The occupational therapist as a consultant.

The Occupational Therapist as a Consultant: A Model of Community Consultation Occup Ther Health Downloaded from informahealthcare.com by University of Alberta on 11/27/14 For personal use only.

Evelyn Jaffe, MPH, OTR, FAOTA

SUMMARY. Current changes in the health care delivery system have resulted in expanded roles for many occupational therapists in which they have had no training and little previous experience. The occupational therapy manager and administrator, in particular, is asked frequently to consult with and engage in collaborative efforts with interdepartmental personnel, community agencies, and consortia of health care services. Also, occupational therapists in private practice and the school systems often are asked to assume the role of a consultant. The necessary background and skills to perform effectively as a consultant in a variety of systems, including political lobbying activities, are presented in this article in a case approach to the issues. The theoretical constructs and the process of consultation are described in the case presentation. Evelyn Jaffe has been a community consultant for the past eighteen years. She has provided consultation to community preschools, the public school systems, community-wide activity programs for children and youth, and agencies develop ing comprehensive health services for adolescents. Her major interest has been in disease preventionhealth promotion activities, with an emphasis on community mental health and children and youth programs. She has been a consultant for The Institute for Health Policy Studies, University of California, San Francisco and the program consultant and principal investigator for a federally supported health consumer education and training research project. She has presented numerous workshops and graduate courses on the theory and practice of consultation. s This article appears jointly in The Occupationaf Thempy h f 0 ~ g e r 'Survival Hodbook (The Haworth Press, Inc., 1988) and in Occupational Theraq in Health Cam, Volume 5. Number 1 (1988). 0 1988 by The Haworth Press, lnc. AII rights resewed. 87

Occup Ther Health Downloaded from informahealthcare.com by University of Alberta on 11/27/14 For personal use only.

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consultants of the times. Alinsky'was noted for his theories of social action, political advocacy and conflict resolution in social systems. Bennis, Lawrence & Lorsch4' and others were concerned with organizational development. Likert, Argyris, and Lippitt618 wrote extensively on planned change, group process, and human organization. Caplanqoften called the father of medical consultation, developed his psychodynamic theory based on a clinicaUtreatment model. Cooper and Rhodes'bmbined several of these theories and described a culturaUenhancement model of consultation founded on environmental and ecological principles. The importance of having a background in the theoretical constructs of consultation practice cannot be overemphasized. Before attempting to become a "consultant," it is suggested to study the various models so that the consultant will have the knowledge to assess a situation and choose the model or combination of models from a theoretical perspective, best suited to the individual's own style and personality, and most appropriate to the situation. Consultation often is not a profession in and by itself, but rather additional skills over and above one's original field. It is a professional skill that is developed through training, experience and continued learning. The additional training and understanding of the theoretical concepts of consultation are necessary so that one's own field of expertise does not interfere with the consultation process. A common pitfall of consultation is the expectation by the client or the consultant herself that she is the "expert" and must provide the solutions. When occupational therapists are called in as consultants to nursing homes, school systems, community agencies, or other professional departments they are not expected to give a course in occupational therapy, but rather to impart their ability to assess a situation, contribute to the problem-solving, and suggest alternatives. Consultation is not just a technical skill, but one that involves the dynamics of human relationships in an ever-changing environment. The consultant must be able to utilize the interpersonal relationship and share ideas as an analyst, planner, sounding board, change agent, reviewer, catalyst, and often, library of special knowledge


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with the understanding that any of these ideas might be rejected by the consultee." The consultant must attempt to understand the frame of reference of the consultee and encourage maximum panicipation from the consultee. Usually, the consultant is an "outsider7' to the hierarchical power system of the consultee, with no decisionmaking authority and no direct responsibility for intervention into the target population sewed by the system. There are specific basic steps in the cycle of the consultation process: 1. the consultation entry 2. negotiation of contract 3. establishment of trust 4. maintenance phase 5. evaluation 6. termination 7. possible renegotiation"

These steps will be described in greater detail in the context of the actual consultation. Consultation also may occur on one of several levels: Level I: case-centered consultation Level 11: educational consultation Level Ill: program andlor administrative consultati~n'~.~~

The case description of a child care program for children of high school student parents will demonstrate how an occupational therapy consultation progressed from a case-centered consultation to the educational level to, finally, an attempt to institute a Level Ill program comultarion where greater risks and constraints were involved. THE PARTICIPANTS In the early 1970s, high school counselors, teachers, and principals in a California county were concerned with the increasing dropout rate of female high school students due to pregnancy and often the resultant birth of children to very young girls. After four


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years of planning and studying the problem, a project was proposed to the county board of education. It would provide quality child care for children of high school age parents, with the provision that to have their children participate in the program the young mothers must remain in school. The professional participants directly involved in this project included the educational director of the center and her child care staff, the school nurse, and subsequently, an occupational therapist. An Advisory Committee, composed of district high school personnel, county administrators, the child development specialists at The Center, the school nurse, and community members was established to oversee the administration, goals and evaluation of the program. The Advisory Committee reported to the county superintendent of schools and the district high school board of directors.

This project, at its inception, was unique, in that the program was housed in a public high school under the auspices of the community high school district, a division of the county offices of education. When this program began in the early 1970s, child care for teenage parents was not readily available. Those few existing programs in the country were in alternative high schools or outside the mainstream of public high school education facilities. The program to be described, The Tamalpais Union High School District Infant Children's CenterIParenthood Development Program (known hereafter as "The Center"), was organized as an integral part of one of the high schools in the district. The child care facility and playground were within the main school building, immediately adjacent to high school classrooms and the student outdoor recess area. This close proximity of the child care center to the high school facilities allowed the high school students to interact and observe the babies in the program. The Center was established as a property tax supported program, operating under a contract services agreement with the county superintendent of schools office during the regular school year, September to June. The summer program was conducted by the high school district as part of the summer school session. Both programs


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required evaluation. The evaluation process was organized by a subcommittee, chaired by the school psychologist, and included the occupational therapist, school nurse, dental hygienist, child development teacherfdirector of The Center, high school counselor, high school life-skills teacher, and the administrator of the county child development programs. The program evaluation was designed to serve several functions: (1) to monitor the individual growth and development of each young child enrolled in The Center's program, (2) to assist the program staff and Adviso~yCommittee in the area of program development, and (3) to provide data for decision-making regarding the future of the project. The evaluation process was designed to collect and analyze data that were valid and reliable, to serve the above three functions, and to indicate the degree to which the program had accomplished its stated objectives. The &cupational therapist was an integral part of the subcommittee that refined the objectives of the project. A multi-dimensional needs assessment, conducted by the sibcommittee, revealed the necessity for three major components of the project: (1)a program for the young children which would provide quality child care, (2) a program for the teenage parents to provide parenting skills, awareness of community resources, and counseling, and (3) a program involving high school students at the Center site to provide a practicum opportunity in child development and parenting. The child development center was located at one of the county public high schools, and provided services to children from three months to thirty-three months of age. Admission to the program included the requirement that the school age parent remain as a fulltime high school student. The Center, which was open from 7:30 a.m. to 5:00 p.m. Monday to Friday, provided quality child care and emphasized appropriate early childhood learning experiences based on published studies and theories of child growth and development. The parents of the children enrolled at The Center were required to attend a parenthood development class one evening a week (7-10 p.m.) for eight weeks each semester. The majority (75%) of the families involved in the program were single-parent families with little or no relationship with the fathers of the children. However, when possible, the fathers were encouraged to attend the par-


enthood class also. Issues of parenting, nutrition, health and development, welfare rights, services, and child legislation, child abuse, and community resources were among - the topics covered in the seminars. High school students participated in the program through the Child Care Practice Class taught by the high school life-skills teacher of the home economics department. The students studied theory and stages of child development, legislation concerning child care, organization and activities of child care centers, comrnunication and self-awareness skills. A practicum in The Center was required for all high school students enrolled in the class. The students interacted directly with the young children and the staff in all phases of The Center program, including play activities, eating, child care, and reports. Specific program objectives were defined for the young children's program, the parent program, and high school student program. Evaluation instruments were designed to measure the three components of the project through pre- and post-assessments in all three areas.

CHRONOLOGY OF EVENTS The key events which led to the author's involvement in the program are reviewed briefly to gain an understanding of the background in which a consultation experience may be initiated.

1. Four years of planning and negotiations for implementation of The Center 2. Development of an Advisory Committee 3. Hiring professional child development staff 3. Opening of The Center 4.' Public announcement of the need for community members on the Advisory Committee (occupational therapist appointed to the Committee) 5. Skills of individual members of the Advisory Committee presented (occupationaltherapist presented the unique skills and knowledge of her profession .pertinentto this program)


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The d)ccorpotio~lThemm Manager's Survival Handbook

6. Review of program and request by county for evaluation report (occupational therapist requested to participate in the evaluation process) 7 . Subcommittee on evaluation developed measurable objectives and assessment instruments for the major components of the program (occupational therapist was a member of the evaluation subcommittee, and to this point all involvement wos as a volunteer) 8. Hiring of a developmental testing consultant for evaluation report (occupational therapist was hired on a contractual basis)

CONTEXT (OCCUPATIONALTHERAPY CONSULTATION) The author, an occupational therapist, learned of a request for interested community citizens to participate on the Advisory Committee. As child development and the high risk problems of adolescent pregnancy were a particular interest, a curriculum vita and statement of interest were submitted by the author to the chairperson of the Advisoly Committee. The Committee originally had not considered the specific skills and knowledge of an occupational therapist as necessaly to this project. However, after being chosen as a community member of The Center Advisoly Committee, the author used this opportunity to educate fellow members of the Committee about occupational therapy. The author became an active participant on the Committee, which met once a week during the first six months of operation, and soon was elected secretary of the Advisory Committee. In this role, she met frequently with the principal of the school in which the program was housed and The Center director, who were also members of the Advisory Committee. Since this program initially was a pibt project, with the plan to continue operation pending evaluation, program evaluation was of vital concern to the Advisory Committee. The Advisory Committee, mow more cognizant of occupational therapy skills, asked the author if developmental testing could be used as part of the overall program evaluation. The basic ingredients of consultation appeared to be present in the request for the evaluation skills of the occupational therapist. Therefore, the therapist accepted a contract with The Center on a


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consultation basis. The nature of the contract initially included prepost developmental testing on all the children enrolled at The Center, (in September and again in June), consultation with The Center staff regarding the developmental status of each individual child, analysis of the assessments, composite analysis of the data for program evaluation, and final reports to the Advisory Committee to be included in the yearly evaluation report submitted to the district school board and the offices of the county superintendent of schools. The basic steps of consultation were followed. Entry: There are four ways to enter a system for the purpose of consultation:

Planned entry-The individual develops a strategy and presents a proposal. Opportunistic entry-The situation arises spontaneously and the individual seizes the moment. Uninvited entry-The individual perceives a need and attempts to enter. Invited enoy -The individual is invited because of specific skills. The initial involvement in this system was essentially opportunistic in that the situation occurred spontaneously by the announcement of the need for community members on the Advisory Committee. The therapist pursued the request at her own initiative based on interest in the program. However, the actual entry as a consultant was invited, the most preferable form of entry. Planned, oppotnutistic, and uninvited methods will fail if the individual is not ultimatelv invited to enter the mstem. ~eiotiarionof contract: contracts should be in writing, with the needs, focus, limits, objectives, and goals of the consultation clearly delineated. The role of the consultant and the expectations of the system or consultee also should be mutually understood. The initial contract for the first year of the program was limited to the actual hours of developmental testing of the children, consultation with the program staff and the analysis of ttie data. Attendance at the Advisory Committee o r subcommittee meetings was still on a volunteer basis. Any additional time spent with program staff; county administrators, school board members, and the media to

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The O c c u p a t w ~ &rap l M a ~ g e r ' sSuwival Handbwk

publicize the project and enhance the program were also at the interest of the consultant and not included in the contract. Establishment offrust: Essential to any consultation is an understanding of the system in which the consultation will take place. In order to establish the mutual respect necessary to a successful consultation, the consultant should have a thorough knowledge of both the formal and informal lines of communication, the politics of the situation, the key power figures, and the ways in which decisionmaking occurs in that system. Local, state, and a national trends and legislation must be addressed as well as the local political environment of elected school board members and county school administrators. Since this project was under the auspices of both the district and county school systems, and scrutinized closely by the community and local school board, it was essential to understand the impact of the key people in these areas. Additionally, the social trends of the seventies were instrumental in determining the implementation of this program. Teenage pregnancy was just becoming a national concern and this project was to serve as a model for other school systems. The program staff and the life skills teacher were anxious to develop high quality programs that would ensure the success of the project and meet the needs of the community. The consultant spent considerable time conversing informally with the staff and teacher, after the formal evaluations and conferences, to become better acquainted with them and to demonstrate interest in the program and their concerns. It is often during these more casual ccantacts that the bond of mutual trust and respect is built. Maintenance phase: The ongoing aspect of the consultation is the maintenance phase during which a communication network should be developed. Linkages both within and without the system are essential to assure that the information received is accurate and that the consultant's perceptions are on target. Inherent in this process is a feedback system." An occupational therapist, trained in communication skills, is eminently qualified to develop the "cognitive map" required in a feedback system to review observations and perceptions and see where they lead. A feedback system is like an insurance policy in that the consultant can check out his or her perceptions with others in the network to clarify impressions and ensure that one's views are similarly shared. The complex nature of the school system as previously de-


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scribed, made this communication,feedback network of ultimate importance to the success of the child care project. By listening to all cues in formal reports and casual conversation, both at meetings and community gatherings, it was possible to ascertain concerns of some school board members and administrators regarding the costbenefit of this project. The consultant became a sounding board for staff concerns and an advocate for the program. The relationship among staff and the high school life-skills teacher was strengthened in the next year of operation when the program was in jeopardy. (This aspect will be discussed later in the paper.) The maintenance phase also involves understanding the hierarchical power base of the system, building and increasing power blocks, being cognizant of the environmental factors which affect the system, and developing an educational and training program if necessary. These aspects of consultation for this project will be described in the section on Risks. Evaluation: The evaluation process of consultation should involve both fonnal and informal methods of evaluation. The formal method consists of data collection and analysis based on the specific outcome objectives desired from the consultation. As described previously, the evaluation subcommittee designed instruments to measure the three major components of the program. The (occupational therapist) consultant used the Denver Developmental Screening Test (DDST)initially as the pre and post assessment." The Gross Motor and Personal-Social sections of the test revealed the greatest number of children functioning within normal limits. The area of functioning demonstrating the most developmental delay was language. Many of the children enrolled in the program did not have home environments where language was stressed, In addition to measuring growth and development, a major objective of the program, the test results were used by the occupational therapist to review programming. The therapist consulted with the The Center staff in selecting specific activities for the children to encourage verbal communication and develop language skills and other activities designed to improve growth and development in all areas of functioning. In addition to the formal evaluation instruments, informal evaluation of the program and the growth and development of the children were made through periodic observation throughout the year of the


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childrens' functional skills, interpersonal skills, and ability to cope and adapt to changes in their environment. The therapist consulted with the staff on their concerns about individual children, program activities and structure, and political issues regarding the entire project. The formal and informal consultation formed the basis for evaluation of needed program changes. As information was collected, the consultant was able to redefine the situation, the problem, and the possible range of solutions.15 Termination: Actual termination preparation should begin at entry during the development of the initial contract.12 The goals and time frame of the consultation should be established at the onset of the consultation experience. Some contracts have a renegotiation clause built into the contract. The occupational therapy consultation was considered time-limited for the first year of the project. Neither the Advisory Committee members nor the county administrator had experience with the type of consultation planned for the program. Therefore, the consultation was to be evaluated as well as the program. By the end of the first year, many things had occurred in this project which warranted further study and consultation. Several issues and changes were being considered, relative to the individual children in The Center, the activity programming, an expansion of services, and the economic and political climate. Possible renegotiation: As mentioned above, some contracts initially consider the possibility of renegotiation. Most renegotiation occurs at the conclusion of the consultation period, pending the outcome of the experience. As a result of the consultant's findings regarding individual children and the program activities, it was determined that the occupational therapy consultation cantract be expanded and renegotiated. CHOICES

In the project described, the author became aware of a number of problems and alternative possibilities during the course of the initial consultation experience. Originally, the choice of consultation followed the more traditional clinical model described by Caplan in which specific professional skills, in this case, evaluation techniques, were requested. The consultant was viewed as a specialist, responsible for diagnosis through observation, interview, and as-


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sessment. Consultation with The Center staff was mainly case-centeted. This model is perhaps most familiar to occupational therapists as it is easily adapted from traditional clinical skills.'z As the consultant leaned more about the children, the parents, the staff, the activity programming, and the external political forces, the model of consultation began to shift. The conferences with the staff revealed the need to expand the services of the program to more comprehensive care for the children with special problems and greater support for the young parents. The consultant decided to use a more comprehensive and sophisticated measure of infant development, the Bayley Scales of Infant Development, (BSID),16to ascertain specific developmental problems, in addition to the general screening of the DDST. The focus of the consultation, was still, at times, the case-centered conferences on individual children who, during the course of evaluation, were found to have such problems as substance abuse and fetal alcohol syndrome, mild cerebral palsy, language and motor delays, eating disorders, and emotional problems. The consultant helped The Center staff find the appropriate referral to community resources for these children and their parents. However, as the consultant viewed the needs of this high risk population, the model and focus of consultation was extended from the narrower case-centered consultation to the broader educationuI consultation. Center staff needed help with programming ideas for the specific activities required for the children with special problems. The parents needed ideas on parenting for the child with special needs and support for their own problems. Being a teenage parent was difficult enough. Having the usual financial and emotional problems coupled with the concerns of raising a child with unusual needs was in some cases overwhelming. These problems had not been considered when the program was conceived. Thus the consultation became targeted at the staff and parents with the ultimate goal of improving their functioning and ability to cope with present and future problems. An in-service training approach was chosen for the staff, and individual educational consultation was provided to the parents to help them improve their coping and parenting skills. Gradually, other requirements became apparent. The curriculum of the high school child care practice class needed modification and


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changes in light of the potential problems of a high risk child and parent program. The consultant was requested to give some lectures to the class on normal growth and development, developmental delays, and potential emotional and handicapping conditions. Through their direct experience with The Center, the high school students were becoming more aware of the many issues involved in teenage sexuality, pregnancy, and parenthood. Consultation with the teacher involved brainstorming on ways to expand the curriculum to meet student needs of decision-making skills, communication and interpersonal skills, self-awareness techniques, and studies in values and attitudes. The class broadened from the initial child care practice curriculum to a more comprehensive study of life skills. Additionally, the consultant saw the possibility to progress to program consultation in which the target is broadened considerably to the social system, and the goal is to promote institutional change by means of administrative or program cons~ltation.'~'~ During the second year of operation, the consultant presented to the Advisory Committee her view of a comprehensive, community-wide disease preventionhealth promotion project for sexually active teenagers, yoilng parents and their children. It included an outreach component from the schools to those pregnant adolescents who had dropped out of the school system.

RlSKS AND CONSTRAINTS The original consultation contract posed little risk, to the consultant or to the school system. Allocation of funds for developmental testing was justified for both evaluation of the program and the developmental progress of the children, and the educational consultation provided a much needed service. However, the decision to present a comprehensive health promotion program to the school board at this time which would move the consultation to Level 111, was fraught with considerable risks and constraints. The concept was appealing as the need was obviously present. However, the school system was not in a position to fund an expanded program. The Advisory Committee gave the consultant approval to write exploratory letters to several private foundations to


determine if there was interest in funding such a project. Several foundations expressed interest in receiving a proposal. The consultant was requested to develop a preliminary grant proposal in consultation with The Center director for presentation to the Advisory Committee, the county school administration, and the elected school board members. The consultant chose the cultural-enhancement model of csnsdtation with the emphasis on the social and cultural issues indigenous to this community in preparation for developing the grop~al.'~." Prior to writing the proposal, a needs assessment was conducted to determine the extent of teenage pregnancies in the county, the I(PCUS of most of the problems, and the degree of need for a comprehensive health promotion program for sexually active adolescents in this community. The proposed project was to expand services considered vital to an exemplary infantlparent program, provide counseling and outreach services to girls that drop out of school because of pregnancies or birth of children, and develop collaborative, costeffective referral networks with existing mmmunity agencies. The ultimate goal of the program was to promote positive institutional change through a community-wide disease preventionhealth promotion program. As an additional benefit, this project could provide graduate students in occupational therapy, early childhood development, and psychology with the opportunity to participate in the program and to design their own research studies under the di.rection of the project director. There were several constraints before submitting the final proposal, which would create a Level I11 consultant position. It had to be reviewed by The Center staff, the parent group, the Advisory Committee, the district and county school superintendents, and finally the school board. The consultant also became cognizant of the many political, bureaucratic, regulatory, and financial constraints in the school system and other community agencies during the yearlong process of developing the proposal. The proposal received the endorsement of the Advisory Committee and the district and county school superintendents and was submitted to the school board for final approval before sending to external institutions for funding.


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Unfortunately, the timing of the proposal coincided with a grand jury review and investigation of county-supported programs. There were some influential, fiscally and socially conservative members on the jury who questioned the need for the original teenage parent] child care program and the expense of operating it. They were adamant about not expanding the program and spoke up against the proposal at the school board hearing. The school board was split in the preliminary vote. The consultant spent considerable time over the next few months speaking to individual members on the school board, demonstrating community need, and the risks associated with the outcomes of adolescent pregnancies. The proposal was presented again and proponents that included the occupational therapist consultant, The Center director, the school psychologist, and an educational psychologist (former occupational therapist) were speakers for the project. About this time, the Alan Guttmacher Institute study on the problems of adolescent pregnancies in the publication 11- illi ion Teenagers was receiving national notice." The day the school board hearing was held, the newspaper headlines outlined President Carter's budget proposals for the coming year. The Office of Adolescent Pregnancy ( O M ) had been established in federal legislation in 1977 and of high priority in the president's budget was funding for programs under the jurisdiction of the OAP. This information was conveyed to the members of the school board and was received with interest. However, once again the timing for expanded community social programs was wrong. The Jarvis-Ganns Initiative in California, known as "Proposition 13," was being studied in communities all over California. This Initiative would eliminate the property taxes on which the infandchild care and parent program were dependent for operation. The school board was reluctant to approve funding of "soft money" or time-limited external funds that would be the responsibility of the school system to continue when the external funding had ended. Although the program received greater support at this hearing, it was suggested to try collaborating with other county agencies for the expanded program. Again, the consultant, using some necessary political lobbying


skills, and The Center director, presented the proposal, this time to the community mental health advisory board. The intent was to show the possibility of an inter-agency collaborative agreement between the school system and a community service agency. W o hearings were required before a decision would be made. Despite accord with the principles of the project, some members of this board were concerned with problems of authority, control, and communication between the two systems. There had not been community-wide program contracts between the mental health center and the public school system at this time. Political and bureaucratic concerns and jealousies were the essential issues which prevented the required unanimous vote to co-sponsor the project. OUTCOME When "Proposition 13" (which eliminated escalating property taxes) was enacted in California, communities throughout the state had tb cut back on most social 'and community se&ces. No new programs were started and eventually those programs supported by property taxes were eliminated if other sources of funding were not found. The school board would no longer even consider an expanded, comprehensive project. The county took over the financial support for the original child carelparent program during the regular school year only. The summer program was dropped. In 1981, the Alan Guttmacher Institute produced follow-up studies to I 1 Millon Teenagers in the publication Teenage Pregnancy: The Rvblem That Hasn't Gone Away.18 Although the county of The Center had diminishing funds to support a program which addressed these concerns, the county of San Francisco had become aware of the increased number of teenage mothers in the city. Ninety percent of these young women dropped out of school. Special programs were initiated in two of the city high schools for the pregnant students, but there was no program for the children of teen parents. A consortium of community agencies were interested in the model established at The Center program. The Center director and the occupational therapist consultant were asked to provide program consultation to this new group. An essential part of the consultation was the suggestion to provide comprehensive services to pregnant


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teenagers and teenage parents and to develop a "collocation of services" that would involve several community agencies. In 1982 the Teenage Pregnancy and Parenting Project (TAPP) of San Francisco was initiated, modelled after the proposal described above.I9 The program was funded by the county of San Francisco and the federal Office of Adolescent Pregnancy. Subsequent program evaluations of TAPP demonstrated that a comprehensive service model can provide the basis for effective public policy strategies that meet the needs of pregnant adolescents. Also indicated was the cost-effective way in which existing community programs and resources could be coordinated to develop a comprehensive network of services of adolescent^.'^

CONCLUSION Although it was disappointing that The Center never achieved the system-wide focus proposed, and eventually the program was dissolved entirely, the initial consultation was viewed as successful. The expected outcome of consultation is an increased level of awareness and ability on the part of the consultee to cope with the specific problem and with future similar problems by using suggested resources and/or alternatives. The ultimate goal of the consultation process is the delivery of more effective service to the client or system. The consultant, however, must remember that he/ she is an outsider to the system and final responsibility for change rests with the consultee. Despite the choice that the original Level 111 consultee (the district school board) made to reject the proposal, the therapist consultant was able to see the results of a long, and often frustrating, experience come to fruition through the increased awareness of the issues related to teenage pregnancy in another community's program, TAPP.

QUESTIONS 1. What skills are necessary to become an effective consultant? 2. Why is it necessary to the potential consultant to analyze a system when contemplating a consultation experience and how


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does one assess the situation to determine if one can contribute effectively? 3. What are the ways in which to enter a system, which is usually most successful and why, and what are the motives of the consultant for becoming involved? 4. What are some of the different models of consultation and what factors must be considered in order to select the most appropriate model? 5. How does the consultant know when to incorporate or introduce change to another model or level? How does the consultant guide the process of adaptation and change? 6. Why does the consultant have to consider the outcome of consultation at entry? What are the limits and/or pitfalls for the consultant in the situation? What are the potential motivations of the consultee toward change? 7. How does the consultant evaluate the consultant experience?

REFERENCES 1. Lippitt R: Dimensions of a consultant's job. J of Social Issues, 155-1, 1959 2. American College Dictionary, Newly Revised. New York: Random House, 1964 3. Alinsky S: Reveille for Radicals. New York: Vintage Books, 1969 4. Bennis WG: Changing Organiurrions. New York: McGraw-Hill. 1969 5. Lawrence PR, Lorsch JW: Developing Organizulions: Diagnosis and Action 6. Likert K: 7he Human Orgathtion. Its Ma~gemenland Value. New York: McGraw-Hill, 1961 7. Agryris C: Interve~ionl k o r y ond Methad: R Behavioml Scienee Vkv. Reading: Addison-Wesley Pub Co., 1970 8. Lippitt R, Watson J, Wesley B: 7he Dynamics of Planned Change. New York: Harcourt Brace and World. Inc.. 1958 9. Caplan G: The Theory and Phlctice of Mental Health Consuhatwn. New York: Basic Books. Inc., 1970 10. Cooper and Rhodes; Consultation c o m e . Guest faculty, Ann Arbor, MI, July 1972 11. Rhodes W: Conceptual overview of behavioral consultation, Consulration course. Guest faculty. Ann Arbor. MI, August 1971 12. Jaffe E: The role of the occupational therapist as a community consultant:


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primary prevention in mental health programming. Occup Ther in Mental Health, 1:47-62.Summer 1980 13. Maddwr IF: Consultation in public health. Am J Pub Health, 45:14241430, 1955 14.Denver Developmental Screening Test. FrankenburgW et al.. Ladoca Publishing Foundation, 1973 15. Duhl U.Planning and PredLting: Genernl Systems %oty and Psychiahy. Boston: Little Brown Co., 1969 16. Bayley N: Bayley Scaler of Infaru Developmew. New York: The Psychological Corporation, 1969 17.Alan Guttmacher Institute: 11 M W n Teenagers. New York: Planned Parenthood Federation of America, 1976 e The Problem That Hasn't 18. Alan Guttmacher Inslitute: T e e ~ g Pregnancy: Gone Away. New York: Alan Guttmacher Institute, 1981 19. Mitchell F: Teenage pregnancy and parenting project. Reseatrh Highlighrs 1:l-3,June, 1983

Occupational performance and self-determination: the role of the occupational therapist as volunteer in two mountain communities.

The therapist as psychoeducator.

Role of the Occupational Therapist in an On-Site Occupational Rehabilitation ProgramA Case Study.

The student nurse as therapeutic consultant.

The pharmacist as a consultant to children with chronic diseases.

The psychiatrist as a consultant to self-help groups.

The role of the occupational therapist in the care of people living with lung cancer.

The minister as consultant to the medical team.

Efficacy of kinesiology taping for recovery from occupational wrist disorders experienced by a physical therapist.

Family therapy as seen by a group therapist.

The school consultant as an object for externalization.

Occupational Therapy as a Profession.

The clinical psychologist as program consultant: When is enough enough?

A revised consultant contract.

Becoming an occupational therapist: perceived influence of international fieldwork placements on clinical practice.

The new consultant contract.

The state consultant.

Occupational therapist practice patterns in relation to clients with cognitive impairment following acquired brain injury.

The role of the occupational therapist in the management of neuropsychiatric symptoms of dementia in clinical settings.

The new consultant contract.

Assault on the therapist.

The new consultant contract.

The new consultant contract.

Keeping the therapist alive.