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Introduction

Cognitive orientation to occupational performance (CO-OP) is a meta-cognitive problem solving strategy that can be used to help individuals with impaired executive functioning perform self-identified daily tasks that they need and want to do and are currently having problems (Dawson, et al., 2009). The CO-OP is useful in helping individuals with a TBI by promoting generalization within the treatment sessions to improve daily functioning (Dawson, et al., 2009). Individuals that suffer from a TBI often experience significant executive functioning problems that cause a reduction in quality of life and negative changes in everyday life. CO-OP is a unique approach that uses a problem solving strategy to facilitate their ability to reach their self identified goals. The CO-OP approach consists of:

• Goal (What do I want to do?)
• Plan (How am I going to do it?)
• Do (Carry out the plan)
• Check (Was my plan successful?)

Theory 

The PEO model is regularly used by occupational therapists to increase their client’s success in occupational performance (Strong, et al., 1999). Individuals with traumatic brain injuries often have impairments in their executive functioning, which falls under the person factor (Gaines, Soper, & Berenji, 2016). Using the PEO model, the OT and the client can work together to address barriers within the client, environment, and/or the occupation (Strong et al., 1999). CO-OP specifically changes the person, which ultimately increases the occupational performance (Dawson et al., 2009).

Evidence

Evidence shows that metacognitive strategies have been used to help performance of executive dysfunction and providing rehab in self identified tasks that help promote generalization (Dawson, et al., 2009). One of the metacognitive strategies used is the CO-OP. The study showed that use of the CO-OP has the potential to improve performance in daily functioning for adults with executive function following a traumatic brain injury (Dawson, et al., 2009). In this study, a single case design was conducted with 3 adults post TBI. Over the course of 20 1 hour sessions, patients used the CO-OP problem solving strategies to complete tasks previous identified by the COPM. Findings found positive change in 7 of the 9 trained goals identified and 4 of the 7 untrained goals.

Case Study

Samuel is a 28-year old veteran of the army national guard. As a combat medic on patrol in Afghanistan his convoy encountered an improvised explosive device (IED). Due to this traumatic event, Samuel experienced a traumatic brain injury (TBI) and now suffers from PTSD. Samuel recently expressed that he wished he didn’t have to spend so much money on take out but cooking has become difficult for him after his TBI. Samuel is frustrated because he used to cook often prior to his accident and but finds it difficult to remember the order of ingredients and steps to cook some of his favorite meals. Samuel also identified that he is unsatisfied with how he completes other daily tasks. Based on previous interactions, the therapist suggested using the CO-OP approach to address meal preparation.

Intervention plan

Problem statement  

Client is having difficulty with meal preparation due to impaired executive functioning.

Long term goals

1. Client will be able to independently use the CO-OP problem solving strategy to complete meal preparation within 20 weeks.
2. Client will be able to generalize and use the CO-OP problem solving strategy in an untrained task for IADL’s within 20 weeks.

Short term goals

1. Client will be able to use the CO-OP problem solving strategy to complete 1 meal preparation with 3 verbal cues in 3 weeks.
2. Client will identify 3 possible solutions to complete a known task without assistance in 3 sessions to improve IADL performance.
3. Client will demonstrate 4/4 steps of co-op problem solving strategy with no errors in 5 sessions to improve meal preparation skills.

Intervention format

Individual

Setting

Samuel will meet with the occupational therapist at the client’s home 2x a week for 60 minutes for 20 sessions. 

Supplies

None

Agenda

– Welcome Samuel and provide a recap of the evaluation results (5 minutes)

– Therapist will educate and explain how the CO-OP will help with thinking through meal preparation (5 minutes)

– Educate the client on the CO-OP process using a cue card (10 minutes)

• 1. Goal – What do I want to do?
• 2. Plan – How am I going to do it?
• 3. Do – Carry out the plan
• 4. Check – How well did my plan work?

– Educate on domain specific strategies that client should pay attention to (10 minutes)

• • Work with therapist to come up with a strategy most beneficial to meeting their goal.

– Have client practice the CO-OP process with a familiar task (20 minutes)

– Samuel will practice CO-OP process by making a bed.

– Summarize the session and get feedback from Samuel (10 minutes)

Documentation

S: Client stated he wants to be able to cook a meal for himself and for other people.

O: Client was educated on CO-OP and how it can be used for his self determined goals. Client was attentive and willing to learn the strategy. Client informed therapist that his main goal was meal preparation but he is currently having issues with performance. Clients identified his goal as preparing a pizza. The cue card was used to help the client formulate a plan. Verbal cues were required due to missing components in the plan. For this session, client was educated on the execution (Do) portion and verbally practiced. The client was able to identify with cues from the therapist on how to check to see if his plan would work. Client was educated on domain specific strategies such as verbal self instruction and attention to doing. The client expressed that these strategies were beneficial to him. Client applied his newly learned CO-OP process to complete a familiar task: making a bed. Client was able to complete the task with verbal cues for the (plan) and (do) portion of CO-OP.

A: It is evident that the client is motivated and has the potential to perform the task. Client’s needed for verbal cues to develop a plan for his goal indicates impaired executive functioning. Client showed improvement after verbal cues for check his plan showed the capability to formulate appropriate questions. Client seems to have some insight into his method of learning by identifying his preferred domain specific strategy that would be beneficial for his goals. Client would benefit from continued practice of the CO-OP process using the cue card for reference.

P: Client will complete 20 one on one sessions for 60 minutes 2x a week. Next session, the client should practice his goal-plan-do-check for his goal. Client would benefit from another familiar task to hone his skills and increase his confidence prior to meal preparation.

References

Dawson, D. R., Gaya, A., Hunt, A., Levine, B., Lemsky, C., & Polatajko, H. J. (2009). Using the cognitive orientation to occupational performance (CO-OP) with adults with executive dysfunction following traumatic brain injury. The Canadian Journal of Occupational Therapy, 76(2), 115-127. http://dx.doi.org.ezproxy.fiu.edu/10.1177/000841740907600209

Gaines, K. D., Soper, H. V., & Berenji, G. R. (2016). Executive functioning of combat mild traumatic brain injury. Applied Neuropsychology: Adult, 23(2), 115-124. doi:10.1080/23279095.2015.1012762

Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., & Cooper, B. (1999). Application of the person-environment-occupation model: A practical tool. Can J Occup Ther, 66(3), 122-133. doi:10.1177/000841749906600304