Occupational Therapy

In the tradition of Mosey's (1985) Eleanor Clarke Slagle lecture (p. 504) as a road map to where this presentation is going, I will present a short preface and first, talk about her story and our professional identity; second, use chaos theory as a way to look at occupation; third, introduce you to Charlotte's Web of Chaos; fourth, make some conclusions about chaos and occupational therapy; fifth, do an ending to this telling, and; sixth, do a summary and closing.
 

The experience of being human is embedded in sensory events of everyday life. This lecture reviews sensory processing literature, including neuroscience and social science perspectives. Introduced is Dunns Model of Sensory Processing, and the evidence supporting this model is summarized. Specifically, using Sensory Profile questionnaires (i.e., items describing responses to sensory events in daily life; persons mark the frequency of each behavior), persons birth to 90 years of age demonstrate four sensory processing patterns: sensory seeking, sensory avoiding, sensory sensitivity, and low registration. These patterns are based on a persons neurological thresholds and self-regulation strategies. ...
 

The health care environment of the past quarter century went through numerous evolutionary processes that affected how occupational therapy services were provided. The last iterations of these processes included requests for the evidence that supported what we were doing. This year's Eleanor Clarke Slagle Lecture (a) examines the strength of the evidence associated with occupational therapy interventions--what we do and how we do it--(b) raises dilemmas we face with our ethical principles when some of our practices are based on limited evidence, and (c) proposes a framework of continued competency to advance the evidence base of occupational therapy practice in the new millennium.
 

This article presents a view of occupation as the principal means through which people develop and express their personal identities. Based on a review of theory and research, it proposes that identity is instrumental to social life because it provides a context for deriving meaning from daily experiences and interpreting lives over time. The article proposes that identity also provides a framework for goal-setting and motivation. It is asserted that competence in the performance of tasks and occupations contributes to identity-shaping and that the realization of an acceptable identity contributes to coherence and well-being. Within this framework, it is postulated that performance limitations and disfigurement that sometimes result from illness or injury have identity implications that should be recognized by occupational therapy practitioners. By virtue of their expertise in daily living skills, occupational therapy practitioners are well positioned to help address the identity challenges of those whom they serve. In so doing, they make an important contribution to meaning and well-being.
 

The term occupation conveys the powerful essence of our profession--enabling people to seize, take possession of, or occupy the spaces, time, and roles of their lives. Occupation is activity that is both purposeful and meaningful to the person who engages in it. Our uniqueness lies in our use of occupation as a therapeutic agent, but our unique focus on occupation is not always apparent in practice. Four global groups of activities that occupational therapy practitioners use in practice are described--exercise, contrived occupation, therapeutic occupation, and adaptive occupation. Therapeutic occupation and adaptive occupation are proposed as the legitimate activities of occupational therapy. The Occupational Therapy Intervention Process Model is then presented. This model stresses a top-down approach to evaluation and provides a framework for implementing adaptive occupation for purposes of compensation as well as therapeutic occupation for purposes of remediation.
 

The use of occupation as a therapeutic method is the essence of the profession of occupational therapy. This core of therapeutic occupation is flexible across cultures, times, health care environments, and different philosophies of the nature of the human being. Given this adaptability, the profession espouses diverse models of practice--the multiple frames of reference that guide therapeutic occupation for different populations in different settings. Across the history of the profession, therapeutic occupation has been the common core of otherwise different approaches to intervention. Although each of the many past and current models of practice has a different viewpoint, the common factor is the synthesis of occupational forms designed to elicit meaningful and purposeful occupational performance. Occupational synthesis is the essential act of the occupational therapist. It is necessary that occupational therapists confirm the power of therapeutic occupation through research that examines the profession's central principles. Occupational therapists are also urged to use the term occupation consistently and proudly in their interactions with recipients of therapy, fellow health care professionals, and each other. The profession of occupational therapy will flourish because occupation, its core, is so basic to human health yet so flexible, depending on the needs of the individual human being.
 

The model of occupational functioning leads the author to conceptualize occupation both as treatment end goal and as means to remediate impairments. In both dimensions, meaningfulness and purposefulness are key therapeutic qualities. Purposefulness is hypothesized to organize behavior and meaningfulness to motivate performance. These aspects of occupation need explication through research. Some questions that need to be answered include the following: How does purposefulness of occupation-as-end organize a person's life? Does purposefulness of occupation-as-means organize particular behavioral responses? What effect does meaningfulness of occupation-as-end have on achievement of role performance? Does meaningfulness of occupation-as-means motivate perseverance and effort during therapy?
 

Occupational therapy was founded on values of choice, relevance, and active participation in meaningful occupations. To assure choice in daily living, learning, work, and play for persons with disabilities or significant health issues, occupational therapy practitioners are challenged to gain increased understanding of the unique culture and community of each person and family with whom they work; create opportunities for these persons to develop their capabilities in community settings of their choice; promote more interactive models of practice in which the practitioner affects the arrangements between the person and society; work with communities to welcome the gifts of diversity; and develop skill in analyzing environments and facilitating environmental interaction. The environment category of the spatiotemporal adaptation theory is expanded and a communication model for collaboration in building individual community is proposed as means for addressing the challenges.
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This lecture presents an example of research in the genre of interpretive occupational science and demonstrates how occupational science can inform clinical practice. The innovative qualitative methodology used blended elements of the anthropological tradition of life history ethnography, ethnomethodology, the naturalistic methods used by Mattingly and Schön to study practice, and especially narrative analysis as described by Polkinghorne. The bulk of the paper is presented in the form of a narrative analysis that provides an account of a stroke survivor's personal struggle for recovery, a story that emerged from transcription, coding, and analysis of transcripts from approximately 20 hours of interview time. First, this narrative analysis provides an example of how the occupational science framework can evoke a particular kind of storytelling in which childhood occupation can be related to adult character. Storytelling of this kind is later shown to be therapeutic for the stroke survivor. Next, the narrative illustrates how rehabilitation can be experienced by the survivor as a rite of passage in which a person is moved to disability status and then abandoned. Finally, a picture is given of how occupational story making and occupational storytelling embedded in real life can nurture the human spirit to act and can become the core of clinical practice.
 

We work in a world of traumas and triumphs. Most of the persons we serve come to us out of necessity, struggling with the sequelae of disease and illness or the aftermath of natural or manmade disasters. We bring our expertise and compassion; they bring their bodies, minds, and compromised lives. Our worlds converge around a shared task; identifying and enhancing their capacities for daily living. We pursue problems of movement, perception, cognition, affect, and social capacity within the context of their roles and aspirations. Our contacts may be extensive, but often they are brief and only partially fulfilled. Our patients move on with varying degrees of functional ability--some with determination and buoyancy, others with little confidence that life is actually worth living. We remain, frequently knowing little about the factors that have influenced the outcome of our efforts. In spite of their compelling importance to our patients, our professional viability, and the health care system.
 

This paper presents the hypothesis that in-depth knowledge of the neurosciences serves as a common denominator that enhances our ability to interpret all aspects of human behavior. Neurobiological information can be used to design research to evaluate our existing treatment philosophy and methodology and to develop new theories and technology. Because occupational therapy addresses widely divergent diagnostic populations, three separate areas along the practice continuum were selected to demonstrate the application of neurobiological concepts: (a) neuroimmunomodulation, (b) organic bases of psychopathology, and (c) traumatic brain injury. Philosophical statements regarding effective methods of teaching neurobiology to occupational therapists are included.
 

This paper discusses the place of occupational therapy technology in practice and the growth of scientific technology. It is suggested that practice is an important source for the development of technological theory. A historical review of the treatment of hand dysfunction in cerebral palsy is presented as an illustration of the development of a specific occupational therapy technology.
 

A philosophical framework to explain the value of using activity as a treatment method is the challenge pursued for this lectureship. Primary resources came from Soviet psychology, the only social science discipline using the concept of activity as a focus of study. The focus of study selected for occupational therapy is disability, which is explained within the context of doing an activity. The patient's purpose for doing an activity is described by the degree of sensorimotor thought processed during a functional state. A hierarchy of activity analysis is used to begin the development of typologies for feasible operations, satisfactory results, and desirable activities. The philosophical framework is applied to three types of patient populations that pose problems in stating treatment objectives, patients that have (a) a good prognosis but one that is associated with alternative explanations for change, (b) a poor prognosis associated with a lifelong disability, and (c) a grave prognosis associated with a progressive loss of functional abilities. A refined treatment hypothesis is suggested: Therapeutic activity compensates for disability by using remaining capabilities to accomplish desirable activities with satisfactory results.
 

Occupational therapists have used many media and methods over the years to achieve the therapeutic potential of occupational therapy. Yet the reasons for selecting a specific medium or method frequently have been lost or changed without consideration of the result to the therapeutic situation. When neither therapist nor patient understands fully the rationale for a medium or method, the therapeutic potential of that medium or method may be compromised. The author suggests there are eight factors that influence the selection and discarding of media and methods in the practice of occupational therapy. The effects of the eight factors can be summarized in 14 assumptions. Three examples--arts and crafts, sanding blocks, and work-related programs--are used to illustrate the factors and assumptions. It is suggested that improved analysis of occupations based on values and interests could reduce the separation of meaning and purpose in the selection and discarding of media and methods used in occupational therapy practice.
 

Occupational therapists have long been concerned with the process of articulating their identity. This paper describes in detail two approaches to that process: monistic and pluralistic. It demonstrates the advantages of a pluralistic professional identity.
 

Professional evolution includes a period of disunity, a phase when old values and concepts are being examined, and new perspectives emerge. Disunity can be a positive impetus for dynamic change. Transformation provides a higher level reintegration through which new understanding and progress unfold. Occupational therapy's transformation is now; it is time for careful analysis and creative synthesis. Transformation is a three-fold process of integration of past, present, and future into an upward spiral of professional development. Transformation is a constant flow of activities influenced by both internal and external factors. Although there are multidimensions that influence occupational therapy's transformation, three major components are inherent in the profession's paradigm shift: society's decline in patriarchal authority; decline in allegiance to a biomedical model; and shift in values, dimensions of practice, and education that form the reality of occupational therapy. ...
 

As I join the roster of Eleanor Clarke Slagle lecturers, I am keenly aware of the privilege and responsibility of being so honored by my professional colleagues. Since my selection for the award was based on a recognition of a synthesis of skills in occupational therapy practice, education, and research, it seemed fitting for me to pursue a topic that would in some way enable me to reflect this synthesis. Thus, in developing the theme of clinical reasoning, I have taken a practice issue, studied it from an educational perspective, and formulated a conceptual framework for guiding the development of a clinical science of occupational therapy.
 

Occupational Therapy's roots are in the subsoil of the moral movement developed in Europe during the Age of Enlightenment. Philippe Pinel, a French philosopher-physician, and William Tuke, an English merchant-philanthropist, developed the principles and applied them to the insane in institutions. Moral treatment came to the United States as part of the Quaker's religious and intellectual luggage. It expanded rapidly in private, as well as in public, institutions for the insane. During the last quarter of the 19th century moral treatment disappeared. It re-emerged in the early decades of the 20th century as Occupational Therapy. A diverse group of women and men developed principles and definitions and founded an organization to support the practice of the re-titled moral treatment and management. Susan Tracy, a nurse; George Barton, an architect; ...