How the CO-OP approach has changed our practice as occupational therapists… and so much more!

How the CO-OP approach has changed our practice as occupational therapists… and so much more!

Céline Chavanne, occupational therapist at a pediatric rehabilitation department in Saint-Maurice, just outside Paris (France) and coordinator of intensive rehabilitation programs. Celine is trained in the CO-OP approach (2019) and is participating in various CO-OP studies conducted in the pediatric department.

Hélène Lebrault, occupational therapist and CO-OP instructor. She obtained her PhD in 2023, with a research topic focused on the CO-OP approach. She works with Céline in the same pediatric rehabilitation department.

Our aim

Writing this blog is a great opportunity to take a step back and explore the CO-OP approach in a slightly different way than we usually do; we wanted to share here our insights as therapists who use CO-OP, to put into words the informal conversations we’ve had in the corridors, over a meal (or a beer!), which aren’t directly tied to statistics or study results, but are important and don’t always get the chance to be highlighted.

We wanted to write an article—for once—that isn’t focused on the client, but rather on us, the therapists. To that end, we wanted to explore different facets of who we are… and share our feelings with you, without intending to make any generalizations.

Us, the occupational therapists

Where it all began…

Hélène: “My story with the CO-OP approach began because of (or rather, thanks to!) Elea, a 10-year-old girl with attention-deficit/hyperactivity disorder, developmental coordination disorder, and executive function difficulties… Back then, about ten years ago now, I felt confident to identify all her difficulties through assessments… but when it came to providing occupational therapy intervention—within a French healthcare system still heavily focused on the biomedical approach—a host of questions kept nagging at me: does what I’m offering her really make sense to her? Am I truly addressing her real needs in daily life? And, worst of all: if she weren't receiving occupational therapy sessions, would it make a noticeable difference?... That was the moment I became interested in the CO-OP approach, and that's when it all began”.
Céline: “For me, it all started with Tom. Imagine a young person who, overnight, finds himself in the hospital. He no longer speaks, moves, or thinks the way he did before his health issue. Things that used to seem simple to him have become difficult—sometimes impossible. I started by trying to help him regain his feeling of competency. I suggested activities that were meaningful to him: games inspired by his favorite heroes, board games, and simple but rewarding crafts. I tried to create situations where he could succeed. But nothing worked; Tom wouldn’t participate. Session after session, I saw the same look in his eyes. A sad look, full of confusion, often accompanied by tears. I’d leave those sessions feeling like I was missing something. The more I tried to find the right activity, the more I felt that wasn’t where the real connection was happening. So I changed my perspective. I left the occupational therapy room to join him in his daily life: at school, on the playground, at mealtime, while playing with the teachers. And there, something happened. My presence no longer seemed to be a problem. On the contrary. I felt as though he was saying to me, “Look, I can’t do this… help me understand how to do it.”

The eye-opener

Both of us felt that the CO-OP training program was a turning point in our careers as occupational therapists: both exciting and intimidating, calling our entire practice at the time into question, while offering answers and fabulous opportunities for growth.

We felt that the CO-OP approach truly embodied the philosophy of our profession: helping people become independent and autonomous in their daily live activities.

As therapists, the CO-OP approach makes us feel useful, in our element, and aligned with our beliefs. This feeling is reinforced by the tangible progress we observe in our clients during CO-OP sessions.

Partnership

The CO-OP approach has allowed us to let go of what we already know and gives us the feeling that we’re no longer in a dynamic where “the teacher knows what the learner needs,” but rather that it gives us the opportunity to form a partnership with the child on an equal footing. Forming a partnership as equals can sometimes be stressful (Where is he taking me?) but it’s so fulfilling. And we are often amazed by the strategies the children come up with and try out… strategies we often wouldn’t have thought of ourselves!

Thanks to CO-OP, a special bond develops between the therapist and the child: often, the resulting therapeutic relationship is strong and lasting.

We work collaboratively with the child; each of us highlights certain aspects in our own way, and each of us contributes to the process. Our expertise and experience enable us to take into account, session after session, how the child functions: his/her difficulties, but above all his/her strengths, which we build upon.

Céline: “Working with Theo, I gradually came to understand that one of the main challenges was his difficulty making connections. He didn’t naturally apply the principles and strategies we discussed in our sessions to his daily activities. Over the course of our sessions, I also realized that his working memory made it difficult for him to develop an action plan, and that written materials weren’t helping him. Understanding the process wasn’t always easy for him, and he struggled to maintain his attention long enough to see his line of reasoning through to the end. On the other hand, I discovered that he was much more engaged when he was moving. Walking, handling objects, or moving around allowed him to be more involved in the interaction and more attentive to what he was doing. Verbalizing his plans aloud also helped him organize his thoughts. Finally, the strategies we developed together were more effectively internalized when presented as games that drew on what he already knew. The idea behind this approach is to adapt to the child as a whole—not always easy, but fascinating”.

Using the CO-OP approach challenges our preconceived notions: statements like “He’ll never make it” or “His family won’t get involved” are no longer relevant… the CO-OP approach helps us turn challenges into strengths and reinforces the idea that we need to set aside our preconceptions (because, yes, we all have them…).

It’s not necessarily easy at first to avoid setting limits for yourself: to be able to do that, you need to be comfortable and flexible—and that comes with experience… Using the CO-OP approach requires a great deal of open-mindedness and a willingness to break away from our “traditional” ways of thinking and acting.

A wonderful example: The story of the guinea pig in the office…

The CO-OP approach often pushes us out of our comfort zone, calls on our creativity (but isn't that a hallmark of occupational therapists?) and encourages us to challenge the status quo.

Céline: “My most memorable internship experience was watching Tom learn to ride a bike… When I first heard about the goal, I remember looking at Hélène and saying, “Wow, what a challenge!” And yes, it really was a challenge, given his motor, cognitive, and behavioral difficulties… but the CO-OP approach allowed Tom to gradually develop a plan that matched his abilities and led to real progress—it was incredible to see that from session to session!”
Hélène: “One of my most memorable experiences using CO-OP—which I like to share to illustrate how the CO-OP approach challenges us—is the story of the guinea pig in the office. During my PhD, one of the participants had, among other things, the goal of being able to spend more time caring for her guinea pigs… quite a challenge! How could she convince the hospital’s administration to allow a pet in the aseptic rehabilitation department?... After a lot of negotiations, we did it! So “Kiki-the guinea pig” spent several weeks in the office of our children's division director… which just goes to show that anything (or almost anything) is possible.”

Professional reasoning and support

With the CO-OP approach, in its traditional form, support is provided through individual sessions: you’re alone with the child during the session. What we realize it is actually a team effort… We discuss our reasoning and process outside of the sessions; among colleagues, we share our feelings and questions. The approach encourages reflection and sharing with others.

Since CO-OP is a metacognitive approach to problem-solving, it requires us to try to understand the child thinking—which can sometimes be a real challenge—hence the importance of opportunities for discussion among colleagues…

Beyond supporting individuals in rehabilitation, the CO-OP approach has changed also the way we mentor occupational therapy students coming to our facilities for internships. In encouraging them to experiment with the CO-OP approach during their internships, we feel that we are helping them to also develop their own learning skills by applying CO-OP principles in their own learning. We encourage them to set their own internship goals, use guided discovery in their practical exercises and to view the children through a lens that focuses more on their skills and resources, rather than focusing solely on their disabilities from the outset.

Us, with the children in rehabilitation: Finding the solution isn’t always “easy”

Céline: “I remember one particularly memorable moment—one that was frustrating for both Tom and me, but also incredibly instructive. We were both sitting on the floor, in front of his bike lying on the ground, trying to figure out what had just happened. Why hadn’t the plan worked? At what point had it hit a snag? Together, we formulated hypotheses, tinkered with the bike, took turns testing it, observed, analyzed… We were thinking as a team, as equals, with a shared goal: to understand the source of the problem so we could adapt the original plan.”

Thinking things through together, as equals, allows us to forge a special bond with the child and their family—one that we’d like to describe here as deeper, stronger, and more “close-knit”….

Children sense that we’re thinking on equal footing, which changes their level of involvement: “You’re the driving force! Without you, I can’t do anything!” A sense of mutual trust develops (“We are all in the same boat”), with its moments of success and its difficult moments.

It’s not uncommon for these bonds to endure beyond the duration of their care in our department, and for us to stay in touch with the child and their family long after they’ve left our center. It’s always a pleasure to hear from them and learn how they’re doing.

Furthermore, it's a pleasure to see families and children become wonderful ambassadors for the CO-OP approach once they’ve completed their sessions.

Hélène: “I remember a young girl who, during the back-to-school meeting at her new special education school, explained to her new therapists how she had managed to learn to tie her shoelaces (with one hand, using some incredible strategies!) and that this conversation—which her mother later told me about—had turned into a real “advertisement” for CO-OP on her daughter’s part.”

In today’s society, where expectations of conformity are very strong, approaching an activity using one’s own strategies -which may be unconventional- can sometimes lead to discouraging moments.

Céline: “My experience with Tom showed that it wasn’t easy for the family to understand and accept a different way of doing things. At the start of the program, Tom often came back feeling discouraged and demotivated by cycling after completing his evening tasks, as the feedback from his brothers and parents hadn’t been particularly positive. He felt judged and mocked. During the sessions, he was motivated, spirited and persevering, but also demotivated, angry – even very angry – and disappointed, yet always persevering. This subsequently enabled him to feel more confident when trying out the activity at home.”

It is up to us, as therapists, to be mindful of this and to provide children with a space where they can experiment with different strategies without judgment. It is also up to us to take the time to explain the benefits of such an approach to care partners. CO-OP gives children a space where they can experiment, take risks, make mistakes, question themselves, take their time, try again, come up with all kinds of ideas, and… get tired of it all.

Us, with the parents/the care partners

It’s not always easy to get parents involved in the CO-OP experience: maintaining a daily routine while holding down a job, taking care of other siblings, the distance between home and the center are all factors that can limit parents’ ability to participate actively. We must not forget that what is asked of them is demanding: sometimes, parents may see this as an opportunity to “do things differently,” while for others, it may be perceived as a constraint.

Sometimes, when parents are fully committed, it leads to incredible encounters and interventions that come close to the ideal… It results in truly memorable moments that reaffirm our belief that we made the right choice in deciding to become occupational therapists!

Discussions with parents allow us to take a broader view of the approach we might take individually with a child. This helps us better understand the child’s daily context and refine the way we support them. In this way, parents have the opportunity to be recognized and heard as experts on their own child.

When the care partners are not the parents but other support persons, such as other professionals working with the child who have specific expertise that justifies involving them in the work toward one of the goals, in order to promote generalization and transfer, another interesting dynamic can be observed. In fact, being involved in a relationship that differs from the one a parent might have with their child can sometimes be an “advantage”: less emotional involvement and a more neutral perspective can sometimes allow the child to develop in a different way than if they had been guided by one of their parents.

Céline: “Tom and I worked alongside some key support staff: a physiotherapist and an educator from the rehabilitation department. It was a very rewarding experience for all three of us to be able to exchange ideas and discuss activity plans during less formal settings. It was a very constructive way to get feedback on the evening sessions, to find out how the child was getting on outside of sessions, to share experiences and to ensure we were all working towards the same goals. Tom was delighted to show Marceline (the educator) and Carmen (the physiotherapist) the progress he’d made with his activities; he really looked forward to these moments.”
Hélène: “Recently, I worked with a teenager through the CO-OP approach, and two of his goals were related to his behavior in class. When I explained the principles of CO-OP to his teacher (and mentioned that he would be missing class to attend the sessions), she was initially somewhat skeptical… but it quickly became clear that she was an invaluable resource in helping him apply what he learned through CO-OP in the classroom. Communication was smooth, and each of us was able to draw on our respective observations to best support this teenager.”

Us, and the institution

“What?! You’re riding a bike with her? But you’re not a physical therapist! And a two-wheeled bike? Without any modifications? You’re not going to be able to do it!”... It’s not always easy to bring an innovative approach to a multidisciplinary team. To avoid this kind of situation and to promote effective teamwork, we communicated extensively about this approach with the department’s staff. We organized informational meetings, gave presentations at conferences, and presented the results of the CO-OP studies conducted in the department. All of this helped ensure that the approach was implemented successfully.

Beyond the day-to-day use of the CO-OP approach, the “CO-OP mindset” has enabled us to establish multidisciplinary working groups whose goal is to explore possible and desirable changes within our organizations, in order to provide the most effective care possible. These working groups are still in progress (it’s a massive project! “Rome wasn’t built in a day”), have already led to some interesting developments.

Us, in our own daily lives

The changes brought about by the CO-OP approach are evident beyond our work as occupational therapists; they have also influenced our daily lives…

Hélène: “More than once, my sons have looked at me and said, “You’re doing CO-OP with me right now, aren’t you?”… Yes! That’s right! And it’s working pretty well, isn’t it? Beyond these situations, the CO-OP approach to learning and active problem-solving has influenced my discussions with my children’s teachers but also with their sports coaches on more than one occasion.”

And when our daily mental load becomes too heavy and our occupational balance is threatened, applying the CO-OP principles to ourselves helps a great deal: “One thing at a time! What is my goal, my plan? What is my breaking point?”… These are all factors that help us stay on track.

Conclusion

CO-OP is an approach that benefits everyone… we hope you’ll be convinced of that after reading this for a few minutes! Now it’s your turn!

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