3. Theoretical foundations of occupational therapy
Edward A.S. Duncan
The focus of this chapter is on the internal influences that shape the development of occupational therapy. The chapter commences with a historical overview of the foundations of occupational therapy. The wealth and importance of the historical foundations of occupational therapy are not always appreciated. Readers are encouraged not to skip this section (as can often be so tempting), but to read it and reflect on the relevance of the profession’s pioneers for practice today. Having briefly reviewed the biographical and philosophical history of the profession, the chapter continues with an evaluation of the theoretical influences that have shaped the profession. The chapter then progresses to describe and evaluate contemporary approaches to knowledge development within the profession.
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• provides a historical context to the development of occupational therapy
• gives a clear introduction to the central paradigm shifts that have occurred through the development of occupational therapy
• highlights the importance of using knowledge exchange mechanisms to ensure the rapid transfer of knowledge between research and practice
• provides an introduction to the concepts of complexity, complex interventions and complexity theory.
The only way of knowing where we are going is knowing where we have come from.
As discussed in Chapter 1, the historical basis for health through occupation can be traced back to the biblical times of the Old Testament and the Classical period of the Ancient Greeks and Romans (Wilcock 2001b). The focus of occupation in health came to the fore in Western society, however, during the development of Moral Treatment (p.74), which is recognized as providing a central philosophical basis for occupational therapy. The facts that occupational therapy has both a philosophical and a theoretical basis and that the philosophical basis came first place it in a unique position amongst health professionals (Schwartz 1994). Understanding this historical basis helps us to understand the tensions occupational therapists may perceive when they share their view of a person with other professionals, who view the person from a completely different philosophical perspective.
Occupational therapy, as we know it today, emerged at the beginning of the 20th century. Whilst occupation programmes are known to have been developed from the very beginning of the 20th century (Wilcock 2001a), it was in 1917 that the National Society for the Promotion of Occupational Therapy (which later became the American Occupational Therapy Association) was founded (Schwartz 1994). This group was formed by several individuals who came from various professional backgrounds:
• William Rush Dunton — a psychiatrist
• George Edward Barton and Thomas Bessell Kidner — architects
• Eleanor Clarke Slagle — social service background
• Susan Cox Johnson — a teacher of arts and crafts
• Susan Tracy — a nurse (Schwartz 1994).
The broad nature of the professional backgrounds is noteworthy. This group of individuals had a significant impact on the early conceptualization of occupational therapy. Their individual contributions to the field are not of particular interest in this text, however, and the interested reader is directed to other publications that have described this group in great depth (Schwartz 1994).
Another individual who had a significant impact on the transatlantic development of occupational therapy was Dr Adolf Meyer. Meyer (1866–1950) was born in Switzerland but spent the majority of his professional career in the USA, eventually as the director of the Johns Hopkins University Medical School. Meyer can be looked upon as the father of American psychiatry. Meyer visited the UK on several occasions and acknowledged the impact that these visits had on his development when he expressed ‘a real personal indebtedness to British medicine and British Psychiatry’, p.435. Perhaps one of the most influential of these visits was his first. Whilst on a travelling scholarship, Meyer attended a conference in Edinburgh at which he heard William James, the American pragmatist philosopher and psychologist, give a talk.
Meyer described himself as a ‘mental hygienist’ and assisted in the foundation of the (American) National Committee of Mental Hygiene (Wilcock 2001a). The mental hygiene movement held the following objectives:
• to work for the conservation of mental health
• to promote the study of mental disorders and mental effects in all their forms and relations
• to obtain and disseminate reliable data concerning them
• to help raise the standard of care and treatment (Henderson 1923).
These apparently philanthropic aims are, however, tainted by an aspect of Meyer’s life that is less well known and has had little mention in occupational therapy literature. Meyer, like many others involved in the Mental Hygiene movement, was also a proponent of Eugenics. Eugenics is the proposed improvement of the human species by encouraging or permitting reproduction of only those individuals with genetic characteristics judged desirable. The Mental Hygiene movement was permeated with Eugenic thought, a philosophy most notoriously and extremely supported by the Nazis during the Second World War. From Meyer’s perspective, Eugenics provided an opportunity to eradicate mental illness through the prevention of reproduction by people with mental illness. It has since been broadly discredited. Eugenic organizations do, however, continue to the present day and Meyer’s membership and espousal of such a philosophy provides a different perspective of the man who is credited as providing the first conceptual model of occupational therapy (Meyer, 1922 and Reed and Sanderson, 1999).
During his career, Meyer recognized the impact of instincts, habits and interests, as well as experiences on people’s lives and because of this developed an interest in the impact of occupation with his patients (Wilcock 2001a). Indeed, such was his interest in the impact of occupation that he employed Eleanor Clarke Slagle, following her early occupational therapy training. During this period, Dr David Henderson, a young graduate from Scotland, came to work with Meyer. Henderson saw Slagle’s work within the institution and was impressed by the impact she had on the patients with whom she worked (Wilcock 2001a). On his return to Scotland, it was Dr Henderson, inspired by the time he had spent with Meyer and Slagle, who opened the first occupational therapy department in the UK, at Gartnavel Royal Hospital, Glasgow, in 1919. In 1922, the first ‘occupational therapist’, Dorothea Robertson, was appointed within the same department.
Whilst Dr Henderson was the first individual to introduce occupational therapy to the UK and Dorothea Robertson the first appointed occupational therapist, two other key figures require presentation if we are to understand more fully the introduction of occupational therapy within the UK; they are Margaret Barr Fulton and Elizabeth Casson. Margaret Fulton was the first qualified occupational therapist in the UK. Born in Scotland and raised in England, Margaret Fulton trained to become an occupational therapist whilst in the USA. On her return she was put in contact with Dr Henderson; however, as he was unable to appoint, she was employed by the Aberdeen Royal Asylum. Whilst Margaret Fulton did not write or present a great deal on her philosophy of practice, her work stood out and gained her high office. In 1937, whilst working in Aberdeen, she met Alfred Adler, one-time colleague of Sigmund Freud and founder of Individual Psychology (Wilcock 2001a). He was later to comment, ‘I was particularly struck with the Occupational Therapy department and with the high degree of interest which is shown in psychological problems’ (Aberdeen Press and Journal 1937). Fulton’s capabilities are also apparent in her election to the position of first president of the World Federation of Occupational Therapists (Wilcock 2001a).
Another key British founder of occupational therapy is Elizabeth Casson. Born in 1881, Elizabeth was brought up amongst a family of varied artistic talents, so it is not surprising that the young Elizabeth was noted to be good with her hands, demonstrating practical as well as academic talents (Wilcock 2001a). Following an initial period of secretarial work, Casson worked with Octavia Hill (1838–1912), a remarkable women who is credited with the foundation of several organizations and professions, including the Open Space Movement, the National Trust, housing management and social work (Wilcock 2001b). Hill is believed to have had a considerable effect on Casson during their period together at the Red Cross Hall, where Hill employed Casson as a secretary (Wilcock 2001a). Casson became very involved in the practical activities of the tenants, for whom she organized a variety of educational and recreational activities. Casson then surprised those closest to her by announcing to everyone that she intended to study medicine. Graduating in 1929 as the first female doctor from the University of Bristol, Casson herself states that her ‘real introduction’ to occupational therapy came through reading a description of Henderson’s work in Glasgow. Casson’s medical training and intrigue, coupled with her personal and family talents and social commitment, naturally fostered a profound interest in occupational therapy. This interest culminated in her establishment and development of the first British occupational therapy school at Dorset House, Bristol (Wilcock 2001a). Casson’s importance to the development of occupational therapy in Britain today is honoured by the College of Occupational Therapists through the Casson Memorial Lecture, an annual event at the college’s annual conference.
This overview of some of the historical developments of occupational therapy is provided to demonstrate the very real connections between the external influences on the early development of the profession and the foundations of the profession as we know it today. The history of occupational therapy is a rich tapestry, upon which this text has only fleetingly touched. Interested readers are guided to two fascinating volumes on the subject, from a predominantly British perspective (Wilcock, 2001a and Wilcock, 2001b).
Paradigm shifts in occupational therapy
Having reviewed the philosophical basis and the influential individuals who were responsible for the foundation of the profession, it is important to examine the theoretical developments of occupational therapy. Such developments are perhaps best understood through the concept of paradigms and paradigm shifts. Kuhn (1970) understood that members of a profession were bound by a shared vision of what it meant to be. Paradigms represent the shared consensus regarding the most fundamental beliefs of a profession. Paradigm shifts, therefore, are the moments in which the shared vision and understanding of a field changes and a new consensus regarding the fundamental beliefs of the profession is adopted. Understandably, as paradigms represent the core of a profession, such shifts are both rare and traumatic to the field. The concept of paradigms has been developed by a variety of individuals, including Tornebohm, 1986 and MacIntyre, 1980. Tornebohm (1986) views a profession’s paradigm as the defining feature of a profession and believes that within it can be found a profession’s vision of practice. MacIntyre (1980) argues that paradigms provide professions with their values and concerns for practice.
Within occupational therapy, it is the work of Professor Gary Kielhofner (2009) that is most closely associated with the paradigmatic conceptualization of occupational therapy’s professional development. Kielhofner (2009) develops the work of Kuhn, 1970, Tornebohm, 1986 and MacIntyre, 1980 in his understanding of the paradigmatic content of occupational therapy, and suggests that the occupational therapy paradigm consists of three elements: core constructs, focal viewpoints and integrated values.
‘Core constructs’ of the profession tackles the issues regarding a profession’s service provision. ‘Core constructs’ relate to the need for the profession, the problems it focuses on and the manner in which it addresses such problems. The ‘focal viewpoint’ of a paradigm is interested in the way in which a profession views, understands and interprets the world. The ‘focal viewpoint’ of a profession will also influence the knowledge that is deemed important within the profession. Finally, ‘values’ highlight the level of importance that a profession places on issues from its own perspective (Kielhofner 2004a).
Kielhofner (2009) outlines three different paradigms that have existed in occupational therapy since its inception (Table 3.1): the occupational paradigm, the mechanistic paradigm and the contemporary paradigm. The original paradigm (the occupational paradigm) arose from the work of the profession’s founders and was based on their core construct, views and values. During the 1940s and 1950s, occupational therapy was placed under increasing pressure from the medical profession to become objective and create an empirical basis for its intervention (Kielhofner 2004a). In search of professional acceptance, occupational therapy increasingly focused on biomedical explanations for practice; thus the mechanistic paradigm period of occupational therapy was born. During the mechanistic period, occupational therapists become increasingly competent at measuring and attempting to objectify their practice. However, such developments caused the profession to lose sight of its roots and the original impetus for the profession’s birth. The initial call for the profession to return to its original vision came from Mary Reilly, a highly influential scholar in the history of modern occupational therapy (Kielhofner 2004a). Reilly’s original call for the return of occupational therapy’s focus on occupation came in her Eleanor Clarke Slagle Lecture in 1961. During this keynote speech to the annual conference of the American Occupational Therapy Association, she gave a poetic (but from our current perspective completely un-evidence-based) vision of the impact of occupation on health, stating that ‘man through the use of his hands, as they are energized by his mind and will, can influence the state of his own health’ (Reilly 1962, p.1). Through this clarion call to the profession, a new crisis emerged as practitioners sought to return once again to being occupationally focused, whilst retaining the developments in objectivity and professional status they had gained during the mechanistic period. The return to occupation heralded the contemporary paradigm, in which occupation is understood in a new and more complex manner and the importance of occupation in health has once again been established.
|The nature of paradigms||Core constructs||Focal viewpoint||Integrated values|
|Paradigm of occupation (1900s–1940s)||Occupation is essential to life and influences people’s health|
Occupation includes thinking, acting and existing, and requires each of these elements to be balanced in daily life
Mind and body are intrinsically linked
Occupation can be used to regain function
|Focusing on both personal motivation and the effect of the environment on performance||Human dignity is realized through performance of occupation|
Occupation is important for health
|Crisis||Occupational therapy is placed under increasing pressure from medicine to become objective|
Occupational therapy seeks professional recognition through the adoption of biomedical explanations and approaches to dysfunction
|Mechanistic paradigm (1960s–1970s)||Performance is dependent on the functioning of inner systems: intra-psychic, nervous and musculoskeletal|
Damage to any of the above systems causes dysfunction
Functional performance is regained through addressing or compensating for deficits in these systems
|This period focused on the internal mechanisms described in the above core constructs||In-depth knowledge of inner systems|
Use of occupation to address and measure disordered inner systems precisely
|Crisis||The acceptance of reductionism and focus on inner systems were recognized as incomplete|
Prominent occupational therapy figures called for a return to occupation, with a focus on the importance of occupation to health
|Contemporary paradigm (1980s onwards)||Occupation has a central role in human life. It provides motive and meaning to life|
Lack of access (or restricted access) to occupations may have a negative effect on health and quality of life
The use of occupation to address impacts on health or quality of life is the core of occupational therapy
|This person focuses on a return to occupation and a focus on the whole, rather than its component parts||Respect for the value of human life|
The importance of individuals’ empowerment and engagement in occupation
The integration of individuals into life through meaningful occupation
Professional paradigms are dynamic in nature. Whilst whole-scale paradigm shifts are relatively rare, occupational therapy is constantly evolving and developing. This process, whilst perhaps not quite as traumatic as a paradigm shift, can none the less be painful and challenging. Contemporary debates regarding approaches to theoretical development within occupational therapy constitute one such challenge. Whilst the contemporary paradigm is not being questioned, the manner in which knowledge is developed to support the paradigm undoubtedly is. Wilcock (1998) recognized at an early stage that the developing complexity of occupational therapy theory would lead to ‘heated debate’ between professionals (p.203). Despite acknowledging that ‘heated debate about the profession’s foundation is not part of occupational therapists’ tradition’ (p.203), she felt that such debate was important and would ultimately benefit the profession. This position is supported by Bannigan (2001), who also recognized occupational therapists’ reluctance to argue but supports the requirement of professional argument in order to develop a robust knowledge base and pursue excellence in practice.
Theoretical developments within occupational therapy
Possibly the first elucidation of the theoretical (as opposed to the philosophical) basis of occupational therapy was in 1940, with the publication of a text entitled Theory of Occupational Therapy for Students and Nurses (Haworth & Macdonald 1940). Whilst theoretical developments have emerged throughout each of the profession’s paradigms, it is during the period of the contemporary paradigm that occupational therapy research and theoretical developments have truly gathered pace. These developments are the natural evolution from the paradigm of occupation that has now emerged and established itself as the central focus of occupational therapists’ concern (Kielhofner 2004a).
Theory is a term that is readily used in our everyday conversations (for example, ‘In theory I could do this but …); however, within occupational therapy, theoretical approaches are not always as easily articulated. Mitcham (2003) describes a scenario that will be recognized by many students and practitioners. Discussing the complexity of theory in practice, she states:
we panic when a keen, bright eyed student asks us in the clinic one day, ‘which theoretical approach guides your practice?’ We stumble and mumble a response along the lines of, ‘Oh, I haven’t touched that theory stuff since I graduated’, or ‘I’m eclectic, I use a little of everything’. (p.65)
Such a scenario is commonly recounted by students undertaking fieldwork placements. Whilst the reasons for a practitioner’s inability to justify their practice theoretically may be various, such a response in effect perpetuates the theory–practice divide and suggests to the practitioners of the future that theory is not important in practice. This is not the case and the aim of this text is to demonstrate the importance of theory to practice, to assist students and practitioners to make sense of theory in practice, and to develop understanding of how theory can be developed and implemented in practice.
So, what is theory?Reed (1997) defines it as ‘an organized way of thinking about given phenomena … It attempts to:
• Define and explain the relationships between concepts or ideas related to phenomena of interest;
• Explain how these relationships can predict behaviour or events; and
• Suggest ways that phenomena can be changed or controlled’ (p.521).
Kielhofner (2009) offers another definition, stating that theory is ‘A network of explanations that provides concepts that label and describe phenomena and postulates that specify relationships between concepts’ (p.8).
Creek (2002) defines theory as a ‘conceptual system or framework used to organize knowledge. A theory consists of a description of a set of phenomena, an explanation of how and under what circumstances they occur, and a demonstration of how they relate to each other’ (p.46).
Various definitions of theory have been offered and agreement is clear between authors cited.
Theory and practice
The relationship of theory to practice varies in different professions. Radiology, for example, draws heavily upon knowledge that has been developed in the fields of chemistry, physics, anatomy and physiology. Radiology places less emphasis on the social sciences than occupational therapy. Furthermore, unlike occupational therapy, radiology has not developed its own theoretical understandings to guide practice. Each of these issues can help us understand why some professions do not appear to have a theory–practice dilemma, whilst others, such as occupational therapy, do (Mitcham 2003).
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