In part, the fuzziness of the phenomenon of human occupation arises from its universality (Wilcock 1998). Because it is everywhere, it is taken for granted; it is not really appreciated as a social need. Although social action and explicitly social practices are central to the origins of occupational therapy they have not always been the focus of the environment of practice (Hocking 2007). Now, however, occupational therapy is reclaiming its interest in social contexts and interventions, whether through social occupational therapy in Brazil (Barros et al., 2005 and Galheigo, 2005), transformational approaches and community-based rehabilitation (Watson and Swartz, 2004, Fransen, 2005 and Whiteford and Wright-St Clair, 2005) or through service learning and an attention to the contextual nature of occupation, for example recently in Australia (Hunt 2005), South Africa (Joubert et al 2006) and the USA (Wood et al 2005). Not all of these are new directions: some have been slow-burning developments; social occupational therapy, for example, has been part of Brazilian occupational therapy education since the 1970s (Barros et al 2005), while the antecedents of current practice and service-learning initiatives in South Africa were established in the mid-1990s following the fall of the apartheid regime (Joubert et al 2006).

Occupational therapy bodies, professional and government agencies and other social actors frequently apply a top-down, policy-driven focus to community needs. Even where consultative measures are employed by public health bodies these often operate to a predetermined agenda that does not identify or serve real needs so much as obtain answers that fit a corporate purpose (Coney, 2004, Hammell, 2004 and Hammell, 2007). As allied health professionals, occupational therapists need to explore other forms of alliance beyond the medical professions if they are to address the social and environmental aspects of disability experiences.

There are many other stakeholders, most importantly the people who face disabling situations themselves, clients and carers. Paradoxically, the people who are least able to access services are those who perhaps are best placed to inform challenges to the allocation of health and social care resources. The pursuit of evidence-based practice through a positivist hierarchical framework does not allow for a particular experience to be expressed, or individual needs and diversity in context to be addressed. The evidence hierarchy needs to be able to deal with the complexities that arise from variable data that are difficult to systematize. Occupational therapy needs to develop a moving viewpoint (Good 1994) in order to allow for a diverse perspective on the realities it encounters. In order to be responsive to a diversity of needs, a variable focus is required, rather than one that provides a narrow and false objectivity.

Therapists continuously learn through the stories told them by the disabled people and the relatives and carers with whom they work, and in the process of developing their own narratives of experience and reflection. This set of narratives, with multiple perspectives according to who has told the story and the number of times it has been told, is often revealed gradually. It is often interpreted through the medium of their professional knowledge, the monoglossic lens of occupational therapy culture, but this provides only one perspective. While such narratives may be framed with the occupational therapist as the intended audience, they may also serve a purpose for the narrator, and other people who may be present. Through the course of intervention the therapist and other professionals can often enter the story as protagonists themselves. A complete understanding of disability and restriction of access to occupation can be achieved only through a synthesis and culturally sensitive interpretation of the heteroglossic discourse within which these phenomena are structured (Good 1994). Of course, a therapeutic understanding of disability is different from the client’s experience of disability; the interpretation that mediates this depends on the formation of a rapport with the people therapists are working with and the development of effective responses to immediate practicalities. The same embedding in practicalities can also encourage the adaptation of assessments and standard tools to fit local needs, making comparisons between different sources of evidence difficult.

Bannigan (2007) argues that if clinicians consider the problems clients face rather than the mechanistic application of a small range of solutions such a diversity need not present a difficulty. Although there are many models for practice, none has emerged as an overarching meta-framework that is informed by a heterarchical approach and thus offers a multidimensional perspective (Ch. 3). Instead, each framework deals with some of the issues of human occupation but not others. As a consequence, occupational therapists may have missed opportunities to address occupational choices that clients may prioritize over the interventions they are being offered (Ch. 5). Clearly, more than one discourse is in operation if the client determines different prime needs to those that have been identified by the clinician. Occupational therapists may need to engage in a process of critically reassessing their values and beliefs, but their response to the diverse and divergent discourses related to access and engagement in meaningful and dignified occupation should be carefully negotiated. Complexity can easily slip into confusion.

This divergence is the subject of Fernandez-Armesto’s (1997) attack on the fragmentation of truth through such philosophical movements as postmodernism and relativism. He argues that the individual interpretation arising from such movements makes the possibility of shared interpretation impossible: nothing can be real. All language is like ‘a serpent biting its own tail’ (Fernandez-Armesto 1997, p. 229): it does not refer to other things but to other words, yet none the less words are what we use, along with our senses and actions, to describe the world. Language therefore hovers between the tangible and the intangible but is the means by which we describe truth and untruths. The idea of truth thus remains a possibility that is bigger than the individual; it requires a consensus to establish some idea of a shared objectivity, even though the perceptions of that objectivity may ultimately be individual experiences. Fernandez-Armesto’s position, since he refers to his Catholicism, is particularly interesting, as the validity of early accounts of the Gospel and the higher truth it purports to reveal are based on claims of personal testimony, and the practice of Catholicism involves reflection and personal confession, a process of validating experience through repetition. In the formation of ideas of truth, the living witness is of especial importance. Morley and Worpole, 1982 and Ragon, 1983 and Worpole (1983) have described the importance of personal testimony in working-class writing, a ‘gospel’ of the vernacular that aims to counter the ‘higher truth’ mediated by literary narratives and sociohistorical discourses of the classes of privilege. It is this same personal testimony through which therapists aim to identify the components of occupational lives, the search for the lived experience of people and their communities, the individual meaning of illness or the individual narratives of community values from which a notion of occupational justice can be established (Garro, 2000, Mattingly and Garro, 2000, Simó Algado and Burgman, 2005 and Simó Algado and Cardona, 2005).

While this potentially presents a client-centred occupational therapy based in the individual occupational narrative of an expert patient, earlier discussion in this book (Ch. 6) shows it to be in tension with other elements of social and health contexts. If the client’s experience has to be considered against a biomedical framework of objective, empirically determined truths, it also has to contend with a range of organizational and policy imperatives. These offer a separate set of truths based on economic and commercial data concerning the affordability of treatments, the market for medication, health insurance or access to facilities. If the complexity of occupational therapy is underestimated in the clinical arena (Creek, 2003 and Whiteford et al., 2005), any difficulties in articulating its values are complicated further by the pressures that arise from this. Hammell (2007) has suggested that economic self-preservation may produce a therapist-centred professional approach, concerned with survival and justifying its existence in a competitive health and social care market but in the process distancing itself from negative experiences of its clients.

A history that relies on personal testimony, or perhaps occupational narrative, is something that is remembered, reconstructed and therefore partial. We may think that a better picture can be obtained only by gaining more viewpoints but these further accounts may reveal many differences, confusions and distractions. One narrative, as recorded in the client’s notes, more often reflects the therapist’s interpretation of this negotiation of need than that of the client. In interactions with therapists the client may attempt to seek resolution for problems or to understand them but often has to accept the clinicians’ conceptualization of them in order to obtain treatment. Disabled people find they have to admit all kinds of people into their lives in order to receive care, obtain continued benefits and be observed to be complying responsibly with their treatments. Even when these processes are necessary, they remain an imposition that arises from the way in which disability is negotiated. To argue against this can be interpreted as a refusal of treatment (Kirmayer 2000). The experience of disability, then, may be seen as being occupied or perhaps colonized by the treatment process. The progress of treatment becomes a period of time that no longer belongs to the client but is determined by the way it is broken into usable segments through treatment, appointments for further assessment and the demands for compliance in following up exercises. The narrative recorded in clients’ notes will not indicate the experiences of waiting rooms or of journeys to hospital, or much of the anxieties of families waiting to hear treatment outcomes. While each stage of the intervention and assessments between are recorded, the intervening spaces experienced by the client form no part of the clinical story and the truth of the client experience may differ from the truth of the professional or organizational experience.

Consequently the search for knowledge is an occupation of making successive approximations, each sufficing until a new proposition appears to replace it. It is sometimes important to attend to the intervening spaces to find out why treatments are not working according to plan, clients have not followed advice, or progress is interrupted. Kirmayer (2000) suggests that it can sometimes be difficult for clinicians to think outside their professional focus to accommodate these circumstances into a course of treatment. When the search for new means of uncovering truths runs into a cul-de-sac it can be necessary to return to traditions, or earlier paths, in order to make progress (Fernandez-Armesto, 1997 and Garro, 2000), just as the occupational therapist seeks to enable the rediscovery of previous abilities or the development of new ones, or the profession seeks to develop perspectives for the future by returning to its root values.

In the quest for new occupational territories this also produces difficulties. Johnson (1997) describes how the search for new lands to conquer led to the creation of fantasies and myths. Real geographical features such as the southern tip of Greenland or Iceland were misplaced through error, myth, mirage and the experiences of being lost and identified as new lands. These substantial cartological formations continued to show up on maps for centuries. Although they shifted in position and reduced in size, lack of knowledge maintained such islands through successive generations of navigators and cartographers.

The perception of truth is relative to the amount of access we have to knowledge, education and experience. This is why the early literatures valued personal testimony and supplied reasonings in terms of these experiences to describe phenomena that could not be directly explained. Personal narrative is often a stronger force than the rational written word because it relates the testimony of direct experience. Those who practised the traditions of oral literatures have sometimes described the writing down of ballads and other pieces as destructive. The written variant has sometimes been described as dead because it is fixed in the page and not in the memory, and the process has often involved the introduction of editorial ‘improvements’, which may either be untrue or even bring in elements alien to the oral tradition (Buchan 1997).