Creek (1997, p. 29) said that occupational therapists have a ‘concern with the whole person, who has a past, present and future, functioning within a physical and social environment’, a definition that appears to be congruent with Smuts’ conceptualization of holism. As one of the fundamental tenets of occupational therapy, holism is accepted as an axiom and rarely questioned, yet professional understandings of it appear to vary. Therapists are uncertain of the nature of holism and how it can best be applied to actual practice (Finlay 2001). This polyphony regarding the meaning and the importance of holism might account for its inadequate application in clinical practice.

Although authors such as Wilcock (1998a) and Townsend (Townsend and Wilcock, 2004a and Townsend and Wilcock, 2004b) have indicated the traditional nature of occupational therapy’s concern with social and community factors in health and occupational balance, in practice it appears that holism in occupational therapy is often restricted to an individualistic and professionally constrained understanding of the persons occupational therapists work with. Therapists who accord themselves the credentials of holism as long as they interact with clients as whole persons have often overlooked human interactions with the greater social, political, economic environment in all its cultural diversity. One example of this is the way therapists enact policy and organizational directives even when they appear to conflict with clients’ interests in a disabling and disempowering way (Hammell 2007). Holism as therapists define it, is not always the same as the way clients experience it.

Dickie and colleagues (2006) argue that an emphasis on the individual experience is inherent in many definitions of occupation in occupational therapy. Although they interact through occupation, individuals and their contexts are often seen as two distinct entities. Context is not simply where the individual is located or occupation takes place but, rather, it can be seen as an active and vital component; individual and context are engaged in a dialectical relationship through occupation, each informing and shaping the other.

Dualistic conceptualizations of holism might have served occupational therapy well when it still accepted a role restricted within a biomedical paradigm. They may prove inadequate where occupational therapists act as ‘agents of change’ (Pollard et al., 2005 and Sinclair, 2005), rather than agents of social control (Hammell 2004) in a world facing gross disparities in access to occupation that are often the outcome of deep sociopolitical processes (Chapter 5, Chapter 10, Chapter 17 and Chapter 19). Holism pertains to all aspects of the occupational therapy process, implying an acknowledgement and understanding of the contextual nature of occupation. While holism, client-centred practice and occupation-based intervention are acknowledged as basic mandates of occupational therapy practice (College of Occupational Therapists 2005), there is often conflict between the delivery of practice objectives and organizational demands (House of Commons Health Committee 2006). Often the client comes third in this contest (Hammell 2007).

These beliefs should ideally be engaged in a dialectical relationship with professional practice where they can inform and guide each other so that they are mutually congruent; otherwise, as Owen and Holmes argue (1993, p. 1694), holism becomes merely the means for achieving a ‘veneer of academic and moral respectability’. As Hammell (2007) points out, there is a distinction between acting as an advocate for the client’s needs and responding to organizational pressures by acting as a gatekeeper to resources, especially when policy appears contradictory, even ‘chaotic’ (House of Commons Health Committee, 2006 and Mandelstam, 2007, p. 227). Some of these dangers were detailed by Abberley’s (1995) analysis of holism as a construct to avert guilt. It serves to remove the culpability for a potential failure from therapists and attribute it to the complex nature of the situation. Holism is linked to the process or the form of intervention but not to the outcome, which may depend on factors such as client motivation. Therapists complain of the lack of resources or funding to develop occupational therapy knowledge but do not acknowledge where occupational therapy has not met clients’ expectations because of its own failings. Abberley (1995) argues that holism is a stratagem to retain authority and power within the client–therapist relationship while justifying unsuccessful interventions on the basis that ‘it’s impossible to do everything’. Hammell (2007, p. 263) says that ‘the impotence of the profession’s claims to have clients’ interests at its core … [and]… passive acquiescence to the role of resource gatekeeper’ indicate the redundancy of the claim of being client-centred.

If the focus of the profession is self-serving (Hasselkus 2002) this presents a serious challenge to its claim to holism. Holism is not about a requirement of achieving a set or finite level of knowledge but an open process of developing analytical reasoning skills. When applied to practice these should enable focus on those factors that demand action. Holism thus refers to a disciplined process of knowing how to know that which matters or navigate successfully within complex situations.

This discussion indicates a gap between the professional holism theory and actual occupational therapy practice (McColl, 1994 and Finlay, 2001). The theory is split from the practice of the profession and occupation, and individuals from their context. Yet occupation and context do not inhabit distinct spheres of experience (Whiteford & Wright-St Clair 2005). To use Arendt’s (1958/1998) critique of dualism, occupational therapy can be seen to be expressed through two conditions, the activa of practice and the contemplativa of theory, which have evolved to become mutually exclusive. In other words, the holism postulated by occupational therapy theory is often not informed by practice and thus does not transpire into interventions, while practice is not always prepared effectively to translate theory into action.

According to the American Occupational Therapy Association (2002, p. 610)‘occupational therapists … focus on assisting people to engage in daily life activities that they find meaningful and purposeful’. The American Occupational Therapy Foundation envisaged a society where occupational therapists would:

Arguably, these mission statements reveal the holistic perspective of the respective professional bodies, a holistic perspective that goes beyond the confines of the therapeutic relationship and takes into account the broad underlying reasons for restrictions on access and engagement in occupation. Hammell (2007, p. 266) asks whether the profession and its individual members are currently working towards those aims in practice or merely expressing ‘good intentions’.

Many people whose access and engagement in meaningful occupation is disrupted or is at risk of being disrupted could benefit from occupational therapy services, as evidenced by many of the contributing authors to this book and others (Watson and Swartz, 2004 and Kronenberg et al., 2005). The Well Elderly Study carried out by an interdisciplinary team from the University of Southern California evidenced the benefits of occupational therapy for healthy elderly individuals (Jackson et al 1998), while the New Stories/New Cultures after-school enrichment programme demonstrated how occupation-based interventions can equip young people from low-income urban neighbourhoods with the necessary skills to navigate the social world effectively (Frank et al 2001).

Most occupational therapists work with people who face certain clearly defined biomedical conditions, get a referral and can afford occupational therapy services. Stories of vulnerable and at-risk populations, whose access to occupation is often compromised, still remain largely unheard within the profession. Poor people, healthy elderly individuals, refugees and asylum seekers are among the groups of the population who may experience a state of occupational apartheid or injustice with a pervasive impact on their quality of life (Sussenberger 1998). Such people often fall through the cracks of health care systems or manage to elude them altogether. An alternative view might be that health care systems are sometimes able to avoid identifying the needs of clients who may require more assistance than they can pay for. Consequently, occupational therapists are sometimes unaware of the occupational risk factors these people may be facing, are not empowered to engage with them or face considerable difficulties in doing so (Chapter 15, Chapter 17 and Chapter 19). This represents a paradox for a profession that maintains that its focus is on access to occupation rather than on a mechanistic view of health.

Health in occupational therapy literature is conceptualized as ‘a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity’ (World Health Organization 2001). If human occupation is about expressing the self through doing, being, becoming and belonging (Wilcock, 1998b and Hammell, 2004), it follows that something so apparently natural to the purpose of human life as occupation should be a right. The implication is that, just as Nietzsche says that humanity is the goal of humanity, humans should be enabled to do, and be, and so become (Nietzsche 1986). It is not merely that humans express themselves as they are, but as they have the potential to be.

Such a proposal might be considered an expression of occupational justice. However, humans generally live alongside other humans and other organisms that also do, are, and become in ways that are meaningful to them. Inevitably the interests of humans in expressing their right to occupation will come into conflict with the purposes of others. Nietzsche’s (1986) vision of humanity is that it should continually test its strength and look forward but it seems intolerant of those unable to keep in step, is enviable of others who achieve successes and tries to restrict them.

This continual balancing on an equilibrium that humans are always trying to upset to their own advantage over others is one of the problems facing occupational therapists who want to present occupation as a benign concept. Occupation is ‘the act of occupying; possession; the state of being employed or occupied; the time during which a country etc, is occupied by enemy forces; that which occupies or takes up one’s attention; one’s habitual employment, profession, craft or trade’ (Chambers Dictionary, Kirkpatrick 1983, p. 874). The implication of possession (especially of that which previously had no owner) follows from the verb to occupy. Therefore occupation implies complex relationships between what a person does or people do and the environment, whether it is a raw environment or territory that previously belonged to others. To occupy something may produce the result that access to it may be restricted to others through the concept of ownership and prior right.

Occupation is therefore inextricably linked with a political, social, economic and environmental set of purposes. Occupational justice for one individual or set of people may produce occupational injustices for others. Therefore the utilitarian principle of an occupational equality is undermined by the result of human occupation as a producer of inequality: the poor, vulnerable and those in other disabling circumstances, many of them living in the world’s richest economies, cannot afford to exercise their occupational rights.

Occupational therapy operates in a complex world comprised of interconnected parts rather than segregated entities. This pertains as much to the development and process of occupational therapy within a multiprofessional and multiservice environment as to the nature of the occupational engagement and performance issues people bring in their interactions with occupational therapists.

To illustrate this multifactorial discourse we make use of the Bakhtinian concept of heteroglossia (Bakhtin 1981/1995, p. 218). Heteroglossia refers to the presence of ‘another’s speech in another’s language’, for example the presence of multiple perspectives within a novel, those of the author and those of the protagonists. These multiple discourses are interconnected and are grounded in the diverse cultural discourses operative in every society, which in turn are termed social heteroglossia (Kroeger 2005). In an analogy with the textual construction of a novel, where heroes are situated in interactions initiated by the author and act within preset boundaries, social actors operate within an inescapable dominant cultural discourse. These multiple ‘languages’, the diverse perspectives of the various actors together with the scripts, beliefs and attitudes present in society, comprise the social whole that is the setting of human action. Occupational therapy was constructed and functions within this heteroglossic context and both occupational therapists and the people therapists work with are acculturated into different social discourses, parts of a diverse whole.

The various vantage points from which people view the world, their different perspectives and the different ‘languages’ they speak are intertwined in relationships of power. Some ‘languages’ do not need any translation to make people understand them: they express experiences that are widely recognized as representative of society as a whole. Some others have been marginalized and the realities they communicate need to be reframed according to the rules of the dominant discourse (Beetham 2002; see Chapter 5 and Chapter 14). This chapter opened with a poem written in 1981 by Donna Kate Rushin, an African American woman. She poignantly illustrates how the burden of reframing and translating experiences often falls upon those with less power to influence public discourses. Their experiences often remain unknown unless they can engage in a continuous process of explanation.

The construction of a common language does not resolve this injustice as it both perpetuates power differentials (communications take place according to the norms and experiences of a dominant group) and also excludes people whose experience cannot be understood according to these conventions (Beetham 2002). The ‘nothing about us without us’ mantra so often expressed by disability rights advocacy groups indicates the need to listen to other narratives and interpret them as they are experienced by the people who live them, and not for what they represent to the people who listen to them (Franits 2005).

This entails an acceptance of heteroglossia and the development and application of mechanisms to make sense of it. In practice the achievement of any deep understanding would be very complex, even impossible. The heteroglossic aspect of action is also complicated by variations in the order of the narratives that make it up. Each individual’s narrative depicts a cycle of events, causes and motivations that may ultimately be interrelated, directly or less directly (Ricoeur 1984). For example, one of the tasks of the therapist may be to collect together accounts of an event from a client, carers and professional colleagues, looking for points of consistency and inconsistency in order to develop a treatment plan. However, this composite history can only be partial. It may have to take into account the narratives of an employing organization or the development of policy in order that treatment is effectively implemented. These narratives may not have been considered in the others, although they may come to exert an effect on their future development. In evaluating any outcomes all those involved in composing the various narratives around an experience, for example of illness or disability, are engaged in analysing not just actions but a course of events, for which each individual will continue to maintain their own narrative. These histories are characterized by collapsing or expanding certain details, the progress of events and even their linearity in the course of the story according to their importance for the individual narrator.

Earlier, the impossibility of attaining a complete knowledge or applying a complete practice was criticized as a means of diverting the experience of failure in therapy. In one sense, the holistic practitioner is an unattainable myth. On the other hand, as an ideal, it can remind therapists of the need continually to develop their skills, knowledge and through them respect for the variety of the heteroglossic context of occupation. The development of a heteroglossic cultural awareness would inform theory and practice and enable therapists effectively to ‘translate’ and make sense of the various contexts within which occupational therapy operates and the multiple interactions that influence the process of the profession.

Good (1994) introduced the term ‘semantic networks’ to indicate that disease was grounded within ‘diverse meanings, voices and experiences’ (p. 171). Engagement in occupation is the product of interconnected social processes, in consequence of which its meaning is also multifaceted. Therapeutic encounters incorporate a whole array of perspectives and voices: those of the therapist, client, other therapists and professionals, the client’s social network, including partners, relatives, friends and the voice of the client’s employer. All these are ingrained within the specific cultural setting where interactions take place. The experience of the client is a synthesis of all these voices, as demonstrated in the Case Study below, and many more. This wider chorus includes the voices of administrators and case managers who decide what kind of treatment the person is entitled to, the voices of politicians who can, for example, determine a universal design policy to enable all people to interact with the physical environment, and the voices of legislators who set the framework for the rights and responsibilities of citizens. In this complex interplay any vantage point offers a unique synthesis of these voices but they cannot be heard all at once. A technician setting up microphones to record a choir is aware that poor positioning of the equipment will be detrimental to the balance of the sound. It may be supposed that the therapist is in a key position to synthesize all the voices but may not be empowered to make the most effective judgements even when these are indicated by best practice. The voice of an administrator may carry more volume than that of a client. Policy aimed at large numbers of people may overwhelm the vocalization of need by one individual. The volume of clinical evidence may in some cases produce discordant perspectives of best practice.