2. Theoretical foundations of occupational therapy
Edward A.S. Duncan
This chapter outlines the main external influences on occupational therapy’s theoretical foundation. Philosophy may appear to be a somewhat unrelated subject to the applied nature of occupational therapy; however, in order to gain a comprehensive understanding of occupational therapy theory, it is necessary to gain a conceptual understanding of the impact that various philosophical systems have had upon healthcare in general and occupational therapy in particular. This chapter commences with an overview of what theory is and the main factors that have influenced theoretical developments within occupational therapy. A particular emphasis is placed upon the various shifts that have occurred within occupational therapy’s theoretical foundations over time. In order to understand clearly the various external influences that have shaped and continue to shape the theoretical foundations of occupational therapy, this chapter dedicates a significant proportion of space to understanding the impact that various philosophical systems have had on theory and practice.
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• Occupational therapy’s development has been shaped by the influence of a variety of external philosophical influences.
• This chapter provides an overview of key external influences and how they have shaped the profession.
• The Enlightenment and its consequent influence have led to the development of the evidence-based practice movement.
• Despite its critics, evidence-based practice will remain the dominant force in occupational therapy development over the forthcoming decade and beyond.
What is theory?
The Chambers Dictionary (Schwartz 1994) defines theory as ‘an explanation or system of anything; an exposition of the abstract principles of a science or art’ (p.1795). Despite calls to the contrary (e.g. Ryan 2001), theories, within occupational therapy, are often viewed as being detached from practice. Indeed, until recently, there has been a prevailing tendency to view theories as the activities that a student undertakes whilst in university, whilst practice experience is gained on fieldwork education. Implicit within this split understanding of theory and practice is the idea that theory is unimportant to practice and vice versa. This has led to a theory–practice gap within occupational therapy and other allied health professions (Ryan 2001). This gap is most evident in the difficulties that clinicians have in embedding research in practice (McCluskey & Lovarini 2005). Metcalfe et al (2001) undertook a postal questionnaire study among four allied health professional groups (dietitians, occupational therapists, physiotherapists, and speech and language therapists) within a single English National Health Service (NHS) region; 80% (n=573) of the sample responded. Whilst each group agreed that research (from which sound theory develops) was important, they also highlighted barriers to using such knowledge. These barriers included understanding the literature, insufficient time, inadequate facilities, professional isolation and resistance from colleagues. It is apparent, therefore, that when theory is viewed as a distinct reality from practice, real barriers to their use develop. Such barriers are not simple to overcome. In order to address this issue, theory should grow in and from practice, and be viewed as central to all that it means to be an occupational therapist. It is precisely for this reason that this book places particular emphasis on the clinical application of theories in practice. Each chapter achieves this in a different manner.
Within occupational therapy, the term ‘theory’ has wide usage and meaning. It has been used broadly to discuss theoretical understandings of the profession in general, to refer to broad theories that are not profession-specific (e.g. Freud’s understanding of development), and finally as a term used to identify developments in understanding that are particular to occupational therapy. Kielhofner (2002) states that theory should be viewed as ‘a network of explanations that label and describe phenomena and propositions that specify relationships between concepts. It is important to differentiate theoretical explanations that give a plausible account for how something works from mere description of statements of beliefs or values’ (p.4).
Where do theories come from?
All professions are formed and informed by ideas, explanations and systems that assist individuals and services in understanding and guiding what they are or should be doing. Theoretical ideas develop from a variety of principles, which can include the research and knowledge available at the time, the values, attitudes and ethical basis of the individual(s), and their practical experience of the phenomenon under question. All of these factors can be strongly influenced by the prevailing environmental influences.
Environmental influences on theory development
Professions do not exist in isolation and are therefore open to influence from the pressures and prevailing norms of other professional groups and the environment in which they exist. Occupational therapy, existing predominantly within the health and social fields of society, has been observably influenced by the environmental influences within these settings and the prevailing pressures on professional groupings within these fields. In order to understand the environmental influences that have shaped occupational therapy throughout the ages, it is necessary to take a historical viewpoint of the development of the profession. One may ask how history relates to theory; however, when history is read, it becomes apparent that it is interesting not only for its own sake, but also because it ‘facilitates understanding of contemporary roles and relationships. Just as our sense of personal identity demands roots in the past from family history, our professional identity and understanding of the contexts in which we work are enhanced by knowledge of their development’ (Paterson 1997). Such history, Paterson (1997) continues, illustrates that, whilst early occupational therapy intervention held a humanistic concern for individuals’ well-being, it was consistently accompanied by efforts to build a theoretical understanding about the various processes involved in their work.
When examining the history of occupational therapy, or at least the effect of occupation on health, it is possible to go back as far as biblical and classical periods, where the remedial and health promotional effects of occupation can easily be seen (Wilcock 2001b). Occupation came to the fore of care again in the 19th century, with the development of ‘moral treatment’, although the focus of occupation during this period was perhaps more for economic than therapeutic gain (Wilcock 2001a). Whilst this appears to be a less than positive image of occupational therapy, it is perhaps in the ‘moral treatment’ movement and the vision of William Tuke, a Quaker and key proponent of ‘moral treatment’, that the enduring patient-centred philosophy of occupational therapy can find its roots (Tuke 1813). With the onset of the 20th century and the formal establishment of occupational therapy training within the UK, the environmental effects of medicine and other disciplines upon occupational therapists can be seen more clearly. Such influential effects on theoretical and practice development have been described as ‘paradigmatic shifts’ in the profession’s understanding of the who, what and why of its existence (Kielhofner 2009) (see Chapter 3 for further information).
The influence of philosophy
Further to the external environmental influences that have directly shaped occupational theory and practice, it is also important to note the influence of philosophical perceptions of ‘reality’ and their impact on the development of occupational theory and practice. Philosophy is ‘the pursuit of wisdom or knowledge … the principles underlying any sphere of knowledge’ (Schwartz 1994, p.1280). A basic understanding of the philosophical principles relating to ‘truth’ is important for occupational therapists to attain, as it is from these that the foundational concepts for future theoretical developments discussed in this book emanate. Fundamentally, two concepts exist within the various philosophies that are central to all theoretical understanding: ontology and epistemology. Ontology can be most easily understood as the nature of knowledge, whilst epistemology is the approach taken to knowledge (Hill Bailey 1997). Both are complex. Two fundamental views of nature exist that are important to understand when considering occupational therapy’s theoretical developments: positivism and anti-positivism.
Positivistic and post-positivistic paradigms
Positivism contends that there is an absolute reality, which can be measured, studied and understood, whilst post-positivism has been described as the perspective that an absolute reality can never be understood and may only be approximated (Denzin & Lincoln 2000). Positivism emerged from the thinking of the Enlightenment, an important period of philosophical development during the 17th century in Europe. Since its emergence, positivism has been very influential within medicine and healthcare in general. This influence has assisted in the discovery of cures for many diseases and has had a significant impact on people’s lives (Creek 1997).
Influence of positivist thinking on healthcare and occupational therapy
As discussed above, positivism and the scientific approach are believed to have directly influenced occupational therapy’s willing acceptance of the reductionist period, during which occupational therapists attempted to gain professional credibility through employing medical-type interventions and theoretical concepts that were not necessarily understood through an occupational framework (Pols 2002). Whilst the profession has moved on within itself, it continues to be externally influenced by the positivistic tendencies of healthcare in general. Most recently, this influence can be witnessed through its acceptance of evidence-based practice (EBP).
Evidence-based medicine (as the term was originally known) emerged from the McMaster medical school in Canada during the 1980s (Taylor 2000). However, the origins of the concept can be traced to the mid-19th century and Paris, and to Charles Alexandre Louis, considered a founding father of modern medical statistics (Hadjiliadis 2004). Sackett et al (1996) defined evidence-based medicine as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’ (p.71). Best evidence, in this context, is information that has been researched using quantitative methods such as randomized control trials and meta-analysis, both procedures that embrace the objective/positivistic nature of knowledge. EBP is not, however, a purely objective pursuit. Sackett et al (1996) emphasized that EBP is only part of the clinical decision-making process. Taylor (2000) reinforces this, stating, ‘Evidence is gathered conscientiously but is used judiciously so that the experience of the OT, the needs of the patients/client, the demands of the system and the up to date best evidence are weighed together in order that the best care is given’ (pp.2–3). EBP has proven to be more than a passing trend and its influence is embedded within government healthcare policy and the College of Occupational Therapists’ Code of Ethics (Taylor & Savin-Baden 2001). Despite the original emphasis on individual experience, as outlined in the above quotation from Sackett et al (1996), EBP has well-developed hierarchies of evidence that place greatest importance on objective studies such as meta-analysis and randomized control trials, with least emphasis given to clinical experience. Such studies are not universally accepted as appropriate methods to be used within occupational therapy and their use or potential use has been the subject of great debate within British occupational therapy literature (Bannigan, 2002, Copley, 2002, Hyde, 2002, Hyde, 2004, Legg and Walker, 2002, MacLean and Jones, 2002, Bryant, 2004 and Eva and Paley, 2004). These authors have expressed strong views about the nature of evidence and its potential use or misuse in guiding practitioners’ practice.
Such is the impact of EBP for occupational therapists that it has been described as ‘a contemporary preoccupation’ (Whalley-Hammell 2001). Despite research indicating that the majority of occupational therapists within one particular region of England (South and West) were overwhelmingly in favour of EBP (Curtin 2001), the realization of a fundamentally positivistic philosophy continues to be criticized by some within occupational therapy literature as incongruent with the profession’s values and beliefs (Ballinger & Wiles 2004).
Not everybody agrees with the suppositions of positivistic and post-positivistic thinking. Many theorists view such structures as fundamentally restrictive and ignorant of alternative perspectives. This has led to the development of, amongst others, constructivist, interpretive and critical theory paradigms of nature. The fundamental basis of such approaches is that they propose multiple constructed realities, as different people are likely to experience the world in differing ways. This, in turn, leads to ‘radical scepticism’ regarding the possibilities for knowledge and a belief that research, and consequently theoretical developments, is only an interpretation of multiple realities (Henwood & Nicholson 1996). Anti-positivism is not, therefore, a single set of beliefs, but a set of approaches, each of which places a particular emphasis on the way that people may experience and understand the world. Such theories often appear initially attractive for occupational therapy, as the profession has frequently tried to define itself separately from the more traditional medical positivistic approach to healthcare. However, these philosophical approaches, whilst useful in delivering an alternative perspective of reality, are often unhelpful in a health economic era where finances are often restricted and scarce resources are dedicated to interventions that have a known efficacy (Duncan 2004). There are too many anti-positivistic philosophies to describe in this text and it is suggested that the interested reader should consult the bibliography and beyond for further information. Some anti-positivistic theories are, however, of particular importance or have been increasingly used in occupational therapy research; three of these theories are introduced below as a primer for further reading.
Developed by the German philosopher Edmund Husserl (1859–1938), phenomenology focuses on describing personal experiences and interpreting these experiences for individuals without developing overarching theories of truth (Schwartz 1994). The fundamental theory that forms phenomenology is that ‘meaning can only be understood by those who experience it’ (DePoy & Gitlin 1998). As we each experience life in differing ways, we will each therefore also make sense and find meaning in differing ways. Occupational therapy literature is increasingly influenced by phenomenological thought. This influence stems from its roots in ‘moral treatment’ and the arts and craft movement (Mattingly & Fleming 1994).
From a phenomenological perspective, illness or disease is not viewed simply as a matter of physiological dysfunction, but is understood through the impact that it has on the broader social impact of the person in society (Mattingly & Fleming 1994). Several occupational therapy studies have explicitly used a phenomenological approach in their research (e.g. Grisbrooke, 2003, Henare et al., 2003, Reynolds, 2003 and Paddy et al., 2004).
As occupational therapists are often interested in viewing a person holistically, it is easy to see where phenomenological thought resonates with occupational theory and practice. An interest in the phenomenological approach to engaging with clients naturally leads occupational therapists to encourage clients to discuss their experiences of illness or disability and to develop meaningful life stories. This technique is known as using a narrative approach. A specific occupational therapy assessment has also been developed from this perspective (Kielhofner et al 1998).
Feminism is a global term referring to the advocacy of women’s rights. Fundamentally, feminism can be explored through three perspectives: liberal feminism, which focuses on the impact of socialization into gender roles; radical feminism, which posits that existence within a patriarchal society subordinates women; and Marxist feminism, which focuses on the exploitation of the capitalist class and its consequential effects on women (Hartery & Jones 1998). Occupational therapy’s gender imbalance is believed to have had a considerable impact upon its development and position in society. Wilcock, 2001a and Wilcock, 2001b acknowledges the overwhelming dominance of female occupational therapists during the early years. Whilst this appears to have been initially unquestioned and indeed related to caring roles previously associated with females (e.g. nursing and infant teaching), its potentially negative impact has more recently been considered. Taylor (1995) used a feminist approach to reflect on the impact of being a predominantly female profession. She highlights how occupational therapy has developed under the mantle of medicine, a profession that is dominated by men and is said to espouse the patriarchal values of society (Hugman 1991). Taylor (1995) relates this relationship to the distancing of the profession from its original connections with the arts and crafts movements and consequential move towards objective science. MacWhannell and Blair (1998) continue this theme, stating that:
a recurring issue within occupational therapy literature is a concern with the development of standardised assessment [a consequence of the patriarchal influence]. If the features that draw people to the profession are associated with engaging people in a process that moves towards growth and personal change and are not measurable or directly open to standardised outcome measures, the profession is in a conceptual conundrum. It is torn between one set of values and another. (p.64)
The impact of the profession’s gender imbalance upon occupational therapy’s development is unquestionable; it has affected both the profession’s value base and its position within society. Taking a single stance on the impact of gender on the profession is, however, unlikely to be beneficial in the long term and leaves one open to bias. A non-occupational therapy example of how such bias can affect the theoretical and research basis of a subject is evident in two studies of therapeutic interventions with women who self-harm and are resident in secure units in England. Liebling and Chipchase (1996) describe a therapeutic group intervention for women who self-harm. Instead of taking a cognitive behavioural approach (see Chapter 12), which is widely used with this client group, Liebling and Chipchase (1996) employed feminist group therapy (Burstow 1992). The authors initially used a range of outcome measures, but these were abandoned, apparently because of resistance. Taking a feminist theory perspective, the authors interpreted this as a rejection of control. Low et al (2001), working with the same client group in a similar environment, carried out a similar study using a broadly cognitive behavioural approach. Unlike Liebling and Chipchase, 1996 and Low, 2001 employed a range of psychometric assessments without apparent detrimental impact. This example of differing outcomes based on opposing philosophical foundations highlights the dangers of adhering to one perspective and the impact that this can have on research and practice, without considering one’s own personal biases in influencing the interpretation or outcome of an event.
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