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This paper is a keynote address delivered at the RCOT annual conference in 2017
Occupational therapy emerged from social movements that were flourishing in the UK and the US towards the end of the 19th and beginning of the 20th centuries, including: women’s suffrage, socialism and the settlement movement. From the beginning, occupational therapy was essentially a women’s profession, dedicated to helping people experiencing marginalisation and deprivation.
In this paper, I discuss the terminology of the margins and the key features of marginal spaces and places that are of interest to occupational therapists. I write about the British Empire, which, at the time occupational therapy was founded, extended around the globe; showing how a colonial worldview influenced the new profession. Great Britain was the centre of the Empire and the colonies were the margins. I explore the two-way traffic of ideas and practices between centre and margins, applying this to both the British Empire and the occupational therapy profession. Occupational therapy, which began on the social margins in Britain and America, became integrated into the mainstream during the 20th century, losing some of its pioneering spirit in the process. I argue that we have much to learn from occupational therapy theory and practice on the margins, where creativity and innovation are thriving. I conclude that mainstream occupational therapy services can be improved by the adoption of ideas, skills and practices from the margins.
The profession of occupational therapy emerged from a number of social movements in Great Britain and America in the late nineteenth and early twentieth centuries. These movements sought to improve the lives of people who were marginalised in society, such as: the urban poor, immigrants, women and those with mental illness. Finding it difficult to enter the established male professions, women started working as volunteers in the social sector and went on to build careers for themselves; for example, as nurses, social workers or masseuses.
One of the social changes that allowed the emergence of women’s professions was compulsory education. At the beginning of the 19th century, a wife in the prosperous middle classes was expected to devote herself to creating a home for her husband and caring for their children (Frader 1987). From 1870 onwards, a succession of Education Acts made education mandatory for all children up to the age of 12, creating a class of educated young women with aspirations. Having an education opened the possibility for women to take ‘…their caring, and previously family oriented, talents to the ministration of others in the extended community’ (Wilcock 2002, p. 28). Opportunities for turning a caring role into a career were advanced by four wars fought by Britain between 1853 and 1918. Women like Florence Nightingale, who organised a team of nurses to tend sick and fallen soldiers in the Crimea (biography.com), and Emily Hobhouse, who worked to improve conditions for women and children in concentration camps in South Africa during the second Boer War (Wikipedia), were trail blazers who introduced other women to the potential for pursing professional careers, usually as an alternative to marriage.
Octavia Hill, born in 1838, is probably best known as the founder of the National Trust but her career was as a housing manager and one of her chief ambitions was ‘to provide better homes for the poor’ (Hilton 2002, p. 392). In 1884, two of Hill’s close friends, Samuel and Henrietta Barnett, founded Toynbee Hall, the first of the Settlements, to offer amenities, education and guidance to people living in impoverished urban areas (Darley 2010). In London, 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). Women from London colleges were invited to live at the Settlement rent free in exchange for their work in the community.
The movement quickly spread to the US, 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). The settlement movement continued to expand across the US, ‘…with an international reputation for social welfare programmes [and] women’s suffrage’ (Paterson 2010, pp. 7-8).
One of the social activists connected with Hull House was Julia Lathrop who, in 1903, 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 in Occupations for attendants in mental institutions at the School (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).
In Britain, the Women’s University Settlement supplied women for a wide range of social work positions, providing many workers for Octavia Hill, who employed them as rent collectors and district visitors. One of her employees was a young woman called Elizabeth Casson, who went on to study medicine. In 1919, after becoming the first woman to be awarded the degree of Doctor of Medicine at the University of Bristol, Casson decided to specialise in ‘the treatment of nervous and mental disorders’ (A.W.R. 1955, p. 85). She gained a Diploma in Psychological Medicine at the Royal Holloway Sanatorium, where she began to organise occupational therapy; ‘…employing people with particular skills and expertise as there were no specifically trained occupational therapists at the time’ (Wilcock 2002, p. 121). One of these people was Constance Tebbit, who was inspired to go to the United States and train as an occupational therapist. When Tebbit returned to the UK, in 1930, she went to work at Dorset House, the psychiatric clinic Casson had opened in Bristol, becoming the first principal of the Dorset House School of Occupational Therapy.
From this brief account, we can begin to see how the occupational therapy profession, in its early days, was intimately connected with a number of organisations and movements that sought to improve conditions for people living on the margins of society.
What do we mean by the terms marginalised and margins? When we talk about someone or something being marginal, we usually mean that it is situated on the edge, either physically or socially; not fully integrated into the mainstream. The Oxford English Dictionary (2002) defines a marginal position as ‘on or close to the margin below which something ceases to be possible or desirable’. For example, the living conditions in refugee camps may be very close to impossible or undesirable for the inhabitants. The Oxford Dictionary also suggests that having a marginal status means someone or something is ‘of minor importance…having little effect’. For example, people with a mental illness diagnosis in the UK have little power or opportunity to influence the type and quality of services they receive.
A margin can be a physical place, a social space or a personal experience on the periphery of the social mainstream or dominant order. For every margin, there is a centre or core that represents some form or position of authority, power and privilege. (Duncan & Creek 2014, p. 460)
Margins share a number of features, all of which exist in relation to a centre of power, privilege or authority (Duncan & Creek 2014). These features include:
Social and/or physical distance from the centre
Lack of resources and/or inability to access the resources of the centre
Powerlessness relative to the centre
Marginalisation is the process of moving something or someone from the centre to the periphery, to impoverish, depreciate or undervalue. For example, when an unskilled worker loses his job, he also loses his status as an earner and, if he cannot find another job quickly, is marginalised as an economic burden on society. If the loss of earnings leads to loss of his house, then he is also marginalised as a homeless person. Thus, the process of marginalisation can be progressive and cumulative.
Mainstream services, such as the National Health Service, are positioned at the social centre and, usually, at the physical centre of a community; such as the major hospitals located in large towns and cities. However, the concepts of margins and mainstream are not diametrical opposites but:
represent the ends of a continuum, [so] that a setting or position can be more or less mainstream or marginal. For example, in a developed country such as the UK, unemployed people are marginalised, but not to the same extent as people who are both unemployed and homeless. A particular group of people may be marginalised in some ways, but not in others, such as those who have a mental illness diagnosis but are highly successful in their chosen sphere of work. Furthermore, it is possible for a marginal social position to exist in close physical proximity to a social position of privilege and authority, such as street sleepers in the financial district of a city. Far from being an absolute state, marginality represents a family of conditions that may be experienced by different groups in different ways. (Creek 2017, p. 238)
During the first decades of the twentieth century, the time when occupational therapy was emerging as a profession, Great Britain had an Empire that extended around the globe. Power, privilege and authority were concentrated in the administrative structures of the Empire, while the colonies constituted the margins. Goods, wealth, raw materials and labour flowed from the margins to the centre, in exchange for laws, knowledge, education and technology carried by traders, missionaries, administrators and their wives to the furthest reaches of the Empire. The colonisers believed that their ways of understanding and ordering the world were superior to those of the people they governed, and that everyone benefited from the civilising influence of colonial rule (New World Encyclopaedia). But their dominance went further, in that they ‘exercised power and reinforced domination by establishing the parameters of permissible thinking and by suppressing challenging ideas’ (Hammell 2011, p. 28).
With this colonial heritage and context, it was inevitable that the two countries where occupational therapy was first recognised, Great Britain and its most powerful former colony, the United States of America, would see themselves as the privileged and authoritative centre of the profession. Throughout the twentieth century, occupational therapists from these two countries colonised the rest of the world with their own ways of understanding and practising occupational therapy; in a process of ‘theoretical imperialism[,] by which theorists develop and perpetuate theories that privilege their own perspectives while overlooking, ignoring or silencing the perspective of others’ (Hammell 2011, p. 28). Like the colonialists of 100 years earlier, these occupational therapists believed implicitly that their knowledge and skills were superior to those of people on the margins. The flow of knowledge and experience was unidirectional, from the centre to the margins, and English was firmly established as the dominant language of the profession.
Earlier in this talk, I described margins as spaces and places far from the social mainstream. This means that people on the margins not only lack access to the resources and power of the centre, they also function at a remove from the rules and traditions that characterise the activities of the centre. In marginal spaces, where the control of the centre is weakened by distance, creativity and innovation tend to flourish. This phenomenon can be clearly seen in the social movements that gave rise to occupational therapy. The pioneers of the profession, unconstrained by long-established modes of thinking, were able to find new ways of framing social problems that offered realistic solutions. For example, Casson’s decision to become a doctor came from her observation, while visiting poor people on Hill’s housing estates, ‘…that appalling ignorance and neglect of physical weakness and disease accounted for much of the misery and poverty she found’ (Reed 1955, p. 87). Instead of seeing the chief cause of poverty as individual laziness or a persistent refusal to exert effort, a dominant social belief at the time (Darley 2010), Casson linked poverty to lack of education and ill health. This formulation gave her two potential avenues for practical action: she could train as a teacher or as a doctor.
Those at the centre of society have a tendency to keep an eye on the margins and move to colonise them at the point where something useful is produced. An example of this is Banksy, the Bristol graffiti artist, whose work now commands hundreds of thousands of dollars in auction houses (Ellsworth-Jones 2013). This tendency means that the margins are always changing, as formerly marginalised people and ideas are incorporated into the mainstream, while new margins spring up in the spaces that are passed over or missed by the centre.
When innovations from the margins are absorbed into mainstream thinking and practice, they gradually become codified into rubrics and procedures, until no-one remembers that they started out as contingent, mutable and provisional ways of working. This process of calcification has occurred in occupational therapy theory and practice, which were originally tailored responses to the observed needs of people whose access to occupation was blocked by disease, disability or disadvantage. As the profession came under the control of the centre, effectively through the regulating influence of medicine, theory and practice became systematised into precepts and routines, to be applied uniformly.
While mainstream occupational therapy services in developed countries have been striving for standardisation of assessments tools, processes and models, thus narrowing the scope for developing alternative modes of thinking and practice, innovation and creativity have continued to thrive on the margins, in ex-colonies where national identities are being explored. An example of this is the work of Minnie Lagria in the Philippines, who is helping to resettle villagers displaced by Typhoon Yolanda. Lagria co-ordinates a wide range of activities designed to: facilitate the transition from islet to village living; promote the acquisition of new skills for diversified livelihoods; assist villagers to adapt to new routines and habits, and promote better health.
My realisation that there were radically new theoretical and practical developments taking place in the profession came in 1999, during a visit to South Africa. I was amazed and delighted to find that occupational therapists there were finding ways to address some of the major issues facing their country: the HIV/AIDS epidemic, structural poverty, the legacy of apartheid and the consequences of gender inequality. For example, Theresa Lorenzo used the United Nations 22 Standard Rules on the Equalization of Opportunities for Disabled People (UNDP 1994) to guide her work with disabled women in townships around Cape Town (Lorenzo 2004). The 22 Rules cover: the preconditions for equal participation; target areas, and implementation strategies (UNDP 1994). Lorenzo was the first occupational therapist I encountered who had the ambition and courage to measure her interventions against international standards, rather than limiting herself to the application of profession-specific approaches and assessment tools.
Innovative thinking and action on the margins are driven by a combination of extreme need and lack of resources, but they are enabled by distance from the power and control of the centre that leaves people free to devise their own solutions. My observations of occupational therapy in South Africa, and other developing countries, led me to speculate that mainstream practice could learn from practice on the margins. To test this idea, I undertook a PhD study of occupational therapists working on the margins of society: the study was completed in 2014.
For the study, I interviewed practitioners working with people who are unable to access the services or resources of the mainstream and who experience powerlessness in relation to the privileged centre. These marginalised groups included: young men who migrated from the African countryside to the city, where they were unable to find work; people left disabled by war in northern Uganda; repeat offenders in Scotland; homeless people in a UK city, and people in UK towns and cities living with a mental illness diagnosis.
The main findings of my study were that: the process of occupational therapy on the margins is different from the process described in textbooks; practice on the margins is qualitatively different from mainstream practice, and practitioners on the margins share a particular set of characteristics that enable them to work effectively in resource-poor settings. I will briefly describe these three findings.
The starting point of the occupational therapy process in marginal settings is the therapist’s perception of an unmet occupational need and recognition of how that need might be met. For example, one occupational therapist in my study observed that many of the people she visited in prison, as a volunteer, were repeat offenders. She felt that paid employment was an important factor in reducing the reoffending rate so she set up a landscape gardening company to employ men when they came out of prison.
A key aspect of perceiving need is the awareness that something can be done to improve the situation and that the therapist has the skills and knowledge to bring about positive change. Perception of need leads to action by the therapist: action with and on behalf of the people in need. Crucially, the therapist’s actions are not directed by pre-selected theories, models or approaches but are shaped by interaction between the therapist’s own knowledge, skills, experience and attributes and the external resources available.
The South African occupational therapist, Kathleen Brodrick, demonstrated this process when she set up the organisation, Grandmothers Against Poverty and AIDS (GAPA). A longitudinal study by the Institute of Ageing in Africa had found that when one or more parents dies from AIDS the grandmother may become the sole provider and supporter of the grandchildren (Brodrick 2004). Brodrick framed this issue as occupational: the grandmothers needed help ‘to deal with the impact of the AIDS pandemic on their lives, and especially with the devastating financial impact’ (op cit., p. 235). Her response to this perceived need was to organise a series of workshops at which grandmothers could receive useful information, about such matters as HIV/AIDS, nutrition, bereavement and business skills, and share the issues they faced. In 2004, Brodrick wrote:
It was clear from the workshops that there was considerable distress amongst the grandmothers, as well as an urgent need for help with productive occupation[s]. There was only one occupational therapist, and she was not fluent in isiXhosa. Clearly, an individual counselling method would be inappropriate. (Brodrick 2004, p. 236)
The second finding of my study was that practice on the margins differs from mainstream practice along several continua. Occupational therapy practice can be:
Driven by particular ways of doing things, including models and procedures
Focussed on the individual, who is seen as the locus of the issue
Controlled by external forces, such as managers, employers and contracts
Based in an institution, such as a hospital or prison
I suggest that these qualities are more characteristic of practice in the mainstream than on the margins. Practice on the margins is more likely to be:
Responsive to local conditions and needs
Focussed on the collective, that is, on the community, family or work group
Delivered by a professional who is able to make autonomous decisions about what to do and how to do it
Based in the communities where people live and work.
One of the occupational therapists in my study went into hostels for homeless men, to carry out an art project with them. Her approach demonstrates several of these qualities.
One of the key groups that I’ve really… found incredibly difficult to work with were the very…
young men... we’re talking 14 to 16 to 18, that sort of grouping there. Particularly kind of
chaotic; particularly kind of aggressive; very defensive about things; very, very vulnerable. …in
normal circumstances, I wouldn’t have chosen to work with that group… It’s been good having
to, actually, because it’s presented me with a lot of reflection about my own discriminatory
ideas… the group was about people choosing to be in it, so I didn’t have any control about
who came into that group. It was about people saying, ‘I want to be in that’. And sometimes
you just wonder… why do you want to be in it? Because you’re so disruptive, you’re so
breaking up things, why do you want to be here? But again, you know, also being powerless
within the group, I couldn’t say to people, ‘You can’t do that’. I had no official… status so,
again, that meant that I had to recalibrate my kind of therapist self, that I would fall back into as
a kind of protective process to manage the sort of thing.
The third finding of my study was that occupational therapists working on the margins share a number of characteristics that enable them to work effectively in settings that lack the structure and resources of mainstream services: I call them the five enabling characteristics:
Agency is the capacity to take action towards an end
Openness involves taking an anthropological perspective; trying to understand what is there on
its own terms
Responsiveness means being willing to let go of habitual ways of doing things and react in ways
appropriate to the circumstances
Commitment is the stamina to persist with a project over a long period of time, despite
challenges and setbacks
Resourcefulness is imagination and creativity in finding and making use of the human and non-
human resources available in the environment.
All these characteristics are embodied in the occupational therapists I have met who work in townships in South Africa. A few years ago, Madie Duncan, a lecturer at the University of Cape Town, took me to visit a settlement in the Western Cape where she has been taking groups of students for over a decade. We were there to deliver the report of a study carried out by the latest student group into the mental health needs of the community. This was the fourth piece of research undertaken by the students, and the ANC counsellor we met said that he is able to use their findings to support grant applications for improving the lives of residents.
This paper began with an account of how the occupational therapy profession originated from the margins of society, and ended with some of the findings of my PhD study into occupational therapy practice on the margins today.
I would like to finish by arguing that the features and characteristics of practice on the margins make it more effective than institutionalised occupational therapy practice for people living with long-term, complex conditions. I suggest that, as our present health and social care services struggle to deal with increasing numbers of such people, it is time for us to let go of established ways of thinking and practising, and allow ourselves to learn new and more successful approaches from practitioners on the margins.
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