In order to practise effectively, occupational therapists need to have sufficient power to be a credible force in their negotiations and to inspire confidence in those with whom and for whom they are negotiating (Wilcock 1998; see Ch. 7). The central issue is that political skills are essential to demonstrating the relevance of the profession to others with whom therapists are working.

This concern is not just about evidence-based practice or pedigrees in client-centred practice. The ‘allied’ health professional status of occupational therapy presents it with problems (see chapter 5 and chapter 6). Allied to the medical profession in which the male order predominates, occupational therapists are mostly women and so both ‘not-men’ and ‘not-doctors’ (Pollard & Walsh 2000). Occupational therapy is often not well understood by other professionals (Craik et al., 1999, Lloyd et al., 1999a, Lloyd et al., 1999b, Peck and Norman, 1999 and Munoz et al., 2000) and does not have the profile in popular awareness that many of their professional colleagues possess, partly as a consequence of this. The power occupational therapists have as agents of social control in the negotiation of treatment depends upon their professional status, but this is precarious. They can act in ways that are professional-centred rather than client-centred because they are not directly employed by the client but by a state health and social care system or private health system with its own agenda, to which they may feel more obligated (Hammell 2007).

As Hammell (2007, p. 266) argues, occupational therapists are ‘not victims of oppressive institutional practices. We are often complicit’ in their perpetuation. Occupational therapists may chafe about the secondary nature of their ‘allied’ health professional status and its erosion of the position that occupational therapists occupy. But occupational therapists can only take on this issue when they have amassed sufficient evidence to win the contest and demonstrate a capacity to accept the liabilities of clinical consultancy. In the carnivorous world of legal-fee-chasing litigation, these may be dangerous waters.

Accepting the limitations has enabled therapists to remain engaged with clients, propose activities, share knowledge and maintain value as team members (Peck & Norman 1999). Many changes have been driven by policy, such as, in the UK, the introduction of general management under the Thatcher government in 1990 with the introduction of the internal market in the National Health Service (Wilcock 2002) and the introduction of a series of National Service Frameworks or guidelines from the National Institute for Clinical Excellence (Morley et al., 2007 and Stewart, 2007). These have altered the structure and delivery of health services, often translated into a need for cost containment, reduced therapist-client contact, involved the loss of occupational therapy positions in senior management and increased the importance of the multidisciplinary team. These issues can have an adverse effect on the alliances that occupational therapists can establish and ultimately on the power occupational therapists have to negotiate solutions for the benefit of their clients.

Sometimes the multidisciplinary relations in which occupational therapy has been involved are presented as an uneven conflict. Practitioners feel themselves to be a minority, whose identity is threatened by generic pressures (Hughes, 2001, Parker, 2001 and Cook, 2003), especially when their managers come from other professions. There has been much discussion concerning the implications of change and service redesign for occupational therapists; these mostly offer a series of apparently contradictory vignettes and suggest a negative process that therapists have to combat.

The profession has difficulties in promoting itself because its identity and purpose are often unclear. Rebeiro (1998) points to a confused tradition of separating functions out from a view of the whole person, which has prevented focus on occupation as a core component of mental health and has detrimentally affected public awareness of occupational therapy. Craik et al (1999)indicate concerns about the increasing pressure towards genericism contrasted with lack of resources to research core values.

Occupational therapists have been perceived as unskilled, unfocused and filling gaps (Fortune, 2000 and Munoz et al., 2000), with a limited knowledge of medication and crisis intervention that renders them less useful in generic team frameworks (Trysenaar et al 1997). In finding a high degree of convergence between the roles of community occupational therapists and psychiatric nurses, Filson and Kendrick (1997) found that the assessment of activities of daily living was the only area where a significant occupational therapy specialism could be evidenced. Their solution to this was further training for psychiatric nurses, rather than development of occupational therapy. On the other hand, an over-specialization that focuses on one particular area may also be detrimental to the value of professional input, as Fitzpatrick and Presnell (2004) attest in their discussion on the compatibility of occupational therapy with hand therapy. Occupational therapy appears to find itself caught in a paradox: between being too specialized to be regarded as occupational therapy and being insufficiently specialized to be of value. This suggests a further issue of dilution.

Hughes (2001) suggests that the generic nature of community mental health teams both produces the effect of not having the space in which to practise occupational therapy effectively and also puts the activities of daily living skills of the professional worker in potential conflict with the hands-on role of the generic support workers in the team. These dilutions are potentially increased by the need for community teams to work on shift rotas. Therapists may be able to meet a wider range of client needs by working more flexibly (Wigham & Supyk 2001); however, their time may be prioritized for more generic areas of practice when team strength is reduced to offer an out-of-hours service.

In the move from institution to community, occupational therapists are more and more finding themselves working in multidisciplinary teams as the sole representative of their profession (Lloyd et al 1999a). The break-up of unidisciplinary departments has resulted in occupational therapists being managed and supervised by people from other professions with limited managerial knowledge of occupational therapy (Craik et al., 1999, Lloyd et al., 1999a, Lloyd et al., 1999b and Munoz et al., 2000). Peck and Norman (1999) have also highlighted the shorter working experience of most occupational therapists compared to that of workers in other disciplines in mental health settings such as social work and nursing, leading to professional isolation and misunderstandings in community teams. These issues may encourage occupational therapists to avoid conflict and seek consensus in teams, to fit in and be flexible rather than to assert their professional identity. Isolation, loss of career structure and lack of role clarity contribute to increased levels of stress and burn-out amongst therapists (Bassett & Lloyd 2001).

The loss of higher professional staff grades during the 1990s in the UK left the occupational therapist vulnerable to team structures led by managers from other disciplines. Working relationships often depend on the attitudes of line managers and others; for example, in mental health the team psychiatrists play a significant role. Since the latter years of the last century interventions based in medication and psychotherapy have predominated in many areas of practice, because of improvements in medication and continued research (Shorter, 1997, Pringle, 1998 and Burns and Firn, 2002). Although the development of consultant therapy posts in the UK and master’s level entry to professional registration may have begun to address this issue, occupational therapy has not been enabled to evidence itself effectively because it has rarely been able to access adequate research and educational development opportunities (Bannigan, 2001, Bannigan and Duncan, 2001, Illot and White, 2001 and Wilcock, 2002).

For many years there have been insufficient therapists to fill the posts available. Rather than budget for vacancies that cannot be filled, managers under pressure to maximize their use of resources have often responded to a lack of therapists by asking people from other professions to carry out specialist interventions (Stalker et al., 1996 and Wilcock, 2002). If an unqualified ‘activity therapist’ position can be created for a support worker that appears to answer the diversional needs of clients, the need for a scarcely obtainable occupational therapist becomes unclear. Senior staff have been less available to work alongside newly qualified staff, particularly in mental health environments, to the detriment of the experience accessible to their junior colleagues (Morley et al 2007). Occupational therapists continue to be challenged in disseminating a robust and clear understanding of the profession to many of their peers. For example, occupational therapists often find their concerns about the discharge of clients over-ridden by the decisions of others because their opinion is discounted or because they have been unable to argue their case effectively (e.g. Lymbery, 2002 and Atwal and Caldwell, 2003).

These same confusions may feed into the cause and result of deficiencies in education. Mental health in particular has experienced a historic lack of community placements (Trysenaar et al., 1997 and Lloyd et al., 1999a) and good occupational therapy role models for students (Craik and Austin, 2000 and Morley et al., 2007). Unsurprisingly Peck and Norman (1999) suggest that a high turnover of occupational therapists in mental health has contributed to the erosion of posts when specific vacancies have been left unfilled.

Greaves et al (2002, p. 385) point to the ‘consumer-focused value base’ of the profession as a source of occupational therapists’ adaptability and competence. In the medically dominated field of hand therapy it has been suggested that occupational therapists adapt to change and find ways to responding to new challenges, without losing sight of the need to be holistic (Dale et al 2002). Peck and Norman (1999, p. 240) found that occupational therapists were valued by adult community mental health team members for their ‘ambition for service users (e.g. employment)’, ‘therapeutic optimism’ and ‘long-term perspective’, issues that in turn are highlighted as key parts of the practice of occupational therapists in assertive community treatment (Orford, 1999, Auerbach, 2001 and Krupa et al., 2002), along with their ‘therapeutic use of self’ (Burns & Firn 2002, p. 60).

These attributes have led occupational therapists to work in new fields, such as community-based rehabilitation, despite their occasional concerns about the relevance and adequacy of their education (Sakellariou et al., 2006 and Stewart, 2007; see chapter 11, chapter 15, chapter 16, chapter 17 and chapter 18). While some have found it hard to retain their specialist function as multidisciplinary team approaches have demanded more generic working in mental health (Brown et al., 2000 and Cook, 2003), others have found new specialisms emerging in the process of service development, as has been the case for occupational therapy in the expanding economies and social reform contexts of eastern Europe (see chapter 7 and chapter 11).

However, most of these attributes can also be claimed by other professionals, volunteers, carers and clients with whom therapists work. If traditional activities such as woodwork, gardening and socializing show the motivating power of occupation (Mee & Sumsion 2001), these and many of the interventions carried out with clients in community services do not specifically require occupational therapists to ensure they happen. Nor are therapists’ attributes evidence that objectives are being realized, as Greaves et al (2002, p. 385) remark, ‘caution is needed … in presuming that self-efficacy implies task competence’.

Even competence may be misplaced. Therapeutic optimism, long-term perspectives and ambition for service users may not be appropriate if, as Corrigan suggests (2001), the profession is unable objectively to question the basis for its practice. There have been increasing questions about the dominant paradigm of occupation that informs the theoretical base of the profession, a particular view of social responsibility through individual productivity. It has been suggested that occupational therapy has as a consequence encountered difficulties of application in non-Western cultures (Iwama, 2005a, Iwama, 2005b and Odawara, 2005). The self-efficacy of therapists may be harnessed to competence in tasks that are geared to forms of social control and a limited sense of client-centred benefit in which individual clients make progress. However, outside these conditions of compliance the status quo is unchallenged, or else unresolved cultural issues may produce confusion and even detrimental outcomes (Kronenberg and Pollard, 2005a and Hammell, 2007).

This problem of ideology and ethics is a product of the professionalization of the facilitation of occupation. The simplicity of doing is the perennial stumbling block in the case for occupational therapy (Perrin 2001). Occupational therapists themselves have not always placed a high value on domestic activities, while other professionals have consequently been ambivalent about the value of occupational therapy (Hamlin et al., 1992, Pollard and Walsh, 2000, Wilcock, 2002, Hammell, 2004 and Clark, 2007). It is not merely that ‘work lacks scientific kudos’ (Perrin 2001, p. 134) but that, despite all the concerns with the development of occupational therapy’s theoretical models, what a service really needs are people who will encourage clients to take part in activity and can facilitate them in doing so (Burns & Firn 2002).

One answer has been to review generic pressures on professional experiences in the light of an occupation-focused model of practice (Reeves & Summerfield-Mann 2004) but, as Fish (1998) remarks, the theoretical models into which occupational therapists often retreat have little to say about the art of practice, which is evident in many professional transactions concerning the management of clients and clinical interventions (Detweiler and Peyton, 1999 and Peloquin, 2005). Fish and Coles (1998) place the revelation of artistry in practice as a critical process essential to insider practitioner research. They make the point that, despite all the evidence that may be amassed to support intervention, it is the practitioner’s understanding of the process of treatment that is essential to its effectiveness. The practitioner is an inside researcher, embedded in practice, and thus has an advantage over the outside researcher in unpicking the nuances of practice narratives. This applies not only to interventions in clinical settings but also where occupational therapists become involved in community development. To answer the common problems in this field of much official rhetoric but little sustainable involvement (Kapasi, 2006, Lowndes et al., 2006 and O’Brien and Penna, 2007), those involved have to interpret and critically review their experiences in a systematic way (see chapter 7, chapter 10, chapter 15, chapter 16 and chapter 17).

These are just two sides of the 3P triangle (see Ch. 1). The problem described here in terms of professional and personal attributes cannot be resolved by these means alone. Lack of focus, dilution, isolation and erosion are political factors that combine to present both a local and a global problem (since these sources are from many different occupational therapy practices) of the political representation of the profession. It is because of these problems that professional associations themselves (e.g. Pollard et al., 2005, Alsop, 2006, College of Occupational Therapists, 2006, Lawson-Porter and Pollard, 2006a and Lawson-Porter and Pollard, 2006b) are recognizing the need to develop political competences in enabling individual members to be able to represent and assert core values.

However, representing occupational therapy effectively does not just concern well articulated professional narratives of practice or examples of advocacy. The stories of practitioners involve others whose voices do not always emerge except as recounted by the professional – disabled people, their carers and the communities they belong to often do not possess the methodologies required to present evidence in ways that will be understood and exert influence in professional hierarchies (Fine, 1998 and Hammell, 2007). If occupational therapists are to concern themselves with describing their artistry, there is a need to explore and facilitate the articulation of other perspectives as part of the process of empowerment. These, in turn, need to be valued for themselves, not as quaint and curious points of view that, having been accorded a patriarchal (or, perhaps with occupational therapy, maternal and nurturing) smile of encouragement, can be dismissed when the professionals get down to the real business of determining interventions.

The production of professional discourses leads to the imposition of cultural values, to what our colleague Elelwani Ramugondo has called occupational colonization (E L Ramugondo, personal communication, 2007). She explains that occupational colonization refers to the valuing of occupations only when those who represent a dominant group begin to engage in them. This can even lead to some occupations from indigenous people being commodified without benefiting the people from whom these originated. An example is the song ‘The lion sleeps tonight’ in the musical the Lion King. Had it not been for his family pointing out the copyright issues involved, the song would not have rightfully been credited to Solomon Linda. The underlying dynamics in these copyright issues are historical and political, arising from differences in power and the development of one group’s dominance over others. These are political processes. A profession espousing client-centred practice has to listen to the voices of its clients as well as the evidence of professional colleagues. Occupational therapy appears to be caught up in understandings of health and social care that inhibit its full development and the recognition of its interests (see Ch. 1). On one hand it has to accommodate a medical agenda rather than deliver occupation-centred objectives. On the other, the profession sometimes appears reluctant to address gaps in understanding between therapists and clients (Abberley, 1995, Maitra and Erway, 2006 and Hammell, 2007) and ways in which it might be failing to engage with clients’ occupational needs (Stagnitti, 2005 and Hammell, 2007).

Since participation in occupational therapy depends on people feeling that it will meet their needs and that they have a reason to take part in the activities offered, there will always be challenges. Clients do not always want what is in their best interests, cannot always be realistic, articulate, rational (Carr 2001). Cultural and class differences may stand in the way of them being empowered to identify their needs appropriately (Kronenberg 2005; see chapter 16, chapter 17, chapter 18 and chapter 19). There may be significant problems, perhaps due to official doctrines and cultural differences, in identifying ways in which needy groups can be accommodated as clients (Kronenberg 2005; see chapter 10, chapter 16, chapter 17, chapter 18 and chapter 19). Ultimately, however, if occupational therapists do not listen to the voices of the people they are working with and take them into account in the delivery of practice, the profession will cease to be relevant.

The complex and multidisciplinary environments of the institutions and communities in which occupational therapists work evoke tactical questions about picking the right battles and only taking part in conflicts that can be won (Sun Tzu 1998). If occupational therapists take part in conflicts without adequate resources and sufficient evidence, and without the assent of others — for example clients – they can find themselves wasting their energies and, in the long term, damaging their chances of mounting a credible position in subsequent and possibly more significant contests.

Identifying a ‘conflict and cooperation situation’ can in itself be a political issue. The actors who define a problem generally have a stake in determining how it is to be addressed. For example occupational therapists have the power to guide assessment and intervention processes through their choice of practice framework and assessment batteries.

Conflict and cooperation situations can be identified through a narrative strategy. Each situation arises from a particular context. This uniqueness may not fit a systematic formula but depends on lived experiences (Clouston 2003). Such accounts can be termed ‘occupational narratives’ (Kielhofner et al 2002, p. 127), which combine a description of identity with an account of making sense of and interacting in the environment, which includes exchanging stories with other people (see chapter 3, chapter 14 and chapter 20). The therapist might ask ‘What is the story?’ and thereby combine narrative and political reasoning:

It should be noted that, in the analysis of the story, the questions employed here are concerned with revealing the critical qualities of experiences and perceptions and can be worked alongside the ‘3P archaeology’ and ‘pADL’ processes identified in Ch. 1. There is no linguistic ascent into technical terms for, as Fish (1998) points out, discussion has to be open and enabling, rather than elevated to a theoretical and exclusive discourse to which some of the participants do not have access (see Ch. 6).

The points of conflict and cooperation that emerge can be ranged on a scale. At the cooperation end of the axis there is no conflict but it is unlikely that this point will be achieved. At the other end of the axis there is full conflict but, even where this is so, the possibility of cooperation is not fully excluded; as a rule war is expensive and exhausts the combatants to the point where eventually they have to seek peace (Sun Tzu 1998).

What we usually observe is not conflict or cooperation but conflict and cooperation. Actors can cooperate in some areas and conflict in others (Kronenberg & Pollard 2005a). Separating out individual elements carries a danger that they are not seen as a whole process. An effective politician manages both conflict and cooperation strategies in simultaneous fields with the same actors, like foreign policy. A foreign minister can rattle sabres against another country but still act to maintain a trading relationship and joint interests in a federation with other actors. The same applies to individuals and the groups to which they belong. For example, occupational therapists working in different departments within a hospital have alliances with occupational therapists and also with the departments in which they work relating to different fields of health and social care. This can be overlaid with their patterns of social relationships with colleagues, particular interests in areas of practice and other possible affiliations such as membership of professional groups within their main professional body or different health unions, membership of course cohorts, peer supervision groups, and so on. This is of course in addition to other aspects of their social and family life that may not involve work. All answer particular needs in the individual, and in the heavily gendered context of occupational therapy are incorporated into strategies that Wicks and Whiteford (2005, p. 210) have referred to as ‘women’s ways of doing’, because social restrictions acting on these complexities generally affect women differently from men. They may also affect men who work in occupational therapy environments in similar ways to their female colleagues because the surrounding conditions impacting on the profession arise in part from the gendered nature of the allied health professional career structure (Pollard and Walsh, 2000 and Meade et al., 2005).

Throughout its history occupational therapy has responded to changing demands in health and social care systems with many new ideas and innovative practices. This book is part of a recent re-examination and reconceptualization of occupational therapy to recognize a broader, global and social responsibility and acknowledge a need for the profession to realize the goals of occupational justice by addressing inequality and poverty (Pollard et al 2005; see Introduction, chapter 1 and chapter 7).

This re-examination is at the forefront of the strategies of many occupational therapy professional associations. It is recognized that for occupational therapists to meet the challenges of poverty and inequality they need to build on their abilities in working cooperatively and in partnership with communities. Effective occupational therapy depends on gaining acceptance and permission to practise and to offer responses to the needs of local populations. This is a problem of aspect politics in that it requires skills in negotiation and the ability to work with actors across social and political power structures. ‘Politics’ and ‘political’ in this discussion are not about party politics, although an awareness and recognition of party differences is often important (see Ch. 1). Occupational therapists require political competencies to work with problems arising from the social, political, economic and environmental contexts in which they work. An effective occupational therapy needs to:

Historically, occupational therapists in some countries have had periods of political engagement (Thibeault, 2002, Wilcock, 2002 and Barros et al., 2005; see Ch. 7) but this has not often been sustained. Perhaps as a consequence many practitioners have not appeared to appreciate the political nature or importance of occupational therapy (Kronenberg & Pollard 2005a; see chapter 5 and chapter 7). However, its engagement with enablement, advocacy and social reform underpins the development of occupational therapy as an agency for social change and as a form of intervention that has the capability to address complexity (Creek, 2003 and Whiteford et al., 2005). It has been argued that occupational therapy could be more valued in the community base, and to realize this practitioners need to increase activity and networking in the community to find and engage with their clients (Wilcock, 1998, Whiteford, 2000, Creek, 2003 and Scriven and Atwal, 2004).

Occupational therapists have been lamenting their position for many years, bemoaning the lack of research and evidence, the poverty of resources allocated to smaller professions (Wilcock 2002). The authors of these articles, including ourselves (Pollard 2002a), have seen the way forward as calling for more research, but this is not the only way of raising awareness (Kronenberg & Pollard 2006). One of the difficulties the profession has also had to confront is the relatively low profile of occupational therapy as a career. Compared to physiotherapy and nursing, for example, it is not as widely known to school children or their career advisors (Craik et al., 2001, Royeen et al., 2001 and Greenwood et al., 2005; see Ch. 5). Popular culture has been important in this; television dramas in hospital settings and a subgenre of romantic fiction, for example the Sue Barton novels of Helen Doyle Boylston (Philips 1999), emphasize nursing and medicine (Hockenberry 2006).

Human occupation is such a ubiquitous aspect of society that it is perhaps taken for granted and becomes a matter of common sense that is difficult to objectify from a lay perspective (Hockenberry 2006). It lacks the tension of life-and-death drama, of traumatic events that enable people to make neat narrative resolutions in time for the news programme. Assessment and treatment approaches have not, in the main, lent themselves to more than bit parts in fiction.

Occupational therapists often use their own stories to negotiate and work out with people what their needs are and how they can be met. This facility, enshrined in a professional versatility, produces problems in the professional context of demands for generic working. Occupational therapists are often managed by other professionals or are allocated referrals by other professionals and work for opportunities to develop their role rather than their role being clearly understood. This can have the effect that work with a client develops along occupational therapy lines, or has an occupational therapy flavour, rather than the client having been given a specific occupational therapy referral. Therapists may sometimes find themselves taking on referrals in order to have a role and through it to demonstrate the value of occupational therapy (Cook 2003).

This can be a positive strategy that provides opportunities to discover the occupational potential of people who perhaps have not responded to other approaches, or to find new ways of developing a rapport from which to negotiate intervention. There are both problems and advantages in this issue. Some occupational therapists have argued for a long time that they cannot engage in every aspect of human occupation, such as, for example, many of the issues connected with sex, politics and religion (Kielhofner, 1993, Couldrick, 2005 and Pollard and Sakellariou, 2007; see chapter 5, chapter 6 and chapter 21). Occupational therapists have to concentrate their energies or dissipate their effectiveness and even risk burnout, or missing priorities, for being concerned with tangential issues (Brown et al., 2000, Fortune, 2000, Morley et al., 2007 and Stewart, 2007).