Skills for a diverse practice of occupational therapy

This paper was presented at the 2nd National Conference for Occupational Therapists working in Diverse Settings, at the University of Brighton, UK (6th September 2017).

The profession of occupational therapy was founded over a hundred years ago by small groups of people concerned about the inadequacy of treatment for people with long-term conditions, such as psychiatric disorders and physical disability. The first qualified occupational therapists provided practical activities for people in asylums for the mentally ill, sanatoria for people with tuberculosis, military hospitals and curative workshops for soldiers injured in the first and second World Wars (Paterson 2010). These early practitioners were energised by their beliefs in: people’s capacity to promote and maintain their own health through occupation (Meyer 1922/1977), and in the power of occupation to engage interest and build self-esteem (Haworth and Macdonald, 1946).

Occupational therapists in the UK worked in settings that were dominated by the medical profession and, as a result, the developing theory base of occupational therapy was strongly influenced by biomedical theory. For example, a British occupational therapy textbook from the middle of the century asserted that:

'the development of rehabilitation by occupation could only follow the progress of the sciences which contribute to all forms of medical treatment. Those particularly relevant to occupational therapy are anatomy, physiology, psychology and pathology; mathematics and mechanics' (Haworth and MacDonald, 1946 p.3)

From the late 1940s onwards, occupational therapy practitioners embraced a biomedical approach to rehabilitation and the educational curriculum moved away from ‘teaching the application of occupations such as arts and crafts, work and self-care tasks, to the healing, rehabilitation and adaptation of persons with disabilities’ (Cole, 2010, p.78) in favour of teaching biological sciences, developmental theory, physical medicine, psychiatry, psychology and sociology (Creek 2002).

In the early 21st century, patterns of employment for occupational therapists in the UK are in the process of adapting to changing economic circumstances, emerging social and health care needs and developing public expectations of what health and social care services should provide. In order to support this evolution, it is necessary for the profession to devise new approaches and develop new theories to support a more diverse practice.

This paper begins with an account of the development of occupational therapy in the first half of the 20th century, showing how one of the major influences on the new profession was a concern with social justice. It then argues that our theory and practice were reshaped during the second half of the 20th century by occupational therapy’s close alliance with medicine. In the changing world of the early 21st century, occupational therapists are reconsidering our professional role and purpose, both of which are expanding and diversifying in response to emerging social and health needs. The paper identifies the personal attributes, knowledge and skills that occupational therapists draw on when working in non-traditional settings, highlighting the importance of developing a broad range of thinking skills. It concludes that practice in diverse settings is driving innovation and creativity in occupational therapy.

The generation of occupational therapists who trained in the 1960s were taught and supervised by the women who established the profession in the UK, 40 years earlier. The photograph shows Margaret Barr Fulton, the first qualified occupational therapist to practise in Britain, who began her career in 1925, at the Aberdeen Royal Asylum. She is presenting their diplomas to the first cohort of occupational therapists to graduate in Aberdeen, from the Grampian School of Occupational Therapy. In the background, you can see Jennifer Creek, the author of this paper. This direct link between the first occupational therapists and those who started work in the 1950s and 1960s meant that, although we worked in established departments within health and social services, our practice and ways of thinking were informed by the beliefs and values on which the profession was founded.

Occupational therapy emerged from a number of social movements in Great Britain and the United States of America in the late nineteenth and early twentieth centuries, including the arts and crafts movement and the Settlement House movement. These social experiments sought to improve the lives of people who were marginalised in society, such as: the urban poor, immigrants, women and those with mental illness. The Settlement House movement is described here as an example, showing how it contributed to the development of occupational therapy.

The Settlement House movement was started by two philanthropists, Samuel and Henrietta Barnett. In 1884, they founded Toynbee Hall to offer amenities, education and guidance to people living in impoverished urban areas (Darley 2010). The Women's University Settlement was established in 1889, to ‘promote the welfare of the poorer districts of London, more especially of the women and children, by devising and advancing schemes which tend to elevate them, and by giving them additional opportunities in education and recreation’ (Blackfriars Settlement). The movement quickly spread to the USA, where Hull House Settlement was established in Chicago in 1889, with the intention ‘to integrate new immigrants into American society’ (Paterson 2010, p. 7) and ‘… to provide a centre for the higher civic and social life, to institute and maintain educational and philanthropic enterprises and to investigate and improve the conditions in the industrial districts of Chicago’ (Davis & McCree 1931, quoted in Paterson 2010, p. 7).

One of the social activists connected with Hull House, Julia Lathrop, helped to organise a series of courses for caregivers, which evolved into a social work school: the Chicago School of Civics and Philanthropy. In 1908, Lathrop contributed to setting up a six-week training course at the School: Occupations for attendants in mental institutions (Hopkins 1978). One of the social work students, Eleanor Clarke Slagle, attended this course in 1911. Four years later, she organised the first professional school for occupational therapists at Hull House, the Favell School of Occupational Therapy (Friedland 2003).

The first generations of occupational therapists, therefore, were confident that they had the skills to work with anyone experiencing constraints on their ability to participate fully in society’ through engagement in a range of socially acceptable occupations. Those occupational therapists who started their training in the 1980s, or later, tend to have a narrower understanding of traditional occupational therapy practice, based on our restricted professional role in statutory health and social care services and on the dominance of biomedical theories in the curriculum.

When the occupational therapist’s role is limited to promoting independence in activities of daily living, enabling safe discharge from hospital or facilitating return to work, we do not draw on the full range of skills developed over nearly a century of practice. In these roles, we are expected to follow pre-designed programmes and pathways that are approved by our managers and colleagues.

The pioneers of the profession had no protocols or established procedures to follow: they were pragmatists who explored different approaches until they found what worked for individual patients in particular situations.

Similarly, occupational therapists who work in emerging roles outside mainstream health and social care services are also pioneers, who cannot depend on universalist theories and models to guide their actions. As more practitioners take up work in these roles, the profession needs to develop more flexible skills and ways of thinking that will serve us across a range of settings and circumstances.

In recent years, austerity economics have led to pressures on health and social care budgets, necessitating cuts in some services and rationing of others. Following the COVID-19 pandemic, these financial pressures are likely to become more acute and to impact on the number and grade of posts available for occupational therapists within statutory services. Already, it is not always possible for universities in the UK to find sufficient student placements in clinical settings, either within or outside of the NHS. Some universities now offer their final year students opportunities to undertake fieldwork placements in non-clinical settings, such as hostels for homeless people, refugee centres, prisons and shelters for abused women (Duncan and Creek 2014, Lawson-Porter 2014). This has contributed to a revived awareness of the potential for occupational therapists to expand our professional role into non-traditional settings, where needs tend to be defined as occupational rather than medical (Creek and Cook 2017).

The changes outlined above are not confined to the UK. Health services around the world, even in affluent countries, struggle to cope with the rising costs of health care and of supporting increasing numbers of people with long-term, complex health conditions. In order to respond to changing patterns of disease and disability, in both developed and developing countries, it is widely accepted that the cost of health care will continue to rise, but it is necessary to ensure that funding is provided for health promotion and disease prevention as well as for acute health services (NMHCS 2009). In developed countries, governments have to balance the cost of routine interventions to promote and maintain health in the general population against demands for expensive treatments to prolong the lives of individuals with serious illness. In developing countries, where budgets for health and social care are much smaller, the focus is necessarily less on highly specialised individual interventions and more on the universal provision of basic services, such as: maternal and child health; health education, and vaccination (UNDP 2014).

While there is pressure on occupational therapy posts within the NHS and local authority social services, employment opportunities are emerging in other settings, for those practitioners who can envisage themselves in roles that are more concerned with occupation and health promotion than with rehabilitation or therapy. Increasing numbers of occupational therapists are finding or creating roles for themselves in, for example, disability prevention (Byrne-Fraser 2014); accident prevention (Hawthornthwaite 2014); the promotion of physical and mental health (Howard 2017, McNulty et al 2017); occupational health (Cookson 2014), and services to keep people out of hospital (McLachlan 2017, Ward 2014). This movement towards a broader understanding of the legitimate domain of concern of occupational therapy is likely to continue to gather momentum, as more recently educated graduates move into teaching and management positions.

A biomedical paradigm is inadequate to support practice in non-traditional settings, where a more open, flexible and responsive approach is needed. The expansion of occupational therapy’s practice domain is putting pressure on universities to move beyond the limited range of reductionist theories and procedural models for practice that have formed the core of educational programmes for several decades. Practice in marginal settings has to be supported by ‘occupational science, with its focus on understanding the nature of occupations and the challenges to participation in occupations’ that people may face (Lawson-Porter 2014, p.178).

In 2014, the author completed a PhD study of occupational therapy on the margins, at Sheffield University. The margins, by definition, exist at a social and/ or physical distance from the centre or mainstream and are characterised by inability to access the support and resources of the centre. The study found that occupational therapists practising on the margins share a number of attitudes, knowledge and skills that enable them to work effectively in resource-poor settings.

Occupational therapists working on the margins have a vision of what they can contribute towards addressing unmet occupational needs that have an adverse effect on health and are neglected by existing services. For example, one of the practitioners in the study set up a landscape gardening business to provide paid employment for repeat offenders when they came out of prison. These occupational therapists find practical ways of translating their vision into action, with and on behalf of the people in need. Professional action is shaped by the attributes, knowledge and skills that occupational therapists bring to their practice.

Personal attributes are the therapist’s individual characteristics, motivations, attitudes and interpretations; such as an ability to think outside the parameters of everyday professional reasoning and a capacity to innovate in practice. The characteristics shared by most practitioners in the study included, to a greater or lesser degree, initiative, perseverance, cognitive flexibility and self-awareness. These characteristics influence how practitioners perceive and react to situations and circumstances.

Attitudes are the therapist’s habitual modes of thinking and feeling, such as having a positive attitude to life or a flexible attitude to work. Interpretations are the constructions or meanings the therapist puts on what she sees or experiences. Examples of attitudes shared by occupational therapists working in non-traditional settings include positivity and willingness to compromise. These therapists tend to frame difficulties in positive ways that leave open possibilities for action, and they see difficulties as problems or challenges rather than as barriers to action. This is shown in the example in Box 1.

Box 1: A positive attitude

The can-do attitude of practitioners working on the margins is exemplified by an occupational therapy lecturer, Lisa, at St Louis University in Missouri. The University has a commitment to social justice and provides an associate degree in Theology for prison staff and prisoners in the state prison. Lisa observed that the working conditions of prison staff are not good and, as a result, the staff have many health problems. She applied for, and was awarded, a grant on workplace health but the prison was not interested in hosting a project. Lisa then took the grant to the city gaol, where she did a participatory survey of warder health issues. As a follow-up to this study, she set up a healthy eating programme for the staff, who work 10-hour shifts. This gave her some leverage within the gaol, which she used to start a transitional programme for prisoners pre- and post-release. The gaol now employs a full-time occupational therapist to work with female prisoners on issues such as finding work, housing and money management. Lisa also got funding to employ a part-time occupational therapist in the community to continue working with prisoners once they are released.

The occupational therapist choosing to work in a non-traditional setting needs more than a vision of what can be done and a positive, can-do attitude. Successful practice on the margins also depends on the therapist having a range of professional, personal, local and cultural knowledge. Professional knowledge is gained from preregistration education, work experience and continuing professional development. Personal knowledge comes from school education, family, friends, personal interests and other life experiences. Knowledge of local conditions and norms is often accumulated during the course of working. Local knowledge includes understanding: the legal and policy context; organizational structures and systems; the location of power; what resources are available and how to access them, and how to adapt to the local context without compromising the purpose and effectiveness of occupational therapy. The interplay of different forms of knowledge is illustrated in the example in Box 2.

Box 2: Forms of knowledge

Some years ago, I was asked to take over a women’s craft group in a community centre on a housing estate in the north-east of England. This was an area of deep social and economic deprivation. My remit was to help increase the women’s emotional resilience so that they would be better able to cope with the stresses of their daily lives without becoming ill. This was my first experience of a health promotion role and I did not have a blueprint in my mind of how to approach it. I drew heavily on my professional knowledge and experience of adult mental health and of working with groups. I also used my personal knowledge of crafts and creative activities, checking that the activities would be valued by the women and enhance their self-esteem. They were quite protective of me, seeing that I lacked local knowledge and street wisdom, and I was able to develop a reasonable understanding of the local culture during the years that I worked on the estate.

We have considered the personal attributes of occupational therapists working successfully in non-traditional settings and the breadth of knowledge required. We will now think about the range of skills that make up the occupational therapist’s toolbox. These skills are acquired through learning and experience, including both professional and life experience. Professional learning begins with pre-registration training and continues throughout the therapist’s working life, which may include practice in a number of different jobs or even different fields. Life experience includes all the learning associated with growing up and living in particular social groups, cultures, geographical locations and political and economic contexts. The skills of the occupational therapist, acquired from these sources, can be categorised as: professional skills, practical skills, interpersonal skills, entrepreneurial skills and thinking skills.

The occupational therapist working in a marginal or non-traditional setting will find all these categories of skills useful, but makes judgements about the relative importance of different skills to particular projects and selects the most appropriate skills for meeting particular goals. Thinking skills come to the fore when the therapist is faced with an unfamiliar situation.

Clinical reasoning is the thinking process that the therapist engages in when working out the best way to engage or support a particular participant or group. Occupational therapists use different types of clinical reasoning, such as procedural or conditional reasoning, switching between them as the issue under consideration changes. Box 3 provides an example of an occupational therapy intervention in a non-traditional setting that highlights the need for cognitive flexibility.

Box 3: Thinking in action

Two occupational therapist in Missouri volunteered to help when Oklahoma was hit by severe storms, flooding and tornados in 2013. They drove to El Reno, four days after the area was devastated by a tornado. The American Red Cross had set up a shelter at a Community College for victims of the storm, and residents left homeless were being provided with temporary housing constructed from shipping containers. When Jeanne and Sherry arrived at the Red Cross shelter, they were not expected and had to find roles for themselves. They observed that people were waiting up to five hours to be registered, while their children whined and pestered them. The occupational therapists immediately set up a play area for children, to give their stressed parents some relief. It was also important to engage the children in trauma-informed constructive play so that they could process their terrifying experiences and avoid establishing maladaptive responses. There were some large cardboard boxes that had contained donated goods, and the children were encouraged to use these to build houses. Once the children were organised, it was possible for one of the occupational therapists to look for ways to help the adults.

Another type of thinking used by practitioners is reflection on their own place in the intervention, the quality of their performance and the impact of their actions. Reflection enables the occupational therapist to identify what she is doing well, what could be improved, what further action is needed and how to modify what she is already doing. Reflection underpins all professional development.

Ethical reasoning is the type of thinking the practitioner employs when deciding what the morally right course of action, as opposed to the best clinical course of action. This type of reasoning may be based on principles, such as doing no harm, or on outcomes, such as achieving the greatest satisfaction for the largest number of people. Ethical considerations do not always concur with clinical ones.

Professional reasoning includes the types of thinking used when: working with clients, teaching students, establishing new services, developing existing services, negotiating with funders, managing staff and so on. An example of using professional reasoning is shown in Box 4.

Box 4: Professional reasoning

 In 2015, three practitioners, including an occupational therapist, were commissioned to plan and deliver a training programme for staff working in child-friendly spaces in two refugee camps, in Northern Uganda. They used various forms of professional reasoning in developing a programme that would both suit participants’ individual learning needs and be appropriate to the social, cultural, political and economic context of their work. This reasoning took place both in the UK, before the programme was delivered, and during the training week in Uganda, as they observed participants’ responses to each session.

This paper gave a brief account of the development of occupational therapy in the first and second halves of the 20th century, showing how that development was influenced by both social movements and pragmatic considerations. It described how occupational therapists are responding to changing social and health needs in the early 21st century, highlighting the personal attributes, knowledge and skills that we draw on to support our practice in non-traditional settings. In most of the fields where occupational therapists work today, we often find ourselves supporting people who have complex and sometimes intractable problems. Following rules or protocols does not help the therapist’s judgement when the problems that brought the client for treatment intersect with poverty, substance abuse, lack of education, homelessness and the many other factors that commonly accompany illness or disability. In order to work effectively, the occupational therapist has to develop expertise in a wide range of thinking skills and professional judgement (Nixon and Creek 2006, p.78).

One of the key features of occupational therapy practice in non-traditional settings is that the practitioner is not constrained or driven by the need to demonstrate what she knows or what she can do. Rather, she makes continual judgements about what would be most useful for different aspects or stages of the project. She does not seek to impose a theoretical model or predetermined process, developed outside the particular context, but looks for ways of using her knowledge and skills to support working with what is there. This means that the therapist sometimes has to tolerate not having a clear idea of what to do, especially in the early stages, before she has collected sufficient information to formulate clear aims.

The striving by mainstream occupational therapy services in developed countries to standardise assessments tools, processes and models has narrowed the scope for developing alternative modes of thinking and practice. It is in non-traditional, diverse settings that innovation and creativity have continued to thrive.