The great promise of occupational therapy, to enable people from all walks of life to engage/participate in activities and processes that have value, is simple yet profoundly complex and challenging to fulfil for the diverse clientele that typifies an increasingly global, postmodern world (Iwama 2007). Occupational therapists the world over have been challenged to provide occupational therapy that is relevant and responsive to the day-to-day realities of their diverse clientele. An examination of current occupational therapy models reveals that the values and meanings of occupation, like other socially situated constructs, have been ascribed mainly by people situated in the English-speaking Western world, who have a common context of shared experiences (Iwama, 2006 and Lim, 2008a). The meanings of human occupations are uniquely tied to socio-cultural contexts, varying from group to group, from person to person and from situation to situation. Given this degree of diversity and cultural relativity in occupation’s fundamental meaning, a single or universal interpretation of this core construct of occupational therapy is virtually impossible to maintain. How, then, will specific conceptual models in occupational therapy, largely constructed on such universal premises, explain, describe and guide occupational therapy approaches and processes for a diverse clientele in diverse contexts? How well do the learned and tacitly held ideas that essentially reflect middle-class, middle-North American and Western European ideals of self-determinism, competence, individual agency and autonomy explain the day-to-day realities and meanings of occupation for clients that do not fit these socio-cultural ideals?

Though many aspects of contemporary occupational therapy and its locations of practice have aligned with biomedicine, diehard occupational therapists have endeavoured to keep occupational therapy focused on occupation, preferring to shift occupational therapy’s focus and location of practice into the realm of clients’ day-to-day living issues and experiences (Iwama 2005a). Instead of focusing on pathology, symptoms and functional limitations, occupational therapists have maintained an interest in and focus on the consequences of these medically defined factors, on the day-to-day circumstances and needs of a diverse clientele. This is where the power of occupational therapy lies: in the relevance to the client’s day-to-day circumstances to enable people from all walks of life to engage and participate in activities and processes that have personal meaning and value (Lim & Iwama 2006).

Occupation-based occupational therapy is challenging to deliver, especially when diversity and cultural relativity are brought into the equation. Cultural variation and the challenges of diversity were not such strong concerns for the pioneering occupational therapy scholars when they first embarked upon constructing their practice models. Theoretical materials created in the past century in occupational therapy and rehabilitation appear to have been largely constructed on the premise of a relatively homogeneous clientele, whereby a one-size-fits-all worldview or single framework seeks to explain the experience of human occupation and occupational therapy practice for all (Iwama, 2005a and Lim, 2008b). What may work well for clients whose experiences fall within minor deviations from the norm/mean for a particular conceptual phenomenon may possess limitations for those ‘other’ clients who stand as outliers in the demographic mean curve, who may be either excluded or disadvantaged by the same standard. What happens when norms and imperatives of autonomy, personal causation and self-determinism are also foisted on to ‘outlier’ clients who come from a sphere of shared learning and experience that idealizes dependency, group harmony and collective determinism? How does the single-parent client of four young children, a young man with mental illness, and others who have survived circumstances of abject poverty and social marginalization relate to occupational therapy’s middle-class, Western principles and ideals of competence, self-agency and self-reliance (Walley Hammell and Carpenter, 2004 and Iwama, 2006)?

Delivering an occupation-based service for a diverse client population that makes sense of the value of activities and processes of daily life (occupation) in unique and diverse ways remains a daunting task for occupational therapists. Catering to the uniqueness of each client’s day-to-day occupational issues is difficult to enact when conventional theory and the approaches that this theory guides and explains are based on a questionable premise of homogeneity of clientele, their needs and universality of a given occupational therapy model.

Culture is more than individual-embodied features of ethnicity and race. It is broadly defined here as spheres of shared experience and the ascription of meaning to phenomena and objects in the world (Iwama, 2007 and Lim, 2008a). A broader definition that takes in social context qualifies the profession of occupational therapy as a sphere of shared experience, or cultural entity, as much as ‘Western’ or ‘Japanese’ might. Occupational therapy has its own unique sphere of shared experiences, a developing specialized language, tacit rules of professional conduct and acceptable rules for knowledge production, including theory development. For many occupational therapists, the cultural features and imperatives buried within conventional occupational therapy theory may go problematically unnoticed (Iwama 2005a). The preference for individual-centric views of daily life occupations, the imperatives of autonomy and independence in daily living skills and de-emphases on contexts that shape occupational meanings are often taken for granted and accepted as ‘normal’ — especially by those who have shared experiences in Western contexts of daily living (Lim 2008b). Unwittingly, occupational therapists find themselves enquiring about and filtering clients’ unique and rich narratives of their daily living contexts and circumstances through predetermined (and often sophisticated) concepts and principles belonging to someone else’s (unfamiliar) world view and interpretation of human occupation. Problems are identified and plans for intervention are then determined that can potentially stray or diverge from what the client actually regards to be meaningful, valued, worth knowing and worth doing. Often, the ideals of client-centred occupational therapy do not extend far enough into the rich, contextual cultural world of the client (Iwama, 2005c and Lim, 2006).

For many occupational therapists and their clients who fall outside of such mainstream cultural norms, universal models that have risen out of a dominant mainstream culture, infused with its own tacit standards and ideals of what is considered ‘normal’, ‘acceptable’ and ‘good’, can be regarded in some instances as being culturally unsafe (Lim & Iwama 2006). Ramsden (1990) highlights the importance and principles of cultural safety: a framework by which power relationships between health professionals and the peoples they serve are critically considered. The impact of historical, social and political processes on minority health groups holds important implications for equity wherever health issues of a particular group are being described, explained, mediated and evaluated by other people within their own standards (Jungerson 1992). This idea of cultural safety is especially pertinent to occupational therapists when taking their ideas and processes into new cultural domains, including into the lives of their diverse clients and contexts (Gray and McPherson, 2005 and Iwama, 2006). Often the recipients may be in weaker, disadvantaged positions and are discriminated against further by being compared and evaluated against standards and norms belonging to a different cultural context (Lim, 2005 and Lim, 2008a). Further, they may also lack the experience, knowledge and means to examine critically the veracity, utility and cultural safety of the procedures and materials imposed upon them.

There are also relevant issues of cultural safety in the interface between theory construction and theory application. When critical questions are asked about where the ideas have come from, on what realities these materials and ideas have been based, and who has participated in the production of such knowledge, valuable insight is gained into the cultural features of the epistemology and theory of a profession. Theories and models, often developed in academic settings, can be far removed from the very people, situated in diverse, dynamic and changing practice contexts, for whom these theoretical materials and models are universally intended and considered appropriate (Lim & Iwama 2006).

Reconfiguring client-centred practice may be difficult for both the seasoned therapist and conditioned client to come to terms with, as the current way of top-down delivery of occupational therapy often privileges the professional as ‘knowing best’ and the client submitting to the role of ‘patient’. The reliance on certain (universal) frameworks and the standardized tests that reify and accompany them can take some of the guesswork out of professional decision-making and enhance the efficiency of occupational therapy processes, but the occupational therapist must ultimately understand whether the client and their ‘story’ of day-to-day living and circumstances are being comprehended and that the ensuing occupational therapy is being truly client-centred and based on factors that are meaningful to the client.

Occupational therapists stand to benefit from theory, instruments, methods and approaches that enable clients to translate their real experiences of daily living into the therapeutic process, to form the basis on which occupational therapy is fashioned. Ideally, the client’s ‘story’ of their day-to-day occupational issues, constructed and told by the client, in their own words, ought to be enabled and centralized to form the basis to the occupational therapy process (Lim & Iwama 2007). Achieving this to any degree is not an easy or a simple undertaking, for it involves a series of difficult transitions for the professional therapist. Firstly, a change in power relation between the therapist and client is required. The familiar hierarchical power structure of professional and client is upended, and the heterogeneity and diversity of clients and their ‘stories’ become normal. The skills necessary for those engaged in occupational therapy will change from being technical experts capable of delivering standard procedures of assessments and interventions, to health professionals who are able to apply their knowledge and skills effectively according to the unique and diverse clients and their contexts that emerge in each complex therapeutic instance.

Achieving this will move occupational therapy further towards becoming client-centred and more equitable with regard to the power differential that commonly exists in therapeutic relationships, where the occupational therapist is situated as expert and the client is regarded as ‘patient’ (Ramsden, 1990 and Lim, 2005). Rather than forcing and fashioning the client to adapt to some standard requirements of occupational therapy, such an approach requires occupational therapy and occupational therapists to adapt and fashion their occupational therapy to the unique needs and specific requirements of the client. Imagine a process whereby the client ‘names’ the concepts of their occupational therapy model and explains the principles that tie these highly personal concepts together, in which the occupational therapy process is transformed into a collaborative one in which it is bound by the client’s occupational narrative. The client is now (acknowledged and respected as) the ‘expert’ of their own occupational narrative and the therapist becomes a partner or facilitator to enable better life flow.

Such a significant departure from the tacit ways in which theory is normally structured and translated into occupational therapy practice, the empowering of client and their occupational narratives to form the basis of the occupational therapy processes and interventions to follow, represents a revolutionary breakthrough in conventional occupational therapy practice. For conventional practice until now has been to take a set of predetermined concepts and principles that tie these concepts into some plausible, standard narrative and impress these upon the client, assuming that the model was valid and unassailable.

Recently, a group of Japanese occupational therapists, grappling with the issues of incongruent occupational therapy theory and practice forms, embarked on a project that aimed to develop an alternative approach that would transform their occupational therapy and bring it more in line with their client’s day-to-day realities and experiences of disablement (Iwama 2006). The qualitative research processes they engaged in also unearthed the fundamentally overlooked issue of culture, theory construction and practice. These Japanese therapists with the aid of a Canadian therapists endeavoured to develop a conceptual framework that would not impose a universal narrative of occupation on every client but would actually reverse this process and value each client’s unique occupational narrative, reflecting a rich comprehension of the client in the context of their experiences and explanations of day-to-day realities. The qualitative research processes that gave rise to the Kawa Model and its fuller description can be studied in greater detail in The Kawa Model: Culturally Relevant Occupational Therapy (Iwama 2006).

The qualitative research process engaged in by a group of occupational therapists in Japan initially yielded a rather cumbersome, linear representation of their model along conventional, linear box and arrow structures (Fig. 10.1A). At that early stage, it became readily apparent that there were fundamental differences in how self and environment were imagined and represented in established (Western) models and actually lived and experienced by the group participants. For a model purposely to explain self and context, the central placement of a distinctly defined self, adjacent to a separate but distinct environment commonly seen in conventional (Western) models, was non-existent. Further consideration revealed comprehensions of self and environment or context that were more diffuse and inseparably integrated by the Japanese than by their Western counterparts. Consistent with a worldview that imagined self and the world with all of its elements as integrated parts of an all-encompassing whole, phenomena as complex as well-being and disability could not be adequately described and explained by linear diagrams that connect rationally defined categories through logical principles. These Eastern perspectives of wellness and disability states could not be readily contained in and explained by boxes/categories set in a logical sequence, familiarly observable in rational formulae or continua.