Yes. A common question is, ‘Is it MOHO or nothing?’ This question involves the extent to which MOHO can be used in an integrative way with other models of practice. As mentioned above, MOHO does not provide theoretical arguments to understand the capacity for performance that is supported by one's musculoskeletal, neurological, cardiopulmonary, mental or cognitive abilities such as memory, and planning and other bodily systems. A number of occupational therapy conceptual models of practice seek to explain performance capacities that make possible occupational performance. These models provide detailed concepts for understanding some aspect of performance capacity. Consequently, occupational therapists using MOHO will also need to use other frameworks in order to understand and address performance capacity. A combination of frameworks can, therefore, be used to support a full understanding of the client's occupational engagement. Figure 6.4 identifies how this can be achieved. Overarching values and beliefs of occupation therapy (e.g. occupation is important for health, it is important to consider both the mind and the body, it is important to be client-centred, and so on) inform occupation-focused conceptual models of practice (e.g. MOHO). MOHO has very specific detail on how to carry out occupation-focused practice. Both the values and beliefs of occupational therapy and MOHO provide support for the concept of an ‘occupation filter’ (Mallinson & Forsyth 2000). The occupation filter is a way of viewing knowledge from outside occupational therapy and bringing it into our practice in an occupation-focused way (Fig. 6.5). This allows the integration of a range of theories, yet avoids the ‘cutting and pasting’ of bodies of knowledge from outside occupational therapy into our practice and calling it occupational therapy when it in fact closely resembles other professionals' practice. For example, ‘cutting and pasting’ cognitive behavioural therapy into occupational therapy without using an ‘occupation-focused filter’ will result in practice that looks like that of a psychologist and perpetuate role confusion within occupational therapy.

MOHO is recognized as a model consistent with client-centred practice (Law, 1998 and Sumsion, 1999). MOHO concepts require therapists to have knowledge of their client's values, sense of capacity and efficacy, value, roles, habits, performance experience and personal environment. MOHO-based assessments are designed to gather information on and provide clients with opportunities to provide their perspectives on these factors. The client's unique characteristics, in combination with the theory, guide the development of an understanding of the client's unique situation. The understanding of the client, in turn, provides the rationale for therapy. Moreover, since MOHO conceptualizes the client's own doing, thinking and feeling as the central dynamic in achieving change, therapy must support the client's choice, action and experience.

MOHO is, therefore, inherently a client-centred model in two important ways. Firstly, it views each client as a unique individual whose characteristics fundamentally influence the rationale for and nature of the therapy goals and strategies. MOHO theory both focuses the therapist on the unique characteristics of the client and provides concepts that allow the therapist to appreciate the client's perspective and situation more deeply. Secondly, MOHO views what the client does, thinks and feels as the central mechanism of change (Kielhofner 2002). MOHO concepts also propose that the client's occupational engagement (i.e. what the client does, thinks and feels) is the central dynamic of therapy (Kielhofner 2002). MOHO-based intervention supports the client's doing, thinking and feeling in order to achieve change. MOHO-based practice, therefore, requires a client–therapist relationship in which the therapist must understand, respect and support their client's values, sense of capacity and efficacy, value, roles, habits, performance experience and personal environment.

Some have questioned whether MOHO is flexible and pragmatic enough to be used in a wide range of social, geographic and cultural environments.

With respect to the social environment, the third edition of MOHO has been influenced by the disabilities studies literature (Miller and Oertel, 1983, Hull, 1990 and Gill, 1997). This literature argues that many of the problems faced by persons with disabilities can more properly be located in the environment — in everything from physical barriers to stigmatizing attitudes and outright discrimination. A growing theme is that disability occurs because of a lack of fit between person and environment. This implies, of course, that change must include altering the environment. Accordingly, MOHO calls attention to the environment as both an enabler of and a barrier to occupation (Kielhofner 2002). Throughout, an effort has been made to call attention to circumstances both within the person and within the environment that contribute to a person's motivation, patterns of behaviour and occupational performance. The assessment tools that have been developed routinely contain an environmental component and examine the fit between the person and their environment. A MOHO-based assessment that is entirely focused on the environment has been developed (Moore-Corner et al 1998), and others incorporate the environment as an aspect of the assessment.

There have been questions raised about the portability of MOHO to different geographic and cultural environments. The scholarship of practice approach to MOHO development has encouraged an international community of occupational therapists to use and contribute to the development of MOHO. MOHO has, therefore, become an international conceptual practice model. MOHO has received significant attention, including criticism, elaboration, application and empirical testing by occupational therapists throughout the world in such diverse countries as Australia, New Zealand, the Netherlands, Sweden, Denmark, Japan, Korea, Spain, Italy, Portugal, Chile and Colombia.

The theory itself incorporates a respect for each client's individuality and cultural narrative into its concepts, and many of the assessments are specifically designed to capture a client's unique cultural perspective. For example, the OPHI-II (Kielhofner et al 1997) elicits and considers culturally influenced values, interests and roles through the use of narrative ethnography as a predominant interviewing method. For this reason, the OPHI-II and similar assessments are particularly useful when therapists desire to gather information about the client's culturally influenced thoughts, feelings and actions. Concepts of occupational form can also be helpful in identifying how different cultures define how everyday occupations are completed. Each culture includes a wide range of occupational forms that constitute the opportunities and demands that culture will put on its members for doing everyday things. Knowing how occupational forms are culturally defined for each client (for example, the occupational form of dressing has different social expectations based on cultural norms from culture to culture) helps occupational therapists to be sensitive to cultural differences in the ways of doing everyday activity.

Assuring that assessments are relevant and valid with persons from diverse cultural backgrounds requires ongoing development and research. Such work is being undertaken across the MOHO-based assessments. Assessments have been developed in collaboration with therapists and clients representing multiple cultures and languages. Many of the MOHO standardized assessments are now translated into different language versions. Research indicates that many of the MOHO-based assessments do not reflect cultural biases. For example, studies of the WRI (Haglund et al 1997), the WEI (Kielhofner et al 1999), the OPHI-II (Kielhofner et al 2001), the ACIS (Forsyth, Salamy, Simon et al 1997 and the OS (Kielhofner & Forsyth 2001) indicate that these assessments are valid cross-culturally. The UK is very influential in the development of MOHO theory and application. An active group of both researchers and practitioners are working together to contribute to the development of MOHO.

The words that are selected to describe therapy are very important. Complex conditions or procedures can be conveyed and immediately understood when such professional terminology is used. Occupational therapists acquire the professional languages of several disciplines. In college we learn medical language to support our communication with medical colleagues. For example, we can say ‘Alzheimer's disease’ and immediately the multidisciplinary team have a sense of the issues faced by the person under discussion and then can enter into specifics of how the condition has affected this particular person. The medical definition of Alzheimer's disease is very long and having language to name and frame the issue supports effective communication with others who are familiar with the terms. Therefore, one strength of having a unique language is that MOHO terminology can be used in consultation with others who are familiar with the model to convey complex concepts accurately and succinctly. For example, the term ‘volition’ conveys a complex set of ideas about how people are motivated toward their occupations. When someone refers to a client having a volitional challenge, those who know the terminology can anticipate that the challenge involves the client's values, personal causation and interests, and how this manifests in the way clients anticipate, choose, experience and interpret what they do every day. In this way, MOHO terminology can succinctly convey information.

Deciding whether and how to use MOHO terminology in communication and documentation requires consideration of several factors. MOHO terms, like those of any other professional language, offer benefits and pose challenges. The major disadvantage of all professional language is that everyone needs to have a common understanding of the terms. It is, therefore, ineffective to use MOHO terms (or, indeed, medical terms) with colleagues, clients and others who will not understand what the words mean. Therefore, therapists should carefully decide when and how they use MOHO terms in communicating to clients, lay persons and other professionals. Because practitioners, clients and settings differ greatly in terms of their knowledge and understanding of languages associated with particular theoretical models, it is ultimately the clinicians' responsibility and judgement that count in terms of translating the MOHO terms into verbal and written language that accurately conveys the intended knowledge. There follow two examples where MOHO was used to understand the client's situation. Example 1 involves a situation where the occupational therapist decided not to use MOHO terminology and example 2 describes a situation where the occupational therapist found it helpful to use the terminology.

Human occupation is complex (Creek 2003). Most people come into occupational therapy with significant impairments and major disruptions to their lives. Others struggle with declining function or recurring exacerbations of their diseases. A large proportion of clients face the task of rebuilding all or part of their lives. In short, their occupational problems tend to be complex and challenging. The strength and application of MOHO is neither simple nor formulaic. Instead, it aims to understand important multiple dimensions of each client's unique experience and bring a sophisticated understanding to bear on the life issues facing each client in practice.

In occupational therapy, a number of frameworks address aspects of occupational performance and the capacities that underlie it, but these theories tend to exist in isolation from one another. For example, occupational therapy theories that concentrate on physical performance have generally attended to the bodily components (brain and musculoskeletal system) involved in physical doing, while motives have been seen as part of a separate domain. By contrast, MOHO offers an approach to thinking about the capacity for occupational performance that complements existing theory. There is growing recognition of the importance of considering body and mind together in explaining phenomena (Kielhofner, 1995 and Trombly, 1995). After all, motivation for a task can influence the extent of physical effort directed to that task (Yoder et al, 1989 and Riccio et al., 1990), while physical impairments can weigh down the desire to do things (Murphy,, 1987 and Toombs, 1992). Conceptually, MOHO seeks to avoid dividing humans into separate physical and mental components, and instead embraces the complexity of human occupation. MOHO seeks to explain how occupation is motivated, patterned and performed, and implicates both body and mind in each of these major concepts. By offering explanations of such diverse phenomena, MOHO offers a broad and integrative view of human occupation. Consequently, it can be used to explain and guide practice involving a wide range of phenomena and corresponding concepts. Moreover, as stated above, therapists often use MOHO in combination with other conceptual models of practice or with theories borrowed from other disciplines or professions.

Some have questioned the relevance of MOHO in addressing issues of motivation in children and in lower-functioning clients. This perception is perplexing, since those clients who are least able to self-describe and self-advocate most deserve careful assessment of their volition. This can be achieved through careful observation of the client's volitionally relevant actions. The VQ (de las Heras et al 2001), the PVQ (Geist et al 2001) and the MOHOST (Parkinson et al 2001) work well with such clients. A therapist can, therefore, readily gain insight into the volition of children or lower-functioning clients. Additionally, therapists can make good use of unstructured means of assessment for such clients (Kielhofner 2002) that allow for complete flexibility within the assessment process.

Yes. Since MOHO was first published in the early 1980s it has built up an evidence base (see http://www.moho.uic.edu/). The majority of these studies were completed in the last decade, indicating an accelerating growth in research on MOHO, and it is now the most internationally researched, occupation-focused, conceptual model of practice. MOHO provides theoretical evidence for its practice theory and it provides research evidence for its tools for practice.

Yes. Social service colleagues have asked the question, ‘How would I apply MOHO to a client who is having difficulty bathing?’ A biomechanical way of framing this challenge may be to state that the person is having difficulty ‘physically getting in and out of the bath’. A MOHO way of framing the challenge is to state that the person is having ‘difficulty engaging in the bathing activity’. MOHO, therefore, supports therapists in embracing the complexity of bathing rather than reducing it to only an issue of moving the client's body into/out of the bath. MOHO would support the therapist in asking the following questions:

MOHO can, therefore, provide a framework for understanding the life within which occupational therapy is entering and whether adaptive equipment is appropriate. It also provides an understanding of the meaning attached to the equipment and how it might be adapted into the routine of the client. A lack of attention to these details may mean that the equipment is hidden away due to the client not wanting to be seen as ‘disabled’, or the equipment being removed because it was not adopted into the client's habitual routine.

Yes. The analysis of occupations and their use within therapy are among the unique skills of the occupational therapist (Hagedorn 2000). There are many structures that provide a framework for analysing activity (Fidler and Fidler, 1963, Mosey, 1986, Lamport et al., 2001, Creek, 2002 and Foster and Pratt, 2002). Recently, however, there has been some discussion that advocates using theories as a framework for activity analysis (Crepeau, 2003 and Toglia, 2003).

MOHO provides an evidence-based practice theory that supports a therapist in analysing a person's occupational life. Practice-based theories have the added advantage of providing an understanding of how different elements of analysis relate to each other and provide an insight into the change process (Creek 2009). MOHO has an established evidence base to support how different theoretical constructs relate to each other (e.g. Lederer et al., 1985, Barris et al., 1986, Ebb et al., 1989, Davies Hallet et al., 1994, Peterson et al., 1999 and American Occupational Therapy Association, 2002) and has a theory of how therapeutically supported change happens (Kielhofner 2002). It could, therefore, be argued that using evidence-based theory (e.g. MOHO) to analyse activities has several advantages over traditional activity analysis frameworks. MOHO-driven activity analysis simultaneously:

This view has been supported by the inclusion of motor and process skills (Fisher and Kielhofner, 1995 and Kielhofner, 2002), along with communication and interactions skills (Forsyth et al 1998, Kielhofner 2000) in the occupational therapy practice framework (Butts, Nelson 2007). As described in a previous section, MOHO would need to be used with other frameworks (e.g. biomechanical, motor control, sensory integration and so on) to support a complete activity analysis that included analysing performance capacities.

MOHO provides a way for occupational therapists to embrace the complexity of human occupation within their practice. It provides an understanding of the choice, order and performance of occupation within people's lives. It also provides assessment and intervention techniques to support the integration of MOHO theory into practice. MOHO is built for and with an international community of occupational therapists, with the ultimate goal of fully embracing the unique occupational characteristics of our clients and supporting them in their re-engagement with meaningful self-care, productivity and leisure.