difficult

tasks related to her role as a homemaker.
Figure 1 contains the example of Mrs. Sato in
italic font. Self-efficacy in this example is how
confident Mrs. Sato is about her ability to pare anapple despite a tremor, and outcome expectancy is
her expectation of the degree to which paring anapple successfully can change her role in thefamily “If I could pare an apple, I would be able tocook meals for my family and fulfill my role as ahomemaker, which is wonderful.” In order toachieve the actual behavior, which is to pare anapple, Mrs. Sato needs not only to feel confident
enough about her ability to actually pare an apple,
but also to have a positive outcome expectancy
about what being able to pare an apple means toher. After the therapy session, she became eager totry other tasks because she then had both high selfefficacy and positive outcome expectancy towardtasks related to her role in her family as a

26

SELF-EFFICACY AND OUTCOME EXPECTANCY

Table 1. The effects of different patterns of self-efficacy and outcome
expectancies on behavior and affective states

homemaker.

The interactive effects of self-efficacy andoutcome expectancy
Self-efficacy and outcome expectancy work
interactively to change behavior toward andemotional responses to the task. Table 1 shows theeffects of different patterns of self-efficacy andoutcome expectancies on behavior and affective
states. Different patterns of self-efficacy andoutcome expectancy are hypothesized to havedifferent psychosocial and emotional effects. In
Table 1, high self-efficacy and a positive outcome
expectancy are shown as (+), and low self-efficacy
and negative outcome expectancy are shown as (–). The four cells show the effect of different
combinations of self-efficacy and outcome
expectancy.

Cell A Apathy of the table shows that if
people have both low self-efficacy and negative
outcome expectancy, they may become apathetic
and resigned to a self-perceived unsatisfying lifeand not put effort into the task. For Mrs. Sato, she
may believe she cannot pare an apple, and if she
also does not expect anything positive from being
able to pare the apple, she might feel apathetic, bedisinterested to the task and not try to pare anapple.
Cell B Hopelessness of the table shows thepattern in which people perceive themselves as
ineffectual but have a positive expectation of what
the outcome can bring. This situation is apt to giverise to self-disparagement and depression(Bandura, 1997). For Mrs. Sato, this problem
might have been what was happening to her before
she had her occupational therapy session. She didAsian J Occup Ther 6: 22–33, 2007

not feel confident about her ability to pare theapple and, yet thought paring an apple was animportant task, she was feeling depressed at not
being able to perform the task. She may try to parean apple, but loss of self-efficacy may impair thequality of the performance and she may not do agood job.
Cell C Protest of the table shows that if
people have high self-efficacy but negative
outcome expectancy, people will not do the task,
since they believe they cannot gain a valued
outcome. For example, if Mrs. Sato does not value
the future outcome of being able to pare an apple,
she would not find paring an apple as an importanttask for her to achieve, and she may resist paring
an apple and protest to do other task or leave OT
session.
Cell D Hopefulness of the table shows thathigh self-efficacy and positive outcome
expectancy promotes productive engagement intasks and produces satisfaction and fulfillment. As
an example, Mrs. Sato, having achieved the task
successfully in the occupational therapy session,
she felt satisfied for achieving the task, andregained her self-efficacy about preparing food.
As a result, she became eager to try paring an apple
despite of tremor.
Some studies in public health (Grembowski,
Patrick, Diehr, & Durham, 1993; Schuster, Petosa,& Petosa, 1995; Schwarzer & Fuchs, 1995)
support this idea that there is an interactive effectof self-efficacy and outcome expectancy. For
example, Grembowski et al. (1993) found bothself-efficacy and outcome expectancy are
negatively associated with health risk behavior,and Schuster et al. (1995) found a similar effect on
intentional exercise. Schwarzer et al. (1995) useda hierarchical regression analysis of self-efficacy,
outcome expectancy, and vulnerability to predict
intention to engage in cancer screening behavior
for older females (age from 40 to 70). A
significant interaction between self-efficacy andoutcome expectancy was found in older females(β=–.19, p<.01), suggesting that positive outcome
expectancy may help to raise the intention toscreen for cancer in women of lower self-efficacy.
As shown, self-efficacy and outcome
expectancy are not only a factor of one’s behavior

Takahashi K

27

by itself, but also work interactively to change
behavior toward and emotional responses to thetask. To understand a person’s behavior andaffective state and predict his or her future
performance, it is important to understand bothself-efficacy and outcome expectancy and theirinteractions.

Analysis of Measurements
This paper reviews measures specificallyfocused on older adults, because that group is oneof the main populations of occupational therapy(Rijken & Dekker, 1998), and a group that willshow rapid growth over the next decade or two(Kinsella & Velkoff, 2001). Some scales havealready been developed specifically for selfefficacy or outcome expectancy related torehabilitation with older adults. In this part,measurements for self-efficacy and outcome
expectancy are analyzed separately.

Analysis of self-efficacy measures used inolder adults
A search of the literature using PsychINFO
and OVID database, with the keywords of “selfefficacy,” “scale,” “rehabilitation,” and “older
adults” retrieved 22 scales. Of the 22 retrieved
scales, 17 measure task-specific self-efficacy, andfive measure general self-efficacy. The taskspecific self-efficacy scales measure people’s
beliefs about their ability to do a specific task, suchas “touch and hold the snake with gloved hand” ina specific situation, such as “during participating
in a research study” (Bandura & Adams, 1977).
General self-efficacy is overall confidence indealing with life challenges, not just confidence indoing a specific task, such as “I can always
manage to solve difficult problems if I try hardenough” (Schwarzer & Jerusalem, 1995). Fivescales were found that measure this type of selfefficacy (Burger & Cooper, 1979; Sakano &Tohjoh, 1986; Schwarzer & Jerusalem, 1995;
Sherer & Maddux, 1982; Tipton & Worthington,1984). However, Bandura (1997) cautions thatgeneral self-efficacy scales “violate the basic
assumption of the multidimensionality of selfefficacy beliefs” (p. 48) and some researchers also28

SELF-EFFICACY AND OUTCOME EXPECTANCY

Table 2. Task-specific self-efficacy scales used in older adults
Instrument

Task domains
Mobility
BADL

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

Self-efficacy scale
X
Rheumatoid Arthritis Self-efficacy (RASE) scale X
Depression Coping Self-Efficacy Scale (DCSES) X
Arthritis Self-efficacy scaleX
Self-Efficacy Gauge
X
Self-Efficacy for Participation in
Rehabilitation ScaleX
Self-Efficacy Measures
Health care self-efficacy scale (KI-SE)
Self-efficacy scale
Health care self-efficacy scale (HSE)
Self-Efficacy in Leisure-time physical activity scale
The Fall Efficacy Scale
X
Physical Self-Efficacy (PSE) Scale
Occupational Self-Efficacy Index (OSEI)
Self-efficacy scale
Self-Efficacy for Functional Ability Scale
Self-Efficacy for Exercise scale (SEE)

X
X
X
X

Authors (year)

Symptom
ExerciseComm.
Emotion
IADL

X
X
X

X
X
X
X

X
X
X
X

X
X
X

X

X
X
X
X

X
X
X

X
X
X
X

X

X

X
X
X

X

X
X
X
X
X

Lorig et al. (1996)
Hewlett et al. (2001)
Perraud (2000)
Lorig et al. (1989)
Gage et al. (1994b)
Resnick (1998)
Fry et al. (2001)
Krantz et al. (1980)
Montgomery et al. (1994)
Smith et al. (1984)
Stevens et al. (2001)
Tinetti et al. (1990)
Ryckman et al. (1982)
Fletcher et al. (1992)
Moore (1992)
Resnick (1999)
Resnick et al. (2000)

BADL=basic activities of daily living, Comm.=communication, Emotion=emotional well being, IADL=instrumental activities ofdaily living

have shown the limitation of general self-efficacy
scales (Tipton & Worthington, 1984; Wang &Richarde, 1988). Therefore, this review focused
only on the task-specific self-efficacy and its
scales.
Table 2 shows the details of the 17 taskspecific self-efficacy scales. All scales were foundto have a similar structure: items ask “howconfident are you to do (target task)?” using a
Likert scale, which is the format Bandura andAdams (1977) used in their original study. Only
one scale (Gage et al., 1994) out of the 17 scales
was used in occupational therapy research. The
only difference across these 17 scales was theuniqueness of target tasks; each scale had adifferent target task and age group. However, they
did not all precisely follow the theoreticalframework of Bandura. Bandura and Adams(1977) postulated three parameters of selfefficacy; magnitude, strength and generality.
“Magnitude” refers to the level of difficulty of thetask that is rated from easy to difficult, “strength”
refers to the degree to which people believe they
can succeed at a given level of task difficulty(magnitude), and “generality” of self-efficacy
refers to the degree to which the person’s selfefficacy for one task transfers to other similar ordifferent tasks. By measuring all three parameters,
an investigator would be able to predict theparticipants’ future performance. Unfortunately,
all of the 17 scales were found to be only
measuring the level of self-efficacy parameter(strength), and did not include magnitude or
generality. If a scale is not validly following thetheoretical framework, using that scale can resultin a misunderstanding of the phenomenon.

Analysis of outcome expectancy measuresused in older adults
A search of the literature using PsychINFO
and OVID and the keyword of “outcome
expectancy,” “scale,” “rehabilitation,” and “older
adults” retrieved only two outcome expectancy
scales related to Bandura’s self-regulation theory,both from the same study conducted in the field ofnursing research. Resnick (1998) developed two
self-efficacy scales and two outcome expectancy
scales in her study of patient education for older

Asian J Occup Ther 6: 22–33, 2007

adults. Her Outcome Expectation for Functional
Ability (OEFA) scale had six items, such as “Howstrongly do you believe that doing your own
bathing and dressing, rather than having others do
it for you, will improve your strength and ability?”
The Outcome Expectation for Participation in
Rehabilitation (OEPR) scale had three items, suchas “How confident are you that participating in 3
hours of therapy a day will help you increase yourability to take care of yourself?” Each item is rated
on a 5-point Likert scale ranging from 1 (not at all)to 5 (a great deal).
However, the terminology Resnick used in
the OEFA may have biased the answers. She
implied the research hypothesis in the phrasing of
the item, such as “How strongly do you believethat doing your own bathing and dressing, rather
than having others do it for you, will improve yourstrength and ability?” This phrase could imply the
hypothesis that “doing your own bathing anddressing, rather than having others do it for you,will improve your strength and ability.” Asking
clients how much they agree with this sentence is aleading question. Rosenthal and Rosnow (1991)
caution the artifacts that may result when demandof the researcher is too clear. Rosenthal and
Rosnow and other studies in social psychology(Brehm, 1966; Wicklund, 1974) have found that,when demand characteristics are too clear, aperson typically attempts to acquiesce to thedemand, although some attempt to do the oppositeof what is demanded. It is important to make surethat participants are blind to the hypothesis.
Moreover, the outcome one expects from doing
the task (outcome expectancy) may vary with eachindividual. As Resnick’s items explicitly state a
specific outcome expectation, she does not allow
participants to express their unique expectancies
related to doing the task.

Analysis of studies focused on the interactionof self-efficacy and outcome expectancy inolder adults
Resnick (1998) used these two outcome
expectancy scales reviewed in the last section andother two task-specific self-efficacy scales to
examine the impact of self-efficacy and outcome
expectations on older adults in a rehabilitation

Takahashi K

29program. She found that, based on an exploratory
regression analysis, OEFA at baseline was shown
to be an important contribution (R2 change= .06,
p<.05) to the prediction of the variance in the older
adults’ level of functioning after rehabilitation.
However, Resnick’s study did not address theinteraction between self-efficacy and outcome
expectancy. Similar to this study, other studies inpublic health (Grembowski et al., 1993; Schuster
et al., 1995) also have examined both outcome
expectancy and self-efficacy, but examined themseparately, looking at whether each affects andpredicts behavior. In BanduraÅfs self-regulatory
system, self-efficacy and outcome expectancy
affect task performance interactively (see Table 1).
The interaction between self-efficacy and outcome
expectancy may have affected the results, and not
examining the interaction could yield only a partial
understanding of motivation and behavior. Given
the lack of available instruments, newmeasurement tools are needed that can measureboth self-efficacy and outcome expectancy andtheir interactions.

Self-efficacy and Outcome Expectancy ina Clinical Context
In this section, the discussion is about how
theory and measures in this area have been applied
to a clinical context in occupational therapy. In aclinical context, the interaction of self-efficacy andoutcome expectancy is rarely and possibly neverevaluated, even though many scales have beendeveloped specifically to measure self-efficacy. In
the clinical reasoning process, a therapist
automatically evaluates a client’s motivation
without using scales. A therapist observes clients’non-verbal and verbal behavior to identify theirexperience as related to the four conditions ofTable 1. This evaluation process is called“conditional reasoning” (Fleming, 1994).
As an example, this conditional reasoning
process can be applied to the occupational therapy
session of Mrs. Sato. From the interaction with
Mrs. Sato, the therapist understood that Mrs. Sato
felt depressed (the motivational state of
Hopelessness in Table 1), based on her affect andher statement that she could not perform her

30

SELF-EFFICACY AND OUTCOME EXPECTANCY

important and meaningful roles of homemaker.
Likewise, watching the sparkle in Mrs. Sato’s eyeswith her smile and positive comments after she
succeeded in paring the apple, the therapist sensed
that her level of self-efficacy increased and that
she was ready to move on to more difficult tasks(the motivational state of Hopefulness in Table 1).
By tying behavior to Mrs. SatoÅfs possible affect,
the therapist could understand that she has positive
outcome expectancy for the household task andthat she has low or high self-efficacy on that task.
Recent studies in occupational therapy
support that this conditional reasoning is a reliable
way to understand the client’s affect andmotivation (DeGroat, Lyons, & Tickle-Degnen,
2006; Lyons, Tickle-Degnen, Henry, & Cohn,
2004; Lyons, Tickle-Degnen, & DeGroat, 2005;
Tickle-Degnen & Lyons, 2004). Lyons andcolleagues (2004) found an association between
the judged personality by therapists during aclinical interview and the clients’ self-described
personality and mood. This finding supported theidea that therapists can accurately pinpoint aclient’s affect and motivation through both verbal
and nonverbal behavior during open-ended
clinical interviews.
Moreover, using an open-ended qualitative
questioning process, rather than structured andstandardized scales, promotes a natural flow ofintervention. Take Mrs. Sato as an example. It
may interrupt Mrs. Sato’s occupational
performance if a therapist keeps asking her toscore her level of self-efficacy on a Likert scaleeach time she performs a task. Also, since an
occupational therapy session usually lasts 20 to 30
minutes, there is not enough time to sit down andfill out scales every time. In a limited time frame
like that involved in a clinic intervention, it may
not be very beneficial to use a structured scale.
In addition, conditional reasoning also helps
the therapist to respond in a way that will develop
a strong working alliance with the client (Cox,Holbrook, & Rutter, 1981; Cox, Rutter, &Holbrook, 1981; Cruz & Pincus, 2002; Eisenthal,
Koopman, & Lazare, 1983; Lustig, Strauser, Rice,& Rucker, 2002; Roter & Hall, 1992; Safran &Muran, 1998). Working alliance is defined ascollaboration between a client and a counselor

based on the development of an attachment bond
(Bordin, 1979). The development of strong
working alliance is found to result in better
outcomes for a variety of rehabilitationinterventions (Al-Darmaki & Kivlighan, 1993;
Connors, Carroll, DiClemente, Longabaugh, &Donovan, 1997; Cruz & Pincus, 2002; Goering,
Wasylenki, Lindsay, Lemire, & Rhodes, 1997;
Kivlighan & Shaughnessy, 2000; Kokitovic &Tracy, 1990; Mallinckrodt & Nelson, 1991).
Although no studies on working alliance havebeen done in occupational therapy area which may
limit the implication in other disciplines, here
again, using an unstructured interaction is likely to
be more flexible way to assess a client in a clinicalsetting than use of a paper-and-pencil rating scale.

Implications for PracticeThe self-regulatory system model explains
the interactive effect of self-efficacy and outcome
expectancy on behavior (Bandura, 1977, 1986,
1991, 1997), and this model is highly consistent
with philosophical assumptions in occupational
therapy practice. However, Bandura’s selfregulatory model has not yet been integrated
systematically into occupational therapy clinicalpractice (Gage, Noh, Polatajko, & Kaspar, 1994),
and the importance of outcome expectancy has notbeen recognized in the occupational therapy
literature. This lack of integration of the model
into practice may be due to occupational
therapists’ lack of awareness of the constructs ofself-efficacy and outcome expectancy, and to thelack of useful assessment tools for measuring these
constructs (Gage et al., 1994).
In clinical settings, therapists often makejudgments about clients’ motivational state
quickly and spontaneously throughout clinicalinteraction. However, the process of thisidentification is so automatic that it is not wellarticulated and is thought to be “art.” Clear
understanding of self-efficacy and outcome
expectancy is important because those are thefactors influencing the actual task performance.
The studies reviewed showed that current methodsof assessing the client’s motivational states
involve self-report measures which do not enableAsian J Occup Ther 6: 22–33, 2007

therapists to quickly and spontaneously make their
judgment. By observing a client’s behavior andaffective states during an open-ended clinicalinterview, therapists may be able to identify
rapidly whether the person has positive or negative
outcome expectancies and high or low selfefficacy, and quickly adjust their intervention to be
more effective. For example, for a client who isapathetic or protesting, the therapist can change
the activity to increase the client’s positive
outcome expectancy. If the client was resistingparing an apple, it might be better to change theactivity to which the client finds it meaningful
such as ironing a shirt. Likewise, for a client who
is hopeless, the therapist can help the client toincrease self-efficacy on that activity. If the client
could not pare an apple easily, the therapist would
demonstrate strategies such as stabilizing the apple
and using an adaptive equipment to perform theactivity successfully therefore increase the client’s
self-efficacy. Though a limitation of using theself-regulatory system model could be that there
may be other factors affecting people’s behaviors
such as physical dysfunction or pain, conditional
reasoning can be used to understand the factors
why the client is in a specific motivational state
and adjust the intervention accordingly.
Research is currently underway to develop asystematic method for identification of what client
cues are valid and reliable expressions of selfefficacy and outcome expectancy. Once we areable to measure these expressions reliability andvalidly, we may be able to improve theintervention to speci fically address eachmotivational state.
Acknowledgment: The author thanks Dr. Linda
Tickle-Degnen, Ph.D., OTR/L, FAOTA, Dr.
Patricia Nemec, Psy.D., C.R.C., C.P.R.P. and Dr.
Nancy K. Latham, PhD., PT for their comments on
earlier drafts of this paper. This paper wascompleted in partial fulfillment of therequirements for the author’s doctoral degree inrehabilitation sciences.

References
Al-Darmaki, F., & Kivlighan, D. M. (1993).

Takahashi K

31

Congruence in client-counselor expectations for
relationship and the working alliance. Journal ofCounseling Psychology, 40, 379–384.
Bakshi, R., Bhambhani, Y., & Madill, H. (1991). The
effects of task preference on performance during
purposeful and nonpurposeful activities. Am. J.
Occup. Ther., 45, 912–916.
Bandura, A. (1977). Self-efficacy: Toward a unifying
theory of behavioral change. Psychological
Review, 84, 191–215.
Bandura, A. (1986). Social foundations of thought
and action: A social cognitive theory. Upper
Saddle River, NJ: Prentice-Hall.
Bandura, A. (1991). Social cognitive theory of selfregulation. Organizational Behavior and Human
Decision Processes, 50, 248–287.
Bandura, A. (1995). Self-efficacy in changing
societies. New York: Campridge University Press.
Bandura, A. (1997). Self-efficacy: The exercise ofcontrol. New York: W.H. Freeman.
Bandura, A., & Adams, N. E. (1977). Analysis ofself-efficacy theory of behavioral change.
Cognitive Therapy and Research, 1, 287–310.
Bordin, E. S. (1979). The generalizability of thepsychoanalytic concept of the working alliance.
Psychotherapy: Theory, Research & Practice, 16,
252–260.
Brehm, J. (1966). A theory of psychologicalreactance. New York: Macmillan.
Burger, J. M., & Cooper, H. M. (1979). The
desirability of control. Motivation and Emotion, 3,
381–393.
Christiansen, C. (1991). Occupational therapy:
Intervention for life performance. In C.
Christiansen & C. Baum (Eds.), Occupational
therapy: Overcoming human performance deficits(pp. 3–43). Thorofare, NJ: SLACK.
Connors, G. J., Carroll, K. M., DiClemente, C. C.,
Longabaugh, R., & Donovan, D. M. (1997). The
therapeutic alliance and its relationship toalcoholism treatment participation and outcome.
Journal of Consulting and Clinical Psychology,
65, 588–598.
Cox, A. C., Holbrook, D., & Rutter, M. (1981).
P s y c h i at r i c i n t e r v i e w i n g t e c h n i q u e s : V I .
Experimental study: Eliciting feelings. British
Journal of Psychiatry, 139, 144–152.
Cox, A., Rutter, M., & Holbrook, D. (1981).
Psychiatric interviewing techniques: V.
Experimental study: Eliciting factual information.
British Journal of Psychiatry, 139, 29–37.
Cruz, M., & Pincus, H. A. (2002). Research on the

32

SELF-EFFICACY AND OUTCOME EXPECTANCY

influence that communication in psychiatricencounters has on treatment. Psychiatric Services,53, 1253–1265.
DeGroat, E. J., Lyons, K. D., & Tickle-Degnen, L.
(2006). Favorite activity interview as a window
into the identity of people with Parkinson’s
disease. OTJR: Occupation, Participation and
Health, 26, 56–68.
Dickerson, A. E., & Fisher, A. G. (1997). Effects offamiliarity of task and choice on the functional
performance of younger and older adults.
Psychology and Aging, 12, 247–254.
Eisenthal, S., Koopman, C., & Lazare, A. (1983).
Process analysis of two dimensions of thenegotiated approach in relation to satisfaction in
the initial interview. Journal of Nervous andMental Disease, 171, 49–54.
Ferguson, J. M., & Trombly, C. A. (1997). The effectof added-purpose and meaningful occupation on
motor learning. Am. J. Occup. Ther., 51, 508–515.
Fleming, M. H. (1994). Conditional reasoning:
Creating meaningful experiences. In C. Mattingly& M. H. Fleming (Eds.), Clinical reasoning:
Forms of inquiry in a therapeutic practice (pp.
197–235). Philadelphia: F.A. Davis.
Fletcher, W. L., Hansson, R. O., & Bailey, L. (1992).
Assessing occupational self-efficacy among
middle-aged and older adults. Journal of Applied
Gerontology, 11, 489–501.
Fry, P. S. (2001). Predictors of health-related qualityof life perspectives, self-esteem, and life
satisfactions of older adults following spousal
loss: An 18-month follow-up study of widows andwidowers. Gerontologist, 41, 787–798.
Gage, M., & Polatajko, H. (1994). Enhancing
occupational performance through anunderstanding of perceived self-efficacy. Am. J.
Occup. Ther., 48, 452–461.
Gage, M., Noh, S., Polatajko, H. J., & Kaspar, V.
(1994). Measuring perceived self-efficacy inoccupational therapy. Am. J. Occup. Ther., 48,
783–790.
Goering, P., Wasylenki, D., Lindsay, S., Lemire, D.,& Rhodes, A. (1997). Process and outcome in ahostel outreach program for homeless clients withsevere mental illness. American Journal of
Orthopsychiatry, 67, 607–617.
Grembowski, D., Patrick, D., Diehr, P., & Durham,
M. (1993). Self-efficacy and health behavior
among older adults. Journal of Health and Social
Behavior, 34, 89–104.
Hewlett, S., Cockshott, Z., Kirwan, J., Barrett, J.,

Stamp, J., & Haslock, I. (2001). Development andvalidation of a self-efficacy scale for use in British
patients with rheumatoid arthritis (RASE).
Rheumatology, 40, 1221–1230.
Kinsella, K., & Velkoff, V.A. (2001). An aging
world: 2001. Washington, DC: U.S. Government
Printing Office.
Kircher, M. A. (1984). Motivation as a factor ofperceived exertion in purposeful versus
nonpurposeful activity. Am. J. Occup. Ther., 38,
165–170.
Kivlighan, D. M. J., & Shaughnessy, P. (2000).
Patterns of working alliance development: A
typology of client’s working alliance ratings.
Journal of Counseling Psychology, 47, 362–371.
Kokitovic, A., & Tracy, T. (1990). Working alliancein the early phase of counseling. Journal ofCounseling Psychology, 37, 16–21.
Krantz, D. S., Baum, A., & Wideman, M. V. (1980).
Assessment of preferences for self-treatment andinformation in health care. Journal of Personality
and Social Psychology, 39, 977–990.
Lorig, K., Chastain, R. L., Ung, E., Shoor, S., &Holman, H. (1989). Development and evaluationof a scale to measure perceived self-efficacy inpeople with arthritis. Arthritis and Rheumatism,32, 37–44.
Lorig, K., Stewart, A. L., Ritter, P., Gonzalez, V.,
Laurent, D. D., & Lynch, J. (1996). Outcome
measures for health education and other healthcare interventions. Thousand Oaks, CA: Sage
Publications.
Lorig, K. R., Ritter, P., Stewart, A. L., Sobel, D. S.,
Brown, B. W., Jr., Bandura, A., et al. (2001).
Chronic disease self-management program: 2-year
health status and health care utilization outcomes.
Medical Care, 39, 1217–1223.
Low, M. (2002). Assessing roles and competence. In
C. A. Trombly & M. V. Radomski (Eds.),
Occupational therapy for physical dysfunction(5th ed., pp. 31–45). Philadelphia: Lippincott
Williams & Wilkins.
Lustig, D. C., Strauser, D. R., Rice, N. D., & Rucker,
T. F. (2002). The relationship between working
alliance and rehabilitation outcomes.
Rehabilitation Counseling Bulletin, 46, 24–32.
Lyons, K. D., Tickle-Degnen, L., Henry, A., & Cohn,
E. (2004). Impressions of personality in
Parkinson’s Disease: Can rehabilitation
practitioners see beyond the symptoms?
Rehabilitation Psychology, 49, 328–333.
Lyons, K. D., Tickle-Degnen, L., & DeGroat, E. J.

Asian J Occup Ther 6: 22–33, 2007(2005). Inferring personality traits of clients with
Parkinson’s disease from their descriptions offavourite activities. Clinical Rehabilitation, 19,
799–809.
Mallinckrodt, B., & Nelson, M. L. (1991). Counselor
training level and the formation of thepsychotherapeutic working alliance. Journal ofCounseling Psychology, 38, 133–138.
McAuley, E. (1993). Self-efficacy, physical activity,
and aging. In J. R. Kelly (Ed.), Activity and aging:Staying involved in later life (pp. 187–205)
Thousand Oaks, CA: Sage.
Meyer, A. (1922). The philosophy of occupational
therapy. Archives of Occupational Therapy, 1, 1–
10.
Miller, L., & Nelson, D. L. (1987). Dual-purpose
activity versus single-purpose activity in terms ofduration on task, exertion level, and affect.
Occupational Therapy in Mental Health, 7, 55–
67.
Montgomery, E. B., Jr., Lieberman, A., Singh, G., &Fries, J. F. (1994). Patient education and healthpromotion can be effective in Parkinson’s disease:
A randomized controlled trial. PROPATH
Advisory Board. American Journal of Medicine,97, 429–435.
Moore, E. J. (1992). The relationship among selfefficacy, health knowledge, self-rated healthstatus, and selected demographics as determinantsof health promoting behavior in older adults(Doctoral dissertation, University of Akron,1992). Dissertation Abstracts International, 53,
1788.
Morton, G. G., Barnett, D. W., & Hale, L. S. (1992).
A comparison of performance measures of anadded-purpose task versus a single-purpose task
for upper extremities. Am. J. Occup. Ther., 46,
128–133.
Murphy, S., Trombly, C., Tickle-Degnen, L., &Jacobs, K. (1999). The effect of keeping an endproduct on intrinsic motivation. Am. J. Occup.
Ther., 53, 153–158.
Nakamura, H. (1995). Overuse and misuse inoccupational therapy (in Japanese). The Japanese
Journal of Occupational Therapy, 29, 336–337.
Oka, S. (1995). Overuse and misuse in psychiatry (inJapanese). The Japanese Journal of Occupational
Therapy, 29, 346.
Okumura, N. (2003). Experimental study of overusein treatment plan for changing the dominant hand(in Japanese). Kitasato University Journal of
Occupational Therapy, 6, 101–103.

Takahashi K

33

Perraud, S. (2000). Development of the Depression
Coping Self-Efficacy Scale (DCSES). Archives of
Psychiatric Nursing, 14, 276–284.
Prochaska, J. O., DiClemente, C. C., & Norcross, J.
C. (1992). In search of how people change:
Applications to addictive behaviors. American
Psychologist, 47, 1102–1114.
Resnick, B. (1998). Efficacy beliefs in geriatricrehabilitation. Journal of Gerontological Nursing,24, 34–44.
Resnick, B. (1999). Reliability and validity testing of
the self-efficacy for functional activities scale.
Journal of Nursing Measurement, 7, 5–20.
Resnick, B., & Jenkins, L. S. (2000). Testing thereliability and validity of the Self-Efficacy for
Exercise scale. Nursing Research, 49, 154–159.
Riccio, C. M., Nelson, D. L., & Bush, M. A. (1990).
Adding purpose to the repetitive exercise ofelderly women through imagery. Am. J. Occup.
Ther., 44, 714–719.
Rijken, P. M., & Dekker, J. (1998). Clinicalexperience of rehabilitation therapists withchronic diseases: A quantitative approach.
Clinical Rehabilitation, 12, 143–150.
Rosenthal, R., & Rosnow, R. L. (1991). Essentials of
behavioral research: Methods and data analysis(2 ed.). Boston: McGraw-Hill.
Roter, D. L., & Hall, J. A. (1992). Doctors talking
with patients/patients talking with doctors:
Improving communication in medical visits.
Westport, CT: Auburn House.
Ryckman, R. M., Robbins, M. A., Thornton, B., &Cantrell, P. (1982). Development and validationof a physical self-efficacy scale. Journal of
Personality and Social Psychology, 42, 891–900.
Safran, J. D., & Muran, J. C. (1998). The therapeutic
alliance in brief psychotherapy: G e n er a lprinciples. In J. D. Safran & J. C. Muran (Eds.),
The therapeutic alliance in brief psychotherapy.
(pp. 217–229). Washington DC: American
Psychological Association.
Sakano, Y., & Tohjoh, M. (1986). The General Selfefficacy Scale (GSES): Scale development andvalidation (in Japanese). Japanese Journal of
Behavior Therapy, 12, 73–82.
Schuster, C., Petosa, R., & Petosa, S. (1995). Usingsocial cognitive theory to predict intentional
exercise in post-retirement adults. Journal of
Health Education, 26, 14–21.
Schwarzer, R., & Fuchs, R. (1995). Changing risk
behaviors and adopting health behavior: A role ofself-efficacy beliefs. In A. Bandura (Ed.), Self-

34

SELF-EFFICACY AND OUTCOME EXPECTANCY

efficacy in changing societies (pp. 259–287). New
York: Cambridge University Press.
Schwarzer, R., & Jerusalem, M. (1995). Generalized
Self-efficacy Scale. In S. Weinman, S. Wright, &M. Jonhston (Eds.), Measures in healthpsychology: A user’s portfolio. Causal andcontrol beliefs (pp. 35–37). Windsor, UK:
nferNelson.
Sherer, M., & Maddux, J. E. (1982). The SelfEfficacy Scale: Construction and validation.
Psychological Reports, 51, 663–671.
Smith, R. A. (1984). Measuring desire for control of
health care processes. Journal of Personality andSocial Psychology, 47, 415–426.
Stevens, M., Bakker-van Dijk, A., de Greef, M. H.
G., Lemmink, K. A. P. M., & Rispens, P. (2001).
A Dutch translation of a questionnaire assessing
self-efficacy in leisure-time physical activity.
Journal of Aging and Physical Activity, 9, 223–
232.
Takahashi, K. (2002). Effects of added-purpose
activities on mental concentration assessed bysubjective time estimation and incidence of Fmθ
wave (in Japanese). Kitasato University Journal of
Occupational Therapy, 5, 156–169.
Thibodeaux, C. S., & Ludwig, F. M. (1988). Intrinsic
motivation in product-oriented and non-productoriented activities. Am. J. Occup. Ther., 42, 169–
175.
Tickle- De gne n, L., & Lyo ns, K. D. (2 00 4) .
Practitioners’ impressions of patients with

Parkinson’s disease: The social ecology of theexpressive mask. Social Science & Medicine, 58,
603–614.
Tinetti, M. E., Richman, D., & Powell, L. (1990).
Falls efficacy as a measure of fear of falling.
Journals of Gerontology, 45, 239–243.
Tipton, R. M., & Worthington, E. L. (1984). The
measurement of generalized self-efficacy: A studyof construct validity. Journal of Personality
Assessment, 48, 545–548.
Trombly, C. (1993). Anticipating the future:
Assessment of occupational function. Am. J.
Occup. Ther., 47, 253–257.
Trombly, C. (1995). Occupation: Purposefulness andmeaningfulness as therapeutic mechanisms. Am. J.
Occup. Ther., 49, 960–972.
Trombly, C. (2002). Occupation. In C. Trombly &M. V. Radomski (Eds.), Occupational therapy forphysical dysfunction (4th ed., pp. 255–281).
Philadelphia: Lippincott Williams & Wilkins.
Wang, A. Y., & Richarde, R. S. (1988). Global
versus task-specific measures of self-efficacy.
Psychological Record, 38, 533–541.
White, R. W. (1971). The urge towards competence.
Am. J. Occup. Ther., 25, 271–280.
Wicklund, R. A. (1974). Freedom and reactance.
Potomac, MD: Erlbaum.
Yoder, R. M., Nelson, D. L., & Smith, D. A. (1989).
Added-purpose versus rote exercise in female
nursing home residents. Am. J. Occup. Ther., 43,
581–586.