3 CHAPTER CONTENTS PHILOSOPHICAL DEVELOPMENT OF THE PROFESSION The Influence of Service Settings Epistemological Underpinnings of a Two-Body Practice Terms Used When Talking About Theory Organizing Framework for Occupational Therapy Theory The European Conceptual Framework for Occupational Therapy There are two main parts in this chapter. The first section describes philosophical assumptions and beliefs that underpin the theory and practice of occupational therapy. This includes a brief discussion of the origins of occupational therapy philosophy, an account of how it has changed over the past 100 years and an outline of the main beliefs and assumptions held by occupational therapists today. The second part describes the breadth of theory used by occupational therapists. It begins with an explanation of what we mean by theory and goes on to consider the different types of theory needed to support occupational therapy practice. Key occupational therapy concepts are identified and defined, including core concepts and emerging concepts. Definitions are given of the terms used when talking about theory for practice, such as frame of reference and model. The chapter finishes with an explanation of how knowledge is organized for use in practice, illustrated with an example of an occupational therapy theory: the European conceptual framework for occupational therapy (Creek 2010). The modern profession of occupational therapy dates from about 1917. Since then, the profession has undergone, and is still undergoing, changes in its outlook and philosophy. Philosophy is a ‘system of ideas, opinions, beliefs, or principles of behaviour based on an overall understanding of existence and the universe’ (Shorter Oxford English Dictionary 2002). The philosophy of occupational therapy includes ideas and beliefs about the nature of human beings, society, health, ill health and the relationships between these various elements. Occupational therapy philosophy also includes principles of professional behaviour, and these are discussed in Chapter 7. Initially, occupational therapy operated with a pragmatic and humanistic view of human beings and their relationship with occupation. Some of the main proponents of this philosophy of pragmatism worked in Chicago, where the first occupational therapy course was started in 1908. Pragmatism stresses the relationship between theory and action (Audi 1999): it has been described as ‘the philosophy of “common sense”, problem solving, activity, and adaptation’ (Breines 1986, p. 56). Pragmatism ‘recognizes the inextricable influences on each other of the mental and physical aspects of human beings, their artifacts, their environments, and the societies and times in which they live’ (Breines 1995, p. 16). Adolph Meyer, one of the founder members of the National Society for the Promotion of Occupational Therapy in the USA, was a friend of the two most famous pragmatic philosophers of his day, John Dewey and William James, sharing their perspective (Serrett 1985). From 1913 to 1914, Meyer worked with Eleanor Clarke Slagle to develop a method of treatment called habit training, based on the work of James. This has been described as the oldest model of occupational therapy practice (Reed and Sanderson 1999). Meyer wrote a paper on The philosophy of occupation therapy, which shows clearly the influence of pragmatism (Meyer 1922/1977, pp. 640–641). Direct experience and performance [are] everywhere acknowledged as the fullest type of life. Thought, reason and fancy [are] more and more recognised as merely a step to action, and the mental life in general as the integrator of time, giving us the fullest sense of past, present and future … performance is its own judge and regulator and therefore the most dependable and influential part of life … Our conception of man is that of an organism that maintains and balances itself in the world of reality and actuality by being in active life and active use, i.e., using and living and acting its time in harmony with its own nature and the nature about it. It is the use that we make of ourselves that gives the ultimate stamp to our every organ. The humanistic perspective taken by occupational therapists grew from the profession’s connection with the arts and crafts movement in the UK (Mattingly 1994b). The first occupational therapists believed ‘that unleashing people’s creativity might help them transcend the stultifying effects of incapacity, hospitalization and industrial labour’ (Hocking 2007, p. 23). Humanism views people as ‘growing, developing, creating being(s), with the ability to take full self-responsibility’ (Cracknell 1984, p. 73). This includes taking responsibility for maintaining their own health and for making choices that determine what they become. Several of the early influences on occupational therapy came from outside health and social care services, for example, the arts and crafts movement and pragmatism (Paterson 2010). Nonetheless, the first occupational therapists worked in hospitals for people with mental and physical illness or disability and their actions were constrained by the ethos and expectations of these settings. During the 1950s and 1960s, the reductionist model of science was being adopted by all the life sciences. Reductionism is based on the belief that the structure and function of the whole can best be understood from a detailed study of the parts by observation and experiment (Smith 1983). Western medicine is based on a reductionist medical model, with a ‘focus on pathology … and on the minute and measurable’ (Shannon 1977, p. 231). Scientific advances in medicine in the second half of the twentieth century led to an increasing use of technological interventions and an accompanying need for specialization, so that the focus of health services moved from health to illness and the responsibility for wellness moved from the individual to the medical profession. In the first half of the twentieth century, the profession of occupational therapy did not have its own knowledge base with which to justify a pragmatic approach to intervention; occupational therapists worked under the direction of doctors. This left them vulnerable to pressure to adopt reductionist theories into the educational curriculum: early occupational therapists had a moral imperative to train more practitioners but no knowledge base of their own with which to educate them or much of any status or expertise with which to argue for particular educational practices. This vacuum was largely filled by deference to medical authorities … under the strong influence of physicians, basic medical sciences and applied medical lectures occupied more of the field’s core curricula over ensuing decades. (Hooper and Wood 2002, p. 46) By adopting a reductionist paradigm, occupational therapists were able to develop a great depth of expertise in various fields of practice – for example, many therapists became highly skilled in the use of projective media in analytic group psychotherapy – but the profession as a whole suffered from role diffusion and loss of identity (Kielhofner and Burke 1977). The broad, humanistic perspective was lost and occupational therapists’ concern gradually shifted from people with complex, long-term needs to those who could be cured, while their goals changed from adaptation to the reduction of symptoms. In the 1980s, there was a general move away from a mechanistic view of man and health to a systems view that is more congruent with the pragmatic and humanistic perspective of occupational therapy. Occupational therapists saw the possibility that ‘health care of the future will consist of restoring and maintaining the dynamic balance of individuals, families and social groups, and it will mean people taking care of their own health individually, as a society, and with the help of therapists’ (West 1984, p. 21). This prompted them to reassess the original philosophy of occupational therapy, which had become obscured during the 1950s and 1960s. More recently, the profession attempted to reassert the validity of occupational therapy traditions and values without losing the very real advances in theory and practice made during the reductionist era. The areas of belief that are still relevant to occupational therapy practice in mental health are summarized here and will be explored in more detail later in the chapter: ■ belief in intrinsic motivation, which is an innate predisposition to explore and act on the environment and to use one’s capacities ■ recognition of each person’s need for a balanced range of occupations in their life in order to facilitate development, give meaning to life, satisfy inherent needs, realize personal and biological potentials, adapt to changing circumstances and maintain health ■ acceptance of the social nature of people and of the importance of social interaction in shaping what we become ■ recognition that what we do influences what we become – the primacy of function over structure ■ view of health as a subjective experience of wellbeing that results from being able to achieve and maintain a sense of meaning and balance in life ■ belief in the capability and responsibility of people to find healthy ways of adapting to changing circumstances through what they do ■ acceptance of the role of occupational therapy in serving the occupational needs of people in order to help them restore meaning and balance to their lives ■ belief in occupation as the central organizing concept of the profession and in the use of activity as our main treatment medium. Professional philosophy is the system of beliefs and values shared by members of a profession. Philosophical assumptions are the basic beliefs which make up this system and show how members of a particular profession view the world and their own goals and function within it (Mosey 1986). In occupational therapy, we accept as true certain beliefs about the nature of people, for example that; ‘All people experience the need to engage in occupational behaviour because of their species common combination of anatomical features and physiological mechanisms. Such engagement in occupation is an integral part of complex health maintenance systems’ (Wilcock 1995, p. 69). Without this belief, we would not be convinced of the value of occupation as therapy. It is healthy for us to question and challenge our basic assumptions, which are inevitably modified over time, but the sharing of a set of fundamental beliefs contributes to our sense of identity as a profession. The three areas of belief central to occupational therapy are concerned with: ■ The nature of health and illness ■ The goals and function of occupational therapy. Occupational therapy is essentially client-centred, which means that: ‘the occupational therapist does not force his value system upon the client. But rather, through using his skills and knowledge, exposes the client to a range of possibilities which constitute his external reality. The client is the one who makes the choice.’ (Yerxa 1967, p. 8). This belief in the right of people to make their own choices is made up of three separate beliefs: ■ A concern with the whole person within their environment ■ A belief in intrinsic motivation to be active ■ An understanding of the social nature of people. Occupational therapists see each person as a unique individual, whose body, mind and spirit function together and cannot be understood as separate entities. People change, according to this view, if they are separated from the environmental influences that shape who they are. These influences include the physical environment, the cultural environment, societal factors and social support (Christiansen 1997). This whole-person approach assumes that people can only be understood by seeing the relationships between body, mind, spirit and environment over time because the unique feature of humanity is the ‘capacity of imagination and the use of time with foresight based on a corresponding appreciation of the past and the present’ (Meyer 1922/1977). Occupational therapists are concerned with the person as they are now, at this moment, and with how they function at different times and in different environments. We are concerned with the balance of occupations in the course of the individual’s lifetime, not just with single activities. Western medical science is founded on the principle that human life should be preserved if possible. Occupational therapy takes the principle that human function should be preserved or restored where possible. It is the basic premise of our profession that being able to function and participate in a range of occupations is a desirable condition (Reilly 1962). Indeed, it can be argued that human life and human function are the same thing. People have an intrinsic motivation to act on the environment in order to discover their own potential and to develop their capacities. We do not wait for the environment to impinge on us and then respond; we are able to visualize the ends we wish to achieve and act to realize them. West (1984, p. 13–14) summarized writings on occupational therapy philosophy as follows: Activity is the essence of living and is significantly interrelated with high morale … to some degree life itself is seen as purposeful occupation – that is to say, as activity, as task, as challenge … it is the purposefulness of behaviour and activity that gives human life order … the basic philosophy of occupational therapy speaks to Man as an active being and to the use of purposeful activity as Man’s interaction with and manipulation of his environment. People do not act in isolation: we are essentially social animals who develop and live in the context of groups. Human interaction stimulates biological, psychological, emotional and social development, and people deprived of human company do not thrive. There is a long period of physical and emotional dependency in childhood, and it is both normal and healthy to retain some emotional dependence on others once physical maturity is reached. Social groupings take different forms in different cultures but a small and stable social group is considered most desirable within all cultures. People do not cope well with living in groups that are too large for us to have meaningful contact with everyone else. This means that we have had to devise coping strategies for living in larger groups, for example in cities. Occupational therapists view health as not merely the absence of disease but ‘a dynamic, functional state which enables the individual to perform her/his daily occupations to a satisfying and effective level and to respond positively to change by adapting activities to meet changing needs’ (Creek 2003, p. 54). The individual is seen as healthy, or functional, when they have learned the skills necessary for successful participation in their expected range of roles throughout their life. Not only do occupational therapists believe that health can be defined by what we are able to do, we also believe that what we do makes us healthy or unhealthy. What people do creates functional demands that drive neuroplastic changes and organization, and therefore occupations shape what we become: physically, mentally, socially and spiritually. This belief was expressed in a much quoted phrase: ‘that man, through the use of his hands as they are energized by mind and will, can influence the state of his own health’ (Reilly 1962, p. 2). An even stronger expression of this belief is that ‘engagement in occupation is a central, evolutionary mechanism for the maintenance and promotion of health’ (Wilcock 1998a, p. 1). An inability to achieve a desired state of function is called dysfunction but the two states can be seen as a continuum: ‘there is essentially no break or line of demarcation between that which is considered function and that which is considered dysfunction’ (Mosey 1986, p. 13). Dysfunction is ‘a temporary or chronic inability to meet performance demands adaptively and competently and to engage in the repertoire of roles, relationships and occupations expected or required in daily life’ (Creek 2003, p. 52). Dysfunction occurs when people are unable to maintain themselves within their environment because they do not have the skills necessary for coping with the current situation. It is therefore very individual: for a pilot, fear of flying could be a major disability while, for an occupational therapist, the same phobia may be only a minor inconvenience. Causes of dysfunction fall into four main groups: ■ Environmental or personal changes that the individual cannot cope with, such as war or bereavement ■ New physiological or psychological demands that cannot be met using existing skills, such as parenthood ■ Pathology or trauma causing loss of skills. When the individual encounters a new situation, they use their existing skills to try to master it. If these fail, they try to learn effective new skills. Eventually, if the situation still remains outside their control, they experience disequilibrium or crisis. The pace at which change occurs is important for maintaining equilibrium; too fast a pace means that new skills are not learned quickly enough, adaptation is disturbed and a state of dysfunction may occur (Mosey 1968). The degree and pace of change that a person can manage without losing equilibrium are dependent on both internal factors (e.g. the ability to learn new skills quickly) and external factors (e.g. the amount of support available in the social environment). The occupational therapist’s perspective on health and dysfunction is similar to that described in the International Classification of Functioning, Disability and Health (ICF). The ICF defines functioning as ‘an umbrella term encompassing all body functions, activities and participation’, while disability is ‘an umbrella terms for impairments, activity limitations or participation restrictions’ (WHO 2001, p, 3). Diseases and disorders are called health conditions. The word illness is sometimes used synonymously with disease but is more often used to refer to a person’s subjective experience of having a health condition. The uniqueness of the occupational therapy approach to mental health difficulties lies in the assumption that human beings have the ability to influence their own health through what they do. If people can maintain or improve their health by engaging in occupation, it follows that occupation can be used as a treatment medium to ‘remediate disability, encourage adaptive behaviour, teach skills and build individual and group identity’ (Creek 2007, p. 127). Occupational therapy has been described as a ‘two-body practice’ because it encompasses both a disease perspective, focusing on problem identification and treatment, and an illness experience perspective, which is concerned with the ways that disease affects a person’s life (Mattingly 1994a, p. 37). Occupational therapy addresses the consequences of disease or injury, as they affect a person’s ability to function, rather than the primary pathology. For example, the occupational therapist tries to teach a person how to manage their anxiety so that it does not interfere with their activities and occupations, rather than working directly on the anxiety. However, reduction in anxiety often follows as the individual’s quality of life improves through this approach. The core skills of occupational therapy are activity analysis, adaptation, synthesis and application. The outcome of intervention should be that the client is able to enact a satisfying range of occupations ‘that will support recovery, health, wellbeing, satisfaction and sense of achievement’ (Creek 2003, p. 32). The main aim of intervention is to develop each person’s potentials to the highest possible level, to enhance their quality of life and sense of wellbeing, to increase their satisfaction in daily living and to improve access to opportunities for participation in life situations through occupation. Occupational therapy is concerned with the things that people do in their daily lives, the meanings that people give to what they do and the impact that doing has on their health and wellbeing. This broad focus on ‘the ordinary and extraordinary things that people do every day’ (Watson 2004, p. 3) means that occupational therapy not only contributes to the restoration of health and function but also meets people’s needs within broader occupational and social contexts. Occupational therapy contributes to building people’s occupational identities as much as to restoring physical and mental function, and to building healthy communities that can include all their members, whatever disadvantages or disabilities they may experience. The unique goal of occupational therapy is to help people with performance deficits of any kind make and express meaning through occupation, or intentional, organized performance … Occupations are applied to promote, achieve and maintain human functioning and a quality of life that gives meaning and purpose to living. The primary aim is to address issues of occupational dysfunction, disruption, deprivation, alienation, and unfulfilled potential. (Watson and Fourie 2004, p. 26) Occupational therapy is often concerned with multiple and complex needs and problems but can also be of benefit to people who have minor coping difficulties or for those who wish to maintain and promote their wellbeing (Creek 2003). Intervention may be at an early stage of the person’s difficulties, in order to mitigate or prevent any ongoing adverse effects, or may be appropriate at any stage of a long-term health condition. Occupational therapists work with people of all ages who have problems with carrying out the activities and occupations that they expect or need to do, or with carers or care staff who support people’s daily activities and occupations. Occupational therapy can be focused on individuals and groups, such as a family, or an organization, such as a school. Occupational therapists recognize that their interventions are most effective when the person is involved and engaged in the process of setting and working towards goals. It is a requirement of the Code of Ethics and Professional Conduct (College of Occupational Therapists 2010, p. 16) that the therapist ‘should work in partnership with the service user and their carer(s), throughout the care process, respecting their choices and wishes and acting in the service user’s best interests at all times’. In the traditional professional–client relationship, the therapist is the expert and the client is the passive recipient of that expertise. When the therapeutic relationship is seen as a partnership, the professional is the expert in managing disease or illness while the person is the expert in their own life. Client-centred occupational therapy intervention is a collaborative process in which everyone involved aims to negotiate and share choice and control. This can be at two levels: ■ The level of the intervention: throughout the occupational therapy process, the focus is on the person’s needs, wishes and goals rather than on the requirements of the health or social care system. This includes determining the need for occupational therapy, assessing, gathering data, setting goals, working in partnership to attain goals and evaluating the outcomes of intervention (Sumsion 1999) ■ The level of service planning, delivery and evaluation: service users are represented and take an active role in those committees and working groups responsible for the design, delivery and evaluation of services. There is a third model for the professional–client relationship and this is full self-management, in which the professional is only one of the resources that the person draws on in managing their own health condition (Van Olmen et al. 2011). Choice and control are not shared but are located with the person. When a person is too ill or disabled to take control or to participate fully in the intervention process, the therapist may have to take responsibility for making decisions, remaining aware of the risk of imposing their own goals and values and actively trying to avoid this. One of the goals of intervention will be ‘to work towards increasing client understanding, autonomy and choice’ (Creek 2003, p. 30). The understandings that occupational therapists have of people, occupation and health, and of the relationships between them, determine what they see as their professional purpose. In order to fulfil that purpose, the profession builds a knowledge base to explain, support and justify the practice of occupational therapy. The current knowledge base is outlined in the next section. Theories are conceptual systems or frameworks used to organize knowledge in order to understand or shape reality: they give the mind a conceptual grasp on reality (Dickoff et al. 1968). Theories are constructed for particular purposes and a good theory will fulfil the purpose for which it was designed. For example, the ICF is a theory that was developed to promote international communication about health at every level (WHO 2001). Theory in a practice discipline must provide ways of conceptualizing reality that can guide action towards fulfilling the profession’s professional goals (Dickoff and James 1968). For occupational therapists, theory must enable individualized, responsive, client-centred practice. Occupational therapists use theory: ■ as a guide to practice, to encourage coherent and systematic treatment ■ to suggest alternative treatment strategies ■ to enable effective communication ■ to provide a rationale for practice ■ to provide a basis for researching practice (Creek 2003, p. 35). It has been suggested that occupational therapy theory is not something we learn and then apply in practice. In occupational therapy, theorising is an integral aspect of practice. We do not contribute to theory by first understanding what theory is and then developing a theory of our own. We do theory by developing collaborative models of thoughtful practice that challenge assumptions and suggest new lines of inquiry; we do theory by learning how to align thoughtfulness and practice within specific contexts that require constant negotiation across complex professional, cultural and social boundaries. (Nixon and Creek 2006, p. 77) This view describes a practitioner who is continually thinking about what they are doing, reasoning about the most appropriate course of action, reflecting on the effects of their interventions and negotiating with everyone involved to reach agreement on the best way forward. Formal theories, learned from lectures and books, are only one part of theorizing in complex, client-centred interventions. As described above, occupational therapists work with both a disease perspective that focuses on the identification and treatment of disease-related problems and an illness perspective that considers the ways a health condition affects a person’s life (Mattingly 1994a). These two perspectives represent different ways of knowing, or epistemologies. An American occupational therapist, Hooper (2006), claimed that our chosen epistemology ‘functions as a screen through which we filter the experiences we consider important from those we do not’ (p. 16). It is important to understand not just what we know but also how we know, that is, how we take in and make sense of experience. The two epistemologies espoused by occupational therapy enable us to move, without losing sight of the complexity of occupation, from the ‘minute and measurable’ (Shannon 1977, p. 231) consequences of disease, such as short-term memory loss or sleep disturbance, to the wider aspects of illness experience and its impact on performance. Mattingly (1994a, p. 37), called this a ‘two-body practice’. The capacity to support a two-body practice, by moving between two epistemologies, is one of the strengths and unique features of occupational therapy. Occupational therapists have bridged two contradictory value systems for more than 75 years. The ability to combine the biomedical aspects of patient illnesses with the humanistic values of the Arts and Crafts Movement requires complex patterns of integrative treatment planning. This skill is an asset in today’s healthcare arena where the limitations of scientific medicine encourage practitioners to emphasize the art of patient care. Occupational therapists who have struggled with ways to balance the scientific and artful aspects of practice can guide other professionals to develop more integrative health services. (Schemm 1994, p. 1086–1087)
The Knowledge Base of Occupational Therapy
INTRODUCTION
PHILOSOPHICAL DEVELOPMENT OF THE PROFESSION
Early Influences
The Influence of Service Settings
Reassessing Our Beliefs
Philosophical Assumptions
View of Human Beings
Concern with the Whole Person
People as Initiators of Action
People as Social Beings
View of Health
Dysfunction
View of the Profession
Domain of Concern
Client-Centred Practice
OCCUPATIONAL THERAPY THEORY
Epistemological Underpinnings of a Two-Body Practice
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