CHAPTER 21 Occupational therapy: working with individuals, groups and communities to enable occupation
This chapter provides an introduction to the occupational therapy profession and the role of occupational therapists (OTs) in the Australian health and human service system. It introduces some of the theoretical underpinning to the way OTs use occupation as therapy.
Every day we participate in many different tasks and activities. These may be brushing our hair or cooking a meal, writing an assignment or making a sale, spending time with a loved one or completing a marathon. Some are things that we want to do, and others are things that we need to do. The occupations that each of us do are part of what makes us unique, helping to create our sense of who we are. Occupational therapy is a profession concerned with promoting health and wellbeing through occupation. Occupation means everything that people do to occupy themselves — this includes ‘looking after themselves (self care), enjoying their life (leisure), and contributing to the social and economic fabric of their community’s productivity’ (Townsend & Polatajko 2007: 862).
Occupational therapy is generally recognised as being established as a profession at the beginning of the 20th century by a group of people in the United States (including physicians, nurses, architects and teachers) (Schwartz 2003). Occupation as therapy for people with mental illness was also being used in Sweden (Jonsson 1998) and England (Wilcock 2001) about the same time. The belief of the founders of the profession was that participating in various tasks and activities of everyday life could restore a person with an illness, injury or disability to more healthy and satisfying habits of living (Kielhofner 2004). While occupational therapy was practiced in Australia in the 1920s, it was not until World War Two that the profession really emerged in Australia (Anderson & Bell 1988).
Occupational therapists believe that people’s health is strongly influenced by what they do in their everyday lives (Townsend & Polatajko 2007). A core professional belief is that the individual’s need for occupation is as basic as the need for food and shelter. Our occupations may provide us with a source of meaning, give us a sense of purpose, balance and satisfaction, provide us with choice, control, a means of organising our time, a way of connecting with others, and contributing and interacting with our community. Occupational therapists exploit these characteristics of occupation to enhance health and wellbeing when people’s participation in their occupations has been restricted or limited by illness, disability, social or environmental factors.
Pause for reflection
What daily occupations do you most value? Which give you the most personal satisfaction? Imagine if you were unable to engage in these activities for a month. What would the impact be on your sense of self?
Occupational therapists are interested in the detail of why and how people engage in occupations, including their habits, routines and their roles. When people’s participation in their occupations has become restricted, an OT will undertake a detailed analysis to find ways of overcoming these restrictions so that participation is possible. Research has shown that if the activity a person is doing is not too challenging, nor too easy, it is just right, then the person is more likely to feel positive about what he or she is doing, leading to further engagement in the activity (Csikszentmihalyi & Csikszentmihalyi 1988). It is the skill of occupational analysis that differentiates OTs from other health professionals.
Self-care occupations, such as getting dressed, are generally based on habits and routines that adults take for granted. Habits provide the basis of our daily routines, they decrease the effort required for occupational performance and free up conscious attention for us to use for other purposes. However, what if you were no longer able to use one arm following a brain injury? Performing the most basic of activities such as getting dressed would become very challenging. You would have to consciously learn new ways to do this, which would further impact on the rest of your daily routine. Dressing independently is a role expectation for most of us, something we assume we will do before we engage in other everyday activities.
We all have internalised attitudes and actions that are part of our socially and personally defined status (Kielhofner 2007) and these role expectations exert a strong pull over our occupational choices. It may be that it would be easiest to get someone else to assist you with dressing, so you could put your time and energy into other things that you want to do. However, you may choose to persevere with learning to dress yourself despite ongoing frustration because it is part of your internalised role or because others expect you to do this independently.
Occupational therapists work in three main ways to facilitate a person’s occupational performance. Occupational performance is the result of a dynamic interrelationship between persons, their environment and their occupation over their lifespan (Townsend & Polatajko 2007). First, an OT could change the way the occupation is done by devising ways to make it easier to do. To do this, OTs require detailed knowledge of how an occupation is usually performed, the ability to analyse in detail, the steps and demands of an occupation, and problem-solving to think of alternative ways that the occupation can be done. In our dressing example, you could adapt the clothes you wear so they are easier to put on, learn new ways to dress using one hand or, as mentioned, get someone else to assist you. Most significant in the therapist’s clinical reasoning is what the person with the injury considers important and valuable, so the OT would need to work in partnership with the person in the decision-making process.
The second way that OTs work is by adapting or modifying the environment. The environment can present many barriers that prevent people participating in their occupations. The most obvious of these are the physical barriers, such as stairs and narrow doorways that prevent access to people, such as those in wheelchairs. However, it may be less obvious aspects of the environment that create the greatest barriers. For example, the stigma associated with mental illness is a barrier for many people returning to paid employment (Hocking 2003).
Finally, OTs help a person to change through problem-solving and occupational counselling. For example, a person who experiences fatigue created by doing too much in the morning, can be taught how to problem-solve to reshape his or her time use across a day, by setting priorities and having regular breaks to conserve energy. In doing this, the person has more energy to do the things that are important. Occupational therapists use occupational counselling to help people develop coherent and meaningful narratives, or stories, about their occupations. Occupational narratives integrate our past, present and future. Our identity and our sense of competence are reflected in the stories through which we make sense of our occupational lives (Kielhofner 2007).
The aim in occupational therapy is to enable, and better support, the person‘s participation in what he or she wants and needs to do. A person-centred approach is fundamental to occupational therapy practice. To be person- or client-centred, the OT must be willing to enter the clients’ world and encourage the client to enhance his or her life in ways that are most meaningful to the client, rather than imposing the therapist’s beliefs. Practitioners strive to understand the client as a person who is part of a particular context consisting of family and friends, socioeconomic status, culture and so on. Client-centred practice therefore refers to collaborative approaches aimed at enabling occupation with clients (Townsend & Polatajko 2007). It recognises that clients of occupational therapy have the experience and knowledge about what is best, so the therapists and clients work in partnership to make decisions concerning the client’s occupational needs.
Occupational therapists use various conceptual models of health to guide their thinking about practice. In particular, OTs are interested in the dynamic interrelationship between the person, their environment and his or her occupations. The Canadian Model of Occupational Performance (Townsend & Polatajko 2007) and the Occupational Performance Model (Australia) (Chapparo & Ranka 1997) are examples of occupational therapy models using person, environment, occupation (PEO) as their core. These models are conceptually compatible with international thinking about health and wellbeing, embodied in the World Health Organization (WHO) International Classification of Functioning (ICF), Disability and Health (WHO 2001) as well as population health approaches that focus on health promotion and disease prevention, and traditional approaches that focus on treating or remediating health problems.
Let’s look at an example of how some of these principles apply. The case study of Emily uses the PEO framework to consider the multiple and complex inter-relationship of each aspect applied to her as an individual, and also to understand some of the issues that an OT considers.
Emily is a 30-year-old woman who is a client of a private practice OT. Emily reports to the OT that she wants to meet new friends and that she has difficulties organising her day. Such a referral to an OT is not unusual as people often report what they have difficulties doing, not why this is so.
Emily was hit by a car 5 years ago, receiving a severe head injury. As a result she walks with an uneven gait as she has a right-sided hemiplegia (weakness), with limited use of her right arm that restricts her from engaging in activities she wants and needs to do. She pauses when she talks because she finds it difficult to find the right word and she has difficulty remembering some things. She fatigues easily, a very common experience for a person with a brain injury, particularly later in the day. Because of these problems, she rarely goes out at night. Emily developed epilepsy as a result of her brain injury and receives medication that often makes her drowsy and blurs her vision. She needs regular rest breaks and lots of sleep. Before her accident she had completed a university degree, was working and had many friends. She is sometimes quite depressed with her current situation, particularly with her feelings of isolation related to her loss of friends and worker role, and the loss of her planned career path. However, she tries to be very positive about her life. She is aiming to become financially independent and wants eventually to get married and have children.