The catchy Vona du Toit Model of Creative Ability (or VdT MoCA for the remainder of this article) is a new kid on the occupational block. Developed by a South African lady called -you guessed it- Vona du Toit in the 1960s, it was subsequently commonly used throughout South Africa. It was introduced to the UK in 2004 where it has been gaining popularity ever since. Patrica de Witt (2014) has updated the model in her recent chapter of the book Occupational Therapy in Psychiatry and Mental Health. Wendy Sherwood is a UK OT who is a big advocate of the model and its expansion in the UK. Because of its novelty, MoCA does not have a lot of literature or evidence base surrounding it yet.
The model was previously known by a few different names until frustration at this confusion caused it to be officially named the “VdT MoCA” in 2010. This is an example of a step in the right direction as a lack of uniformity around occupational therapy terms is something that plagues the discipline in general, and holds back its credibility with other professions as well as preventing appropriate critical comparison of theories and evidence.
The first thing to note is that the word creative as used in the model does not refer to artistic ability, such as our friend below is demonstrating.
Instead, creative ability means someone’s level of functioning in relation to being able to change their behaviour and ‘create something that didn’t exist before’ in response to environmental, social or occupational demands in life.
This something that is created can be tangible such as painting your toenails, or intangible such as improved self-esteem. The MoCA model is based on the ideas of motivation, action (the observable physical output of someone’s motivation to do something) and the sequential stages of normal human development (which is to say that a particular skill cannot be achieved until any previous skills or stages it depends upon have been successfully completed… “don’t try to run before you can walk” and so on). Du Toit describes creative ability as ‘motivation expressed through action’.
So the creative ability that the model talks about isn’t a patient’s artistic flair, but the ‘creation’ of themselves, through the development of skills .
VdT MoCA allows the OT to clearly identify which level of occupational functioning (or ‘creative ability’) a patient is currently at by observing occupational performance actions and attributing these to corresponding levels of motivation.For the purposes of assessing a patient, the model divides someone’s occupational performance actions into four key areas: personal management, social ability, work ability and use of spare time. By observing actions in these areas, the OT can establish the patient’s level of creative ability (ie occupational functioning), as well as chart any improvement or regression. Once this level is established, the OT can then ascertain how much independence the patient has at this level – whether they are in the therapist-directed, patient-directed or transitional phase. This allows for a gradual, graded approach in the patient moving between phases and levels.
In occupational therapy, grading a task is altering it’s complexity to allow completion by a patient wherea s adaption is altering the environment to allow completion. Illustrated with that great stalwart of occupation, making a cup of tea, this would be either labeling the sugar , mug and kettle and having them ready out on the counter (grading) or using a tipper-kettle and a perching stool to sit on (adaption).
Back to the model. The levels of creative ability and corresponding motivations and actions according to MoCA are shown in the table below:
MoCA level of CREATIVE ABILITY
MOTIVATION LEVEL
ACTION LEVEL
9
8
7
6
5
4
3
2
1
Usually only levels 1 to 6 are seen in clinical practice as people at levels 7,8 & 9 are not in need of healthcare services. However knowledge of these higher levels can be useful for OTs when they are managing staff performance or students on placement.
Descriptions of what each level entails can be seen in the more detailed table below. It also shows the three groups that each level is categorised into; a patient can be assigned to one of these groups by OTs or other health professionals for the purposes of referral to OT services.
What’s good about it?
As well as being able to ‘diagnose’ a patient’s ability clearly, a benefit of the model is that du Toit provides a very clear treatment framework for how to progress and advance someone’s level, including guidance on selecting activities based on level of creative ability. Because the levels go from absolute rock bottom (no response or awareness of environment), the model can also be implemented from ‘Day One’ with patients who previously may have been deemed initially too unwell for OT services, eg in acute mental health.
Another key benefit of the model is that it enables practitioners to track the outcome of a patient‘s subtle yet existent movement between levels, so concrete progress is identifiable in what is often a subjective and nuanced area- the qualitative nature of most of occupational therapy’s outcomes means being able to actually measure outcomes and effectiveness is high on the agenda for most OTs. The increased need for OTs to evidence their contribution in healthcare settings has been called for for by COT (2008) and MoCA allows OTs to do this clearly; one reason for its popularity. An example of evidence gathered from the VdT MoCA being used to justify service provision changes can be seen in an article in the COT’s April 2012 edition of OT News (Wilson & White 2012). Being able to distinguish patients into groups in this way can also help with MDT referral to OT services and the standardisation of services between teams & locations; while also increasing other health professionals’ understanding of the OT role by making more observable the patient improvement it achieves.
What’s not so good about it?
Criticism of the model includes views such as that not all concepts are defined, and that some terminology needs to be updated in line with modern practice to be a bit more sensitive and ‘European’. This refers to terms such as destructive which in the context of the model means not purposefully manipulating objects to create an outcome, only incidentally handling them. Some people feel it sounds as though people operating at this occupational level (perhaps someone with learning disabilities or experiencing a period of poor mental health) as being referred to as deliberately destructive in the sense of malicious damage.
In addition since the death of the original author Vona du Toit, there is noone taking responsibility for the continued development/updating of the model and to direct the direction of research. Another complaint is that there is no dedicated reference text with access to copies of the assessment tool (…although a very new text –
The Vona du Toit Model of Creative Ability: a practical guide for acute mental health occupational therapy practice– has just been published which may address this concern). While practitioners in the main part welcome the clear treatment framework, some are concerned that it is overly ‘prescriptive’ and takes away a practitioner’s clinical reasoning by dictating responses which reduce the Occupational Therapist’s expertise skill level to that of a technician carrying out instruction. However others feel that the model is highly individualised and ability-centred enough so that it still allows for targeted treatment, while also having the benefit of making outcomes and clinical reasoning clear to everyone.
MoCA is similar to MoHO (Model of Human Occupation) but it considers motivation more as well as action, whereas MoHo considers only action. MoCA is increasingly being used in place of or in conjunction with MoHO in practice by OTs. It is commonly (and successfully) used in the areas of learning disability, acute mental health, forensic mental health, dementia, neuro-rehab and paediatrics although this list is not exclusive. As well as the UK and South Africa, it is popular in Japan. The APOM (Activity Participation Outcome Measurement) assessment tool is based on creative levels of ability across eight areas of occupational performance actions (as opposed to MoCA’s four) and designed for use in mental health; it is becoming a popular tool because of its ability to measure outcomes clearly (it produces a beautiful spider diagram which can be used to clearly illustrate a patient’s progress due to OT input in MDT meetings!). As with all aspects of VdT MoCA, more research is needed to back it up however.
The MoCA is not be confused with the other MOCA, the Montreal Cognitive Assessment, which is an assessment tool and not a model.
For articles on other models such as PEOP, KAWA or MoHO, click on ‘OT Models & Process’ under the Categories section in the menu to the right.
De Witt (2014) Creative Ability: A Model for Individual and Group Occupational Therapy for Clients with Psychosocial Dysfunction in Occupational Therapy in Psychiatry and Mental Health (5th edition) Editors Crouch & Alers. London:John Wiley & Sons, [accessed on 23.01.16 at http://www.vdtmocaf-uk.com/assets/images/documents/creative_ability_a_model_for_individual_and_group/de_Witt_chapter_2014.pdf]
Du Toit HJV (1970) Creative ability in Patient volition and action in occupational therapy (1st edition). South Africa: Vona and Marie du Toit foundation
