PEO Model

The Person-Environment-Occupation Model

The Person-Environment-Occupation (PEO) model (Law et al., 1996) is an ecological model that uses a transactional approach to understanding the relationship between the person and their environment. This relationship is elegantly explained with the aid of a visual model (see below). In the PEO model, three rings are interconnected equally with each ring representing one concept: Person, Environment, and Occupation. In the middle they intersect in harmony with no ring overlapping one more than another, this equally distributed intersection is occupational performance. The degree of congruence, occupational performance, is influenced by the interaction of the three concepts which is expected to change over the life course as contexts and occupations change. When one element is impacted the other two respond by moving away from the center indicating reduced occupational performance.

PEO model visual

Note. Representation of transactive relationship between person, environment, and occupation described by Law et al. (1996).

Key assumptions of each construct are key to understanding their relationships. The PEO understands the person as a, “dynamic, motivated and ever-developing being, constantly interacting with the environment,” and that personal characteristics determine how one interacts with the environment and affects the occupations they engage in (Law et al., 1996, p. 17). The environment is a dynamic concept and simultaneously influences occupations, and jointly influences/influenced by a person’s behavior. Environments can support or hinder occupational performance. Occupations “meet the person’s intrinsic needs for self-maintenance, expression and fulfillment within the context of his/her personal roles and environment” (Law et al., 1996, p. 17). Finally, occupational performance is dynamic, changes across the lifespan and is shaped by the transactions between person, environment, and occupation (Law et al. 1996). While the concepts of person, environment, and occupation are interconnected and dynamic, there are distinct features of each that exert influence on one another, change across the lifetime, and therefore bring about changes in occupational performance. Features of each construct are listed below, for greater detail, see below drop-down for a PEO Table.

Person

Biopsychosocial (body, mind, spirit)
Objective & subjective
Life experiences

Environment

Physical
Social
Cultural
Socioeconomic
institutional

Occupation

Activites
Tasks
Occupations

It is the task of the occupational therapist to increase the congruence between these areas by targeting any combination of person, environment or occupation; but first areas of incongruence must be identified. The PEO advocates for starting with a top-down approach (see figure below) by soliciting client subjective and objective input regarding occupational strengths and issues/problems with occupational performance before interviewing the client about occupational history (Law et al., 1996). In PEO outcomes consist of a change in the form of occupational performance further reflecting the top-down nature of this model.

Interventions commonly targeting performance contexts such as the environment or person-environment fit (Brown, 2019). Using interventions in a combination of areas increases the likelihood of a change in occupational performance and provides expanded opportunities for intervention strategies (Turpin & Iwama, 2011). The environment is typically easier to bring about a change in than the person, this is especially true when the occupation itself cannot change. (Law et al., 1996). Notably, the PEO does not have any fixed assessments such as with other OT models; this contributes to its utility and flexibility in various clinical environments and ensures clinicians use a variety of valid tools and assessments to address their client’s occupational performance needs.

Note. This figure represents the PEO process as described by Law et al., 1996.

Blank PEO Table

This blank table breaks down the PEO model into its composite parts and is used later to sort information from case study examples. This is provided as a blank version for practitioners to use as they see fit. A fillable copy of this table is available here, and in the appendix of the OT Toolbox itself.

PEO Low complexity case study: Betty

Betty is a petit 76 year old woman of German descent who resides at an upscale Lutheran retirement community in independent living with her husband of 55 years. The home is single level with a ramp leading to the front door. Inside, the floors are carpeted, except in the kitchen and bathroom. The home is free of throw rugs and trip hazards, Betty had a home assessment completed after one of her friends fell and broke a hip. Her bathroom has a walk in shower with a bench and railings. Her home is otherwise typical for an upper middle class family in the United States. She is receiving OT services after she fell while playing tennis and broke her right wrist (CARF). Her home is tidy and organized, with religious images proudly displayed next to numerous photos of children at various ages. One wall of her home is dedicated to photos from vacations she’s taken with her husband since the 1960s. She points out the numerous candid photos from places one is from the Eiffel Tower and, next to it is a photo of her at a Trump campaign rally (this is the only memorabilia of a political nature in the house). As she walks through the horse her gait is smooth and she appears sure footed. There is a fine layer of dust covering everything and there are take out boxes on the counter from dinner the night before and dishes are piled up in the sink. Betty’s appearance is as tidy as her home but she apologizes for, “This hair! And my face! I can’t get the rollers in or put on my makeup right now, you’ll have to excuse my appearance.” She reports missing tennis but that she wouldn’t want to be seen by her friends right now without her hair done and makeup on. While in the kitchen she gazes briefly out the window at the tennis courts, a well-maintained sidewalk is just visible leading up to them.

She indicates boxes and explains, “I prefer to cook all our meals, except on Friday night, that’s date night, oh and Sunday! We go to lunch after church…my husband, he can’t cook, so we’ve been going out or eating in more.” She smiles and laughs at her situation, “Well, it’s just a broken wrist. We’ll manage, but I would like to put on my face and cook.”

PEO Medium-high complexity case study: Koshi

Koshi is a tall, slim, 62 year-old man receiving OT services during his stay at a skilled nursing facility (SNF). He is at the SNF after breaking his hip (CARF). Koshi slipped and fell while fishing with his grandson, he hit his head on a rock during the fall and was diagnosed with a mild concussion in addition to the broken hip. Koshi’s chart indicates that he has a diagnosis of type 2 diabetes which he manages with insulin, and that he has slightly high blood pressure but does not take medication for it, there is no mention of additional health concerns or vision impairments. Koshi’s daughter is visiting at the time of his initial assessment. He asks her to stay for the appointment, but she has to leave to pick the children up from school. On her way out she reports Koshi has a recent diagnosis of Parkinson’s disease, this was not indicated in his medical record. His handshake is firm and appropriate in duration. During interactions Koshi is polite and respectful but does not answer questions directly. He gives vague answers when asked about occupations he is good at. When asked about things that are challenging to do he says, “I am good at everything” and resists initial probes. Finally, he brings up “work waiting for him” and he elaborates when asked and reveals, “We own a marina, I fix the boats. My wife does the office.” When asked about his family he says that he is proud of his children and grandchildren, but wishes they lived closer (his daughter’s family recently moved a few blocks away and had been living in the houseboat one sloop over). He moved to the USA from Ghana with his wife when he was 22 years-old. He appears most comfortable talking about his loved ones. When asked about any pain in his hip he smiles and says, “My hip is fine. I should be at home.” He asks when his daughter will visit and does not seem to realize she just left.

When asked if he would like to use the restroom or complete morning hygiene he adamantly declines. When presented with a washcloth and basin of warm water he gently washes his face and then scrubs his hands, paying close attention to his fingernails. He then asks for his glucometer, but it is nowhere to be seen. He agrees to complete a “quick screen” on a tablet, which is the WHOQOL-BREF. While completing the assessment his hand holding the tablet is stable while the hand he uses to select answers tremors slightly while at rest. After five minutes he returns the tablet (this is a bit long for the assessment), the only area he indicates dissatisfaction with is sleep.

His responses indicate he perceives a very good quality of life and overall satisfaction with his occupations. However, nursing staff reports that he refuses all assistance to the restroom and that he has fallen multiple times since arriving the night before.

Using the PEO as a guiding model of practice:

PEO perspective:

Koshi’s occupational performance is limited during the initial session.
Low congruence between person, environment, and occupation.
Observations:
- New environment with unfamiliar tools and attributes
- Occupations are in an unfamiliar context.
- Personal factors may not be fully understood or documented (cognition, PD).
- Disruption to routine and “flow” of an average day.

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