Influenced by Charles Darwin, Freud based his ideas on the continuation of the species, which he believed had to be sexually driven. For example, a baby’s pleasure is sought through body sensations, and moves from oral activity around the first year of life, through interest in anal activity in the second and third years, and finally to the genital phase around 3–5 years of age. These stages shape later life, and if the baby experiences trauma of either too little or too much stimulation at any of these stages it can hinder development and create problems later in life (Symington 1986). Erikson’s (1980) interest in child development emphasized the conscious and unconscious progression through eight life stages, resulting in a strengthened synthesis of thoughts and feelings. Freud’s longstanding friend and colleague, Sandor Ferenczi, continued to work with the environmental concept of trauma, realizing that, like children, his adult patients with neurosis longed to have what was passively beyond their grasp (Ferenczi 1949). For this to happen, trust had to be established, so that the shift into active engagement could take place. The later object–relations theorists, Winnicott, 1971, Bion, 1961 and Bowlby, 1988, took up Ferenczi’s belief in a form of maternal love (Ferenczi 1984) to counterbalance what had been lost. This was provided through attentive listening, sensitivity and piecing together of the trauma without overstepping boundaries. Object relations theory departed from the exclusive focus on the self by exploring the individual’s relationship with the environment and the urge to form relationships in the pursuit of well-being and the effective achievement of goals (Sutherland 1969). The intention of object relations is to attach meaning to relationships, artefacts or abstract concepts. Those were the ideas that caught the imagination of Fidler and Fidler (1963), whose communication process in occupational therapy revolved around activity, communication and the relationship with objects. Likewise, Mosey (1970) was interested in how symbolism and object relations were evident within clients’ engagement with activities. In Scotland, Batchelor (1970), while still an undergraduate, sought to differentiate occupational therapy from mainstream psychotherapy by the presence of objects that were ready-made, offered or created.

Donald Winnicott’s attention to the mother–infant relationship (Winnicott 1971) overlaps with the idea of object relations, and gives a sense of reciprocity that can lead to the first sense of unfolding identity. Winnicott, like Bion, saw the start of the infant’s inner emotional and intellectual life as being separate from, yet able to relate to, the outer world. He considered that, from the onset, the infant is part of a couple, and the intensity of this relationship gives the child the illusion that they exist as a single entity. Winnicott’s (1971)‘holding environment’ allows the infant the possibility of tolerating their surroundings, not unlike the therapeutic relationship. To assist an infant in coping with the gains and losses of separating, an object, such as a cloth or toy, is utilized to help make the alteration. Winnicott called this substitute used to replace the wanted object a ‘transitional object’, and it forms the first symbol of language. The absence of the object allows space for play, which, with ‘good enough mothering’, extends into adult life through culture and creative activity. In the occupational therapy literature, this idea has been embraced by Fidler and Velde (1999) in exploring the meanings that are inherent in activities, and more recently Blair (2000) has entertained the notion that certain occupations can be understood as protective during times of stressful transition. From a research base, the Swedish occupational therapist Eklund (2000) emphasizes the need for an integrative approach to gain a broader understanding of human activity performance. She uses the cultural work of Harry Sullivan and Donald Winnicott to argue that an object relations perspective is comparable with Kielhofner’s (1997) requirements for a conceptual model of occupational therapy practice.

What can be deduced from this brief overview of underpinning theories, all of which focus on the notion of successful change occurring in the mind of the individual, is the way that complex ideas have emerged and been adapted over the years. The therapeutic relationship, as Jenkins (1999) suggests, is seen as pivotal within occupational therapy. This frame of reference underpins specific work in child and family work, palliative care, substance abuse and certain areas of mental health. Apart from occupational therapy, the ideas have substantially influenced the practice of art therapy, mental health nursing, social work, education, organizational studies and, more recently, mental health promotion.

Over the last decade there have been a number of therapeutic developments (Box 13.3) that have striven to address the perceived imbalance or restrictions of the classical psychoanalytical therapy. These include a concern over the length of time that psychodynamic therapy takes, its cost and the lack of empirical research. Dialogic methods have become more widespread, and often depart from insight-oriented pursuits to those more linked to action, which is synonymous with an occupational therapy approach to adaptation and change.