Increasingly, occupational therapists are recognizing that there is a political component in the work that they do. For a long time, as allied health professionals, occupational therapists have perhaps tended to work towards a treatment process that has been defined by medicine (Pollard and Walsh, 2000 and Wilcock, 2002; see Ch. 7), but this has often been difficult to reconcile with the knowledge that the causes and experience of disability are linked to social, economic and geopolitical conditions (Wilcock 2002). During the 2004 World Federation of Occupational Therapists (WFOT) Council meeting in Cape Town, occupational therapists agreed a position paper on community-based rehabilitation that recognized the systematic exclusions that prevent disabled people from realizing their right to meaningful occupation (see Ch. 5). The use of the term ‘occupational apartheid’ (World Federation of Occupational Therapists, 2004 and Kronenberg and Pollard, 2005a; see Ch. 4) for these forms of exclusion derives from both the former South African political regime and the experiences of one of the authors in working with street children in Central America (Kronenberg 2005).

Enabling access to meaningful occupation as a right is not just treatment but a political endeavour. The purpose of this book is to explore the meaning of politics in relation to occupational therapy and explain how this might be applied to activities of daily living. It draws on the contemporary experience of occupational therapy practitioners and educators as well as political and historical literature to consider how a political understanding may be of value to the profession and its clients.

Occupational therapists have been concerned with problems arising from the social conditions of the people they have been working with, their families and communities throughout the history of the profession (Townsend, 1993 and Wilcock, 2002). Many of the ideas that have informed current perspectives of the profession derive from an understanding of occupation that has its origins in socialist and utopian political philosophies of the 18th and 19th centuries (Wilcock 2001). The legacy of these philosophies has been powerful and includes tyrannies and revolutionary movements that continue to raise strong antipathies (Latey 1972). When using words that have become value-laden, such as ‘social’ and ‘political’, it is important to be clear that this is not a new reductionism (Galheigo 2005). Although occupational therapy may have, over much of its history, considered itself to be ‘apolitical’, politics is something that occurs everywhere, in all aspects of life (Vaneigem, 1983, Tansey, 2000, Van der Eijk, 2001 and Kronenberg and Pollard, 2005b).

There is a worldwide change in occupational therapists’ perception of their professional objectives. Two examples are the position statements of the World Federation of Occupational Therapists on community-based rehabilitation (2004) and human rights (2006), which gave prominence to the experiences of occupational apartheid, occupational injustice and occupational deprivation. In these, occupational therapists are urged to acknowledge meaningful occupation as a right and critically to explore occupations and disabling situations in their context.

This political consciousness has arisen at a time when many occupational therapists have become concerned about the political nature of the challenges they face in meeting the occupational needs of the people they work with. Occupational therapists have been recognizing extremes of poverty, occupational injustice (Townsend & Wilcock 2004) and occupational apartheid (Cage 2007), even in relatively wealthy states of Europe and North America. Occupational therapists are beginning to recognize the relationship between human occupation, global poverty and disabling conditions, and their professional organizations are attempting to facilitate their members in taking up this new direction (Wilcock, 2002, Pollard et al., 2005, Sanz Victoria and Garcia Rezio 2005, Kronenberg and Pollard, 2006, Lawson Porter & Pollard, 2006a and Lawson Porter & Pollard, 2006b). If occupational therapy is to live up to the holism that is often claimed for it, this entails the development and maintenance of a broad view of human complexity and a living interest in the diversity of cultures (see Chapter 6, Chapter 7 and Chapter 21).

Occupational therapists have a responsibility towards the enactment of occupation as a human right (World Federation of Occupational Therapists 2006). Community membership or citizenship is enabled through occupational justice. This doesn’t just stop at the hospital exit but extends into the heart and soul of the communities we belong to ourselves.

The linking of occupation to citizenship and community participation requires an awareness of the political nature of occupational therapy. Many important political issues have their origins at the community level (Ward, 1985 and Tansey, 2000), in the very issues and among the very strategies addressed by and through community-based rehabilitation (Kay and Dunleavy, 1996 and Edmonds and Peat, 1997) and other approaches linked to health outcomes, such as community development (Pollard et al in press). These issues are often symptomatic of the systematic oppressions that create occupational apartheid and prompt occupational therapists to consider the relationship between rehabilitation and social change.

English-speaking discourses of knowledge have dominated the field of occupational therapy from its very outset (see Ch. 7). The Western or northern hemisphere domination of the dissemination of theory and practice may present some barriers to the exchange of knowledge in the profession and also to the development of an understanding of the complex contexts in which people live and occupy themselves (Kondo, 2004, Iwama, 2005 and Odawara, 2005).

The 2005 World Federation of Occupational Therapists survey of occupational therapists engaged in community-based rehabilitation, for example (Sakellariou et al 2006), revealed that therapists from southern hemisphere countries such as Colombia and South Africa tend to have longer community-based rehabilitation engagement than those from wealthier Western countries, often with established interventions supported by many local structures (Sakellariou and Pollard, 2006, Sakellariou et al., 2006, Pollard and Sakellariou, 2007 and Pollard and Sakellariou, 2008). The short-term involvement of expatriate therapists precludes an understanding of the cultural construction of occupation and disability in ways that could inform occupational therapy theory and practice.

Language presents a significant difficulty. Occupational therapy represents a small part of the international health science textbook market. The publishers of this book have informed us that a good target sales figure might be 4500 copies worldwide. Breaking into this market from other languages, given the dominance of English as a teaching medium even where it is a second language, is difficult. There are relatively few occupational therapy texts available even in other major languages, such as Spanish, and certainly many fewer examples of articles or books originating in other languages being translated into English. Many therapists who speak English as a first language do not have good foreign language skills and come from countries where, as in the UK, there is a long established problem of a lack of facilities or emphasis on foreign language education (see Ch. 7). Occupational therapy education in many countries often requires students to access material in English, yet developments in professional practice, particularly in relation to approaches that recognize the issues associated with poverty alleviation, community-based rehabilitation or social approaches produced by these programmes are often set out in other languages. Despite initiatives such as the social occupational therapy developed in Brazil (Galheigo 2005) being well established, with a history dating back to the 1970s, these experiences have not until recently been available to the English language-dominated professional literature.

Understanding the political context of occupational therapy requires an open exchange of knowledge or a facility of curiosity that enables therapists and those they work with to acquire a functional awareness synthesis of the diverse perspectives they encounter in their practice (see Chapter 3, Chapter 6, Chapter 7 and Chapter 21). The current dominance of Western epistemologies in occupational therapy inhibits the development of culturally appropriate models of practice responding to local needs, or else restricts the exchange of knowledge. However, we do not suggest that one cultural perspective should be valued over the other.

‘Community’ is often perceived as a benign concept (Williams 1976) but it masks a range of differences drawn up on the lines of class, ethnicity, regionality and gender (Woodin 2005). Occupational therapists frequently belong to a different culture, class and sex (see Chapter 5, Chapter 8, Chapter 9, Chapter 10, Chapter 11, Chapter 12, Chapter 13, Chapter 15, Chapter 16, Chapter 17, Chapter 18, Chapter 19 and Chapter 20) from the one in which projects are being carried out, and terms such as ‘social change’ have to be used with caution. Social change is a phenomenon that operates at many levels within a society, traversing concepts such as cultural groups, class, generations and professional groups. The processes are not all completed simultaneously and many natural, geographical, economic and cultural as well as political factors may affect the outcomes (Skocpol, 1980 and Landman, 2000).

In a profession concerned with human occupational activity, and therefore facilitating people in virtually all aspects of human life in which they want to participate, occupational therapists are at risk of taking on a greater range of knowledge than they (or anyone else) can really hope to assimilate. Even dominant occupational therapy perspectives have been made only partially available across language and cultural barriers, with consequent differences and confusions about the implementation of ideas in other localities (Kondo, 2004, Iwama, 2005 and Odawara, 2005).

Given these circumstances the dissemination of ideas is partial and generally one way. The distribution of knowledge and the accessibility of research and literature searching procedures favour a market in which the English language prevails. This produces exclusions, because people either cannot access knowledge or cannot share or distribute it. If the approach being implemented cannot address the needs of the person the therapist is working with, there is a danger that the therapist is actually operating a mechanism for exclusion rather than a technology for treatment. Resolution often requires an adaptation, based in local needs (Kondo 2004). Therefore the term ‘rehabilitation’ is not always useful where it applies to communities if it is associated with the acceptance of values or compliance with a ‘normality’ that may not actually be shared.

Occupational apartheid is about systematic exclusion. Confronting situations and approaches that perpetuate it are, we suggest, at the heart and soul of occupational therapy practice. Every society contains invisible voices, whether street children or psychiatric survivors, voices of people who are marginalized through race, culture, disability, sex, economics or educational level, and often, through their concern with human activity, occupational therapists and other health and social care professionals are concerned with eliciting these narratives in order to work out solutions to their problems. Invisibility can occur whether or not facilities exist to address a particular issue. Workers attached to services may not be sufficiently empowered to obtain the resources they need, or problems may be ignored simply because they are not heard at all and no agency exists to address them.

It is inevitable that those who have wealth seek to isolate themselves from the poor. They protect their lifestyles through security measures and high prices, which insulate them from the daily awareness of deprivation, even though their wealth is generally obtained at the expense of others’ impoverishment. Thus people may physically live in close proximity with each other but be unaware of the occupational nature of each other’s lives (Putnam, 2000 and Galvaan, 2005). The opportunities for exploring each other’s narratives may be there but require active mediation to evolve into a conscientious consciousness.

In the opening chapter of our previous book (Kronenberg & Pollard 2005b), we set out a series of principles. One of these is that ‘everybody is responsible for everything’. This does not mean that occupational therapy should include every dimension of every occupational problem. Instead what it suggests is a principle of contiguity, of interconnectivity between all people, something that is entirely compatible with the feminine origins of the profession and with the best of its practice (Pollard & Walsh 2000). This contiguity is something that cannot be insular but of its nature must reach out and connect, just as individuals must recognize the connection they have with the community and society around them.

This process of making connections is something that begins very early on in human life. In early infancy a child is entirely focused on its own needs, perceiving its mother almost as an extension of itself (Winnicott 1992). Later it begins to recognize that its mother is absent at times but returns at others, and that it can survive and continue independently in the gaps in her presence (Winnicott, 1990 and Bowlby, 1992). The child becomes aware of its separate existence, becomes increasingly self-reliant, sustaining an understanding of its continuous existence by symbolizing the presence of its mother through a transitional object, such as a blanket or comforter.

Children soon acquire attachments to other aspects of their environment, regular routines and preferences (Bowlby 1992). They seek to maintain the security that these routines give them, demanding that Mummy, not Daddy, reads the bedtime story but on occasion, because it is a novelty, that Daddy, not Mummy, reads the bedtime story. These are early experiments with power and influence. ‘I want Mummy’ is a statement of need but it can also be a political statement if, for example, Daddy has just reprimanded the child and it hopes that Mummy will contradict Daddy’s admonishment. Mummy and Daddy inevitably differ, no matter how much they may try to cooperate to offer consistent parenting, and from this the child will learn about situations where it can try and produce conflicts – for example to get the sweets that the other parent has said should wait till after mealtime, ‘But Mummy said I could have them’.

If we reflect, we can all remember employing childhood experiments like this to obtain the things we wanted. Often we found that, by observing certain rules, adopting pieces of etiquette like saying ‘please’ or performing some household chore without being asked, we could ensure favourable conditions for some requests through cooperation. In other situations making a fuss might obtain a concession to keep us quiet. Learning which methods were best and when they might be most effective formed part of the acquisition of social skills and also entailed the germ of a political ability. This ability has perhaps been described by Berne, 1968 and Berne, 1975 as complementary transaction in human relationships, the ability to use a script or a plan successfully to negotiate the satisfaction and exchange of needs with others.

Everyone, therefore, acquires the ability to operate within their local sphere as a ‘politician’, motivated by interests that relate to their particular needs but are shaped by their particular experience. This use of the term ‘politics’ is rather wider than the limited sense that applies to issues of government or the definition of ideas about policy. In Berne’s theory of transactional analysis (1968), the games people play are largely at an unconscious level, although some motivations may be clear. Players of political games are generally more explicit in identifying, at least to themselves, their strategic goals. As we shall explore, political ideas extend from personal interests to having a global, as well as a local, impact and are realized in the means we have as individuals to pursue our daily occupations (Wicks & Whiteford 2005). Just as Berne used the idea of games to explore human relationships, it is sometimes possible to analyse larger political movements in terms of games. Landman (2000) explores the late 20th century transitions to democracy in Poland, Russia and Portugal in which actors in political factions employed clear tactics to develop their desired outcomes through strategic moves, as in a game of chess.

Politics is thus a human occupation and the skills and components from which it is composed are developed over time, both through the rites of passage that make up personal development and through the historical process through which societies develop (Wilcock, 1998, Wilcock, 2001 and Fernández-Armesto, 2000). The nature of society is itself determined by the way in which people occupy raw territory and the tasks that are necessary for people to maintain themselves in the environments in which they settle, including conflict and cooperation with neighbouring societies (Fernández-Armesto, 2000 and Landman, 2000; see Chapter 10 and Chapter 20). The interrelationship between human occupation and the fundamental basis of politics is therefore a very significant one, which is realized through the ability of individuals to participate in community activities at every level of society. Political activities therefore can range from highly localized individual or community issues through to matters of global significance (Ward, 1985, Landman, 2000 and Wicks and Whiteford, 2005). Sometimes individual issues can have a powerful enough effect, as a popular symbol for particular causes, to exert a global influence. Similarly, wider events, the fallout from decisions made at the domain level, impact on the occupations of individuals – for example where they find themselves living near nuclear radiation or pollution hazards and are consequently shunned as a potential source of contamination (Kasperson et al 2001).

To address this kind of complexity we have derived a framework for political reasoning from the work of Van der Eijk (2001). Van der Eijk describes ‘politics’ as being classifiable into two main types, the aspect approach and the domain approach. The aspect approach acknowledges the presence of politics in every facet of life and human interaction. It implies that politics is present in the tensions between conflict and cooperation in almost every human occupation and human relationship. Van der Eijk (2001) explains that conflict and cooperation provide the motor for all political engagement and, since this provides the motivating principle for action, neither should be regarded as necessarily good or bad. Conflict and cooperation are the concern of political activities of daily living (pADL) (Kronenberg & Pollard 2005a). The lower-case ‘p’ in pADL distinguishes this aspect from the domain approach which views ‘Politics’ (with a capital ‘P’) merely as a particular, defined sphere of human relationships, indicated by terms such as ‘the state’, ‘government’, ‘public administration’ or a political party.

In participating in domain politics, politicians, political functionaries and the apparatus of government and administration are also practising aspect politics, or pADL. This may frequently be observed in political diaries, where individuals record their personal relationships with their professional colleagues. Clearly in the behaviours that arise from the interaction of political figures at a personal and aspect level there is an interaction that both affects and is affected by larger domain issues such as international conflict, cabinet changes or the development of new policies (e.g. Luthuli, 1963, Clark, 1994, Howe, 1994, Mandela, 1995, Thatcher, 1995a, Gorbachev, 1997, Major, 1999, Guevara, 2001, Currie, 2002, Mowlam, 2002 and Blumenthal, 2004). Similarly, the behavioural styles and actions of politicians are frequently linked to experiences in their early lives, for example the relationships that Iain Macleod (Shepherd 1994), Edward Heath (Campbell 1993), Harold Macmillan (Davenport-Hines 1992) and Fidel Castro (Thomas, 1986 and Szulc, 1989) had with their parents, as they occasionally admit themselves (Thatcher, 1995a and Thatcher, 1995b). The conduct of politics is not something removed from personal behavioural styles.

Earlier political theories have discussed the conflicts or cooperation of political forces as being engineered or motivated by classes but more recently theorists have argued that this analysis does not take account of the evidence of complexity, of the action of groups within classes, of factions and even individuals (Skocpol 1980). In other words, conflict and cooperation arise from the occupational histories of the various individuals involved (Beagan 2007; see Ch. 5). Political processes are a human occupation, the rich product of occupational behaviours and performances in particular environments. Although often not specifically mentioned in the theoretical models of occupational therapy, they are an important element of the social and cultural aspects that are incorporated in them, particularly where they concern issues around justice. There is a need to lobby for better resources and further developments in health and social care policy (Barbara & Whiteford 2005). To do this, and get the resources to meet the needs of the people they’re working with, occupational therapists need to embrace a deeper political awareness and the facility to employ political argument. In her account of the management of peace negotiations in Northern Ireland, Mowlam (2002) describes the personal and reflective approach she used, stressing values such as honesty and clarity but, above all, using her person as a means to gain rapport with those on differing sides. Irrespective of political stance or professional standing, individual personality is a vital element in the way objectives are attained.

If the characteristics of individuals are key to the way they employ their abilities in political occupations, then it follows that political ideology cannot be fixed. Its interpretation often depends on individual factors, just as again we might see in the history of the Russian Revolution and the differences between the key protagonists both before and after (Latey, 1972, Lenin, 1976, Lenin, 1988 and Trotsky, 1977) or the conservative governments of the later part of the last century (Campbell, 1993, Thatcher, 1995a and Major, 1999). As the pADL reasoning tool identifies, other political variations can occur according to the aims, motives, interests and contextual factors involving the actors. These can range from limitations to means in terms of physical resources as well as limitations in perception and ability on the part of those carrying out actions (Pugh 1994) or the perception that mistakes are being made, as revealed by the marked policy shifts in some socialist dictatorships (Skocpol, 1980 and Thomas, 1986).

These shifts in ideology and the aims, motives and interests, or even the perceptions, are not always admitted or, conversely, are admitted when in fact there hasn’t been a shift, or a clear ideology may not actually exist, as was claimed of the UK Conservative Party during the 1980s (Honderich 1991). There had been a ‘one nation’ consensus policy in the late 1960s and early 1970s based on a mixed economy (i.e. a combination of private and state-run businesses) under Ted Heath but an ideological shift led to the emergence of a tougher, market-determined approach under Margaret Thatcher. It was later acknowledged that Heath was the architect of Thatcherism – but could not put it into effect. The perception that remains is that Thatcher commanded the determination to carry this policy out and is associated with it, whereas Heath lacked the opportunity and the power to do so (Campbell 1993). Such phenomena may not be fully apparent until a historical process has taken place. The cause and effect of political events is not always apparent to participants at the time, even when these actors are driving the strategy. Truth is relative and history a matter of debate.