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The profession of occupational therapy emerged in North America and northern Europe at the beginning of the twentieth century. The first professional occupational therapy association was founded in the USA in 1917 (Paterson 2010); the Canadian Association of Occupational Therapists in 1926 (Friedland 2011) and the Scottish Association of Occupational Therapy in 1932 (Paterson 2010). A meeting to establish an international association was held in England in 1952, when the World Federation of Occupational Therapists was inaugurated. The founder members of the new international body were: Australia, Canada, Denmark, India, Israel, New Zealand, South Africa, Sweden, the United Kingdom and the United States of America. Seven of these founding countries were Anglophone. The first president of the Federation was Scottish (Paterson 2010).
At the time when occupational therapy was emerging as a profession, the UK still had the remnants of an Empire that once stretched all around the world, and the USA also had influence across the globe. It was inevitable that the international language of the new profession of occupational therapy would be English.
Since 1917, the influence of the English language on the development of occupational therapy has been so pervasive that most people take it for granted and cannot conceptualise alternative ways of framing the profession.
Today, throughout the world, occupational therapy principles, values, theories, methods, domain of concern and professional purpose are primarily conveyed in English; through such media as textbooks, journal articles and international conference presentations. When these concepts and ideas are translated into other languages, the process involves deconstructing the meaning behind an English term, making sense of it within another geographical and sociocultural context, and reconstructing the meaning using another language. This can be a challenging process, because different languages do not delineate concepts in exactly the same ways. For example, even within European languages, which share common roots, Danish has only one word for occupation and activity, while German has three words for occupation. The difficulty is compounded by the inability of Anglophone occupational therapists to reach agreement on the meanings of key terms, such as occupation, skill and function. We do not have a standard terminology and many different definitions of our core professional concepts can be found in the literature.
This paper highlights the importance of thinking critically about the language we choose and use, when thinking and communicating about our professional role and purpose.
It begins with a brief explanation of what language is, and discusses the nature and functions of professional language. It goes on to describe how I myself gradually came to recognise the impact of language on what we do, on how we understand what we are doing and on how we do it. This personal journey is illustrated with examples of my work on professional language, with colleagues in the UK, the European Union, South Africa and China.
How language is defined and understood
What is language?
It has been defined as ‘a system of human communication using words, written and spoken, and particular ways of combining them’ (Shorter Oxford English Dictionary 2002). Language can be thought of as a tool for both communicating and thinking. The words that we use are important, because they not only shape how other people see our actions but also influence how we feel about what we are doing.
Words are not neutral but have an impact on how a person thinks, feels and acts.
For example, if you say to yourself that reading this paper is work - a necessary part of your professional CPD, but not something that you expect to enjoy - then you will not think very hard about it. If, on the other hand, you say to yourself that you expect the paper to be stimulating and relevant, then you are likely to read actively and relate the content to your own experience.
The basic building blocks of language are words, and words represent concepts. A concept is ‘an idea of a class of objects [or] a general notion’ (Shorter Oxford English Dictionary 2002). For example, the word furniture represents many of the non-human objects that we see in buildings. The word table represents a sub-set of furniture. Both these words represent concepts, or classes of objects. The term occupational therapist also represents a concept and can be found in a dictionary. If we want to know what concept or concepts a word represents, we can look in a dictionary, where we will find definitions of that word. A definition is ‘an explanation of a concept… or formal explanation of the meaning of a word or phrase’ (Shorter Oxford English Dictionary 2002). Some words have more than one definition. For example, to occupy means:
‘to take possession of [or] seize
[to] enter and remain in (a building etc.) forcibly or without authority
[to] be situated in or at (a place or position)
[to] keep busy, to live in (a place), to make use of
[and to] follow or ply as one’s business’
(Shorter Oxford English Dictionary 2002)
Some definitions can be represented by more than one word. For example, the state of being active can be called action, activity, animation, doing, liveliness, motion, movement or occupation. These words have slightly different meanings but they can all be defined as a state of being active.
As highlighted above, the words we use are not neutral; each word represents a particular way of seeing the world. For example, the people occupational therapists work with may be referred to as: patients, clients, service users, citizens or something else. Each of these terms has a slightly different meaning that indicates something about how we see the therapeutic relationship. When I worked as a Mental Health Act Commissioner, the people I visited were called patients. This term connotes the imbalance of power between the person who is detained in hospital against her will (the patient) and the person who determines whether or not the detention is legal and acceptable (the Commissioner). When I worked in a community centre, the people attending my women’s group were called women. This term signifies the freedom they had as citizens to choose whether or not to attend the group each week: it carries no suggestion of inequality in their relationship with me.
What is professional language?
Each profession and scholarly discipline uses its own, specialised words to refer to key concepts. For example, biologists use such words as: genus, phylum and species when talking about how living organisms can be classified. Particle physicists talk about electrons, bosons and fermions when referring to their field of study. In order to study any discipline or profession, it is necessary to learn the professional language of that field. Professional language is ‘the specialised vocabulary of a discipline’ (Shorter Oxford English Dictionary 2002) that is sometimes called professional terminology.
Having a coherent professional terminology is important to occupational therapists, because we cannot think clearly and logically about our professional purpose and practice without a specialist vocabulary to refer to aspects of occupation.
Precise language is also important for the purposes of teaching, research and sharing good practice. A third function of our professional terminology is communicating the purpose and process of occupational therapy to clients, service commissioners, managers, colleagues from other disciplines and the general public.
My own journey through occupational therapy language
My interest in occupational therapy language was stimulated in the 1980s, on hearing occupational therapists complaining endlessly that no-one understands what we do and seeing numerous articles in the British Journal of Occupational Therapy, with titles such as: ‘Occupational who? Never heard of them!’ (McAvoy 1992) and ‘Explaining psychiatric occupational therapy: an art in itself?’ (Madden 1984). I was inspired to embark on a research degree, investigating the difficulties that occupational therapists have with the language of occupation. The working title of my study was ‘Why can’t occupational therapists say what they do?’
In 2003, my fascination with occupational therapy language led to an invitation to join a European project group, that was attempting to produce a standard terminology for occupational therapy, in all the major European languages. In 2001, the European Network of Occupational Therapy in Higher Education (ENOTHE) had formed a working group, to select and define key occupational therapy terms and to organise the translation of the definitions into all the main European languages. The terminology working group was made up of six members from six different countries, representing six European languages: English, Flemish, French, German, Portuguese and Spanish. Working together for six years, the terminology group developed a method for producing definitions of key occupational therapy terms and a protocol for translating each definition into other languages. By the end of the project, we had selected 30 key terms and produced definitions, in English, that everyone agreed could be successfully translated into their own language (Creek 2010).
To construct the definitions, the group chose to use existing definitions of key terms from the occupational therapy literature, as a basis for constructing consensus definitions. The European definitions were based on the work of occupational therapy scholars from around the world: most of them, of course, Anglophone. Each member of the working group collected definitions from the literature we were using in our own countries. A consensus definition is one that is in accordance with the meanings of the majority of the original definitions of the term and that everyone in the working group could agree on. The working language of the group was English, so definitions that had been written in other languages were translated into English for the analysis. Unsurprisingly, we found very few original definitions of terms in other languages; most of them had been translated from English.
Part of the process of constructing consensus definitions was to consider how each term relates to other, similar terms, so that all the definitions would work together. For example, it was necessary to think carefully about how the concepts of setting, environment and context relate to each other, what elements are common to all and how they differ. When we began working on new terms, we had to revisit our earlier definitions and sometimes rewrite them to clarify their relationship to other terms. This process took a long time, partly because the boundaries between concepts are different in different languages and we had to produce a set of definitions that would work for the whole of Europe. It was my task to suggest definitions, containing the agreed elements, that would work in English.
The other group members would then look at the definition and say ‘No, that doesn’t work in French’ or ‘You can’t say that in Spanish’ or ‘That is ambiguous in German’. We would rewrite each definition many times until we could all agree that it would work in translation.
The final task of the terminology group, before we disbanded in 2009, was to identify the terms that refer to occupation from the perspective of the performer; such as autonomy, habit and task. We found 25 of these terms and organised them into a conceptual framework, that provides a descriptive theory of occupation. All the terms in the framework refer to aspects of occupation from the point of view of the person who is engaged in occupation. For example, during the performance of an activity or occupation, the performer experiences autonomy to a greater or lesser extent.
One of the features of the conceptual framework is that it is organised into three worlds:
the internal world of the performer
the external world in which performance takes place
the interface between these two worlds, in which all actions are performed
(Creek, 2010)
The internal world is made up of the person’s capabilities for action, such as skills and functions, and the person’s energy source for action, including motivation and engagement. The external world consists of the place where action happens, which includes setting, environment and context, and the social contract for action, which includes roles and participation. All the concepts in the internal and external worlds refer to factors that influence what people do, why they do it, how they do it, where they do it and so on. The interface between the internal and external worlds is where all action takes place. It contains all the terms that refer to action, including the boundaries, such as dependence, performance, forms of action and how action is structured in daily life.
It can be useful to reflect on which of these aspects of occupation you tend to focus on when working with clients, and which ones you never think about. Do occupational therapists from different countries and cultural backgrounds all pay the same attention to the same things?
The European Conceptual Framework was published as a book. Most importantly, each member of the terminology working group wrote the book in her or his own language. It was not written in English and translated into the other languages of the group. Each author was able to use the idioms of her or his own language, culturally appropriate modes of expression and relevant examples.
In 2016, I was invited to the University of Cape Town, as a visiting scholar, to share my experience of developing a multilingual occupational therapy terminology. South Africa has 11 official languages; two with European roots - Afrikaans and English - and nine indigenous African languages: IsiNdebele, IsiXhosa, Sepedi, Sesotho, Setswana, Siswati, Tshivenda and Xitsonga. Like many ex-colonies, the country is attempting to decolonise its education system, along with other systems. Decolonisation has been defined as ‘a process by which colonies become independent of the colonising country’ (Encyclopaedia Britannica, 2020). However, this is not just a political process. The Sovereign Union of First Nations and Peoples in Australia (2019) states, on its website, that: '…to achieve true decolonisation, …we must learn to decolonise our minds. This essentially means that we must stop thinking like our oppressor and thereby stop trying to fit a round peg in a square hole.'
Trying to understand the varied and complex occupations of different countries and cultures through the lens of a single language, English, is like trying to fit a round peg in a square hole. This is why I use the term decolonisation, to refer to the work of thinking about occupational therapy in indigenous languages.
One of my activities in Cape Town, as a visiting scholar, was to facilitate a workshop for a small group of faculty and practitioners interested in developing a terminology, for use on the occupational therapy programme. The group hoped to produce a terminology in the three dominant languages of the region: IsiXhosa, English and Afrikaans. It was educational for me to realise that most of the occupational therapy faculty chose not to attend the workshop, possibly because they saw the paradoxicality of asking a member of the ex-colonising nation to assist in the process of decolonisation. Nonetheless, within the group there were native speakers of English, Afrikaans and one of the indigenous African languages: a dialect of IsiXhosa.
I began by presenting the method used to produce the European conceptual framework, then asked the group to carry out a critique of both the method and the framework itself. Some of the feedback was about the impossibility of translating English concepts into IsiXhosa. It took some time for participants to feel comfortable with me and with each other but, eventually, people began to share their own feelings about language. One of the young, black men told us about how he joined the Rhodes must fall movement when it first started. He told us that the group was gradually taken over by people who had experience of activism and who spoke the language of activism, which he did not understand. For example, when they talked about ‘mobilisation’ he thought of joint movement. Eventually, he felt silenced and decided to leave the group.
Participants in the Cape Town workshop also said that it is essential to explore concepts of time, space and place as they are understood in Africa, because these are different from European understandings. The two indigenous African language speakers said that additional occupational therapy concepts would need to be identified and defined in order to express an African worldview. They suggested that these new concepts could form a fourth world, complementing the three in the European Conceptual Framework, to represent the worldview of an IsiXhosa speaker. We had difficulty exploring the nature of this fourth world in English, but the IsiXhosa speakers agreed that the fourth world is transcendental, spiritual, ethereal and is conceptualised as surrounding and shaping all the others. It influences personal and social identity; it is about what will motivate you versus what will motivate others.
The concepts discussed by the IsiXhosa speakers in the workshop are not found in English or Afrikaans, so they would have to be identified and defined by IsiXhosa speakers. A way must then be found to translate these definitions into English and Afrikaans. Speakers of these two languages can then select the terms they will use to name concepts from the fourth world.
When we produced the European Conceptual Framework, we worked with six languages and six cultures. However, all these languages and cultures share similar roots.
The workshop in Cape Town taught me that occupational therapy needs to learn from more diverse languages and cultures, in order to be fit for purpose across cultures and language groups.
Shortly after my trip to Cape Town, I was introduced to a Chinese occupational therapist living in Hong Kong: Teresa Chiu. Teresa observed that occupational therapy concepts and theories are not easily translated into Chinese languages. Working independently, she began to study Chinese characters (that is, the written language of Chinese), to identify which one best represents the concept of occupation, as it is understood by occupational therapists. China has many dialects but only one written language. There is no Chinese alphabet but a set of characters, each of which represents a concept. This means that people all over China, speaking different dialects that cannot necessarily be understood by each other, can understand the written script.
Teresa and I decided to submit an abstract for the WFOT congress in Cape Town in 2018 and we presented a workshop together. There was a large audience, suggesting that the occupational therapy world is beginning to wake up to the importance of language. For me, one of the highlights of the workshop was when a Scandinavian participant said that he now wants to redefine occupational therapy concepts, starting with his own language.
Summary
This paper began with a brief explanation of why English is the dominant language of occupational therapy around the world. It discussed the nature and functions of language and, specifically, professional terminology. My own work on occupational therapy language was described, extending back nearly 40 years and including: a 1980s study into why occupational therapists find it hard to say what we do; the European occupational therapy terminology, published in 2010, and the 2016 language workshop at the University of Cape Town.
Addressing the challenge of defining occupational therapy from first principles, in every language where we practise, will not only be of inestimable benefit to the speakers of those languages, and to the recipients of occupational therapy services; it will also provide the profession as a whole with opportunities to explore new ways of thinking, that are not often found in the English-speaking occupational therapy world. The understandings that can be gleaned from non-English speaking cultures will enrich and enhance the global development of occupational therapy.
References
Creek, J. (2010) The core concepts of occupational therapy: a dynamic framework for practice. London: Jessica Kingsley.
Encyclopaedia Britannica: https://www.britannica.com/topic/decolonization. Accessed: 22 April 2018
Friedland, J. (2011) Restoring the spirit: the beginnings of occupational therapy in Canada, 1890-1930. Montreal: McGill University Press.
McAvoy, E. (1992) Occupational who? Never heard of them! An audit of patient awareness of occupational therapists. British Journal of Occupational Therapy. 55 (6): 229-232.
Madden, A. (1984) Explaining psychiatric occupational therapy: an art in itself? British Journal of Occupational Therapy. 47 (1): 15-17.
Paterson, C.F. (2010) Opportunities not prescriptions: the development of occupational therapy in Scotland 1900-1960. Aberdeen: Aberdeen History of Medicine Publications.
Shorter Oxford English Dictionary (2002). Oxford: Oxford University Press.
Sovereign Union of First Nations and Peoples in Australia: http://nationalunitygovernment.org/content/what-decolonisation-how-do-we-decolonise-1. Accessed 22 April 2018.