Occupation Is Central to the Practice of Occupational Therapy - Essay Example

Occupation can best be described as human activity that is acted out with purpose within a space, and that has meaning for the actor (Blair, 2000; Christiansen & Townsend, 2003). Occupational therapists encourage and support the use of occupation as a method of promoting rapid health gains, and of enhancing existing health and well-being. It is recognized by occupational therapists that the awareness of the conscious intentions and goals of an individual as they carry out their occupation will provide understanding of the purposive influences of the occupation for the person (Christiansen & Townsend, 2003; Fisher, 1998). The following paper will focus on the importance of occupation as defined within the discipline of occupational therapy. Firstly, a literature review of the concept of occupation will be presented. Secondly, case studies will be reflected upon as examples of the use of occupation within different contexts, and will incorporate examples of occupational deprivation and occupational justice. Next, a concise action plan will be outlined to determine essential areas of future practice for an occupational therapist. Finally, the conclusion shall summarise the provided arguments, and provide recommendations for future practice and research within occupational therapy. From the initiation of occupational therapy as a discipline the importance of occupation as an intervention has been debated (Christiansen & Townsend, 2003; Jackson, 1998; Nelson, 1996, 1997). However, a growing number of contemporary practioners argue that occupation as a therapeutic intervention is the keystone of the discipline of occupational therapy (Christiansen & Townsend, 2003; Hammell, 2004; Royeen, 2002). As a concept occupation can be considered to be intentional activity that is structured to enable purposeful and meaningful survival (Crabtree, 1998). These pursuits are structured around social roles, day to day living, work and leisure, for survival and to provide purpose to one's existence. For each person, their occupation is unique in that it consists of the set of pursuits that are uniquely relevant to their life (Christiansen & Townsend, 2003). The ability to meet one's goals is impacted by a person's expectations, feelings of effectance and attributions (Christiansen & Townsend, 2003). It was during the 1970s that occupational therapists became aware of a more direct relationship between mind and body, and that a purely mechanical approach to therapy, that is movement for movements sake, did not fully encompass the complex biopsychosocial nature of rehabilitation (Molineux, 2000). It was during this period that occupational therapists began to understand the integral role occupation has for human well-being. However, debates rose as to the degree that occupation was actually recognized as a central factor in occupational practices (Molineux, 2000). Little (1993) argued that occupational therapists needed to shift their focus to the day-to-day needs of people with disability. Problem-solving, contends Little, needs to be extended to occupation incorporating participation with wider society, such as how to catch a bus and maintain one's dignity, as well as problem-solving activities such as dressing and toileting (Little, 1993). As such, Little contends that an orientation towards issues that occur during performance of occupations needs to be taken up by occupational therapists (Little, 1993). In 1997 Kielhofner suggested that a new approach to occupational therapy was forming (cited in Molineux, 2000). An approach that embraced occupation as essential to human well-being, acknowledged that occupation could become dysfunctional, and that once again emphasized occupation as a therapeutic treatment (cited in Molineux, 2000). Although this approach appears to emphasise the original intentions of occupational therapy, that is, a focus on occupation, the current approach brings with it new elements. Importantly, it is that occupation has become the dominant concept of occupational practice, in fully understanding what it is to be human and in supporting and compensating dysfunction (Molineux, 2000). This reflects a western post-modern philosophy, in that human beings are seen as essentially occupational beings, a moving away from the idea that occupation is a facet of human experience, albeit an important one (Christiansen & Townsend, 2003). Similarly, health and ill health are also viewed in terms of occupation, so that dysfunction is extended beyond the mind/body continuum (Molineux, 2000). The key concept that has remained since the origins of occupational therapy is that occupation can rehabilitate lost function. However, Wilcock (1991) argues that aspects of the discipline's previous mechanistic outlook continue to contribute to the current paradigm in which components of performance continue to be focused upon. To counteract this reductionist trend, it is seen as important to encourage occupational therapists to re-engage with their science, its philosophies, and to once again acknowledge the essential role occupation has to play in human health (Molineux, 2000). Although, the emerging paradigm extends the idea of humans as occupational beings to be inclusive of its multidimensional nature, and so includes psycho-social and cultural factors that contribute to health (Molineux, 2000). In light of these changes in philosophical approach to occupational science, important issues for discourse have been identified for occupational therapists, namely that due to the current direction of the discipline, practioners do not fully understand the concept of occupation, nor fully appreciate the role of occupation in the lives of their clients (Molineux, 2000). As such performance components become the focus of rehabilitation, at the expense of occupation as a whole. Hence, clients are able to perform tasks that have little relevance to occupations that they actually engage in during their life. For example, being able to sort coloured blocks but remaining unable to sort whites from colours for washing (Lewis, 1987). Wilcock (2001) contends that this reflects a disengagement with the philosophy of the science, and an over emphasis on adapting to individual situations. As such, the discipline of occupational therapy has drifted away from occupation as the focus of its practice (Whitlock, 2001). Many within the discipline consider contemporary occupational therapy disengaged from the original philosophical discourse, instead practicing a reductionist medical model (Molineux, 2000). It is argued that the dominance of the medical model serves to dis-empower those experiencing disability as the approach sees the client as experiencing a "problem", and ignores the concept of collective wellbeing (Christiansen & Townsend, 2003; Townsend, 2003b; Unrah, 2004). Wilcock (1998) attributes this dis-engagement to an increase in scientific reductionism, a growing gender bias within the discipline, an increase in growth of scientific professionalism, and a growing emphasis of occupational therapy as a prescription. It is argued that it is necessary for occupational therapists to uphold the authority of therapeutic occupation by contributing to research which questions and monitors the disciplines key practices (Christiansen & Townsend, 2003; Yerxa, 1998a). One way to achieve this is to cultivate the use of the term occupation during discourse with clients, colleagues and members of the public (Yerxa, 1998b). Additionally, occupational therapists need to recognize and promote their approach to the human experience, health and dysfunction as different to that of other professions (Molineux, 2000). Occupational therapy needs also to consider issues of power and justice in regards to occupation (Christiansen & Townsend, 2003). These concepts involve relationships of power and how they inhibit or encourage occupation of a client (Townsend, 2003). In such a way occupational therapists can more fully incorporate an awareness of social issues and social justice, orientating towards a more just society in which those who are marginalized due to disability are enabled to assist themselves, and to be active agents who participate fully in their lives as social and occupational beings (Christiansen & Townsend, 2003). Occupational injustice can be seen in the elitist approach of many interventions being provided to those who are able to afford them, as opposed to those who are in greatest need (Townsend, 2003b). Occupational apartheid refers to the distance between those who experience meaningful occupation and those who, through isolation or other inhibition, are deprived of experiencing meaningful occupation (Townsend, 2003b). Townsend describes occupational apartheid as the taking-for-granted, exploitation and disregard for some occupations, whilst others are paid and valued as benefiting to greater society as well as the life of the individual (Townsend, 2003b). Especially, occupational therapists are encouraged to make visible these injustices, and to promote the discussion and questioning of occupational apartheid and injustices (Townsend, 2003b). Occupational deprivation is a concept used to represent the experience of people who are experiencing occupational apartheid, and so are occluded from fully engaging in meaningful occupations as a result of circumstances beyond their control (Whiteford, 2000). With globalization and the increasing socio-economic divide it is argued that occupational deprivation will be experienced by more people across the globe (Whiteford, 2000). Access to meaningful occupation is a dominant consideration of occupational justice. Those who are excluded from participating in paid employment, or are isolated or confined to low income households, or those who are marginalized due to poverty that tends to accompany disability, are often those who experience occupational injustice (Townsend, 2003a). Occupational justice requires a holistic approach to the therapeutic process, in which the interrelationships of the disabled person within the larger community are taken into consideration (Christiansen & Townsend, 2003; Townsend, 2003a). As such, diversity is embraced, and not considered to be a "loss" or "problem", cultivating an acceptance for all levels of ability to perform occupations (Townsend, 2003a; Unrah, 2004). Occupational justice focuses on ending occupational apartheid and deprivation by looking to enable and empower those with disability who may be marginalized (Townsend, 2003a). Townsend (2003a) states that participation is the keystone of occupational justice, and that this entails the fair distribution of power to clients for decision-making during rehabilitation, and inclusion in the delegation of authority and responsibility of occupational therapy. During practical, students of occupational therapy are able to observe first hand, the meanings experienced and expressed of clients who find themselves occupationally deprived. Yerxa (1998a) encourages a naturalistic design when enquiring into where and how people carry out their occupations, to be able to observe when and what affects a person's performance that results in the person that they are. As such, a naturalistic paradigm allows for focus on the subjective experiences of the client (Christiansen & Townsend, 2003). Mrs Smith is a 71 year old widower, lives in her own home alone, except for her dog. Mrs Smith is not entirely isolated from society, as she has constant contact with her son and daughter, and assistance from neighbors as well as home help visits at least once a week. As such, Mrs Smith may not be considered to be marginalized from society to a high degree and it interesting to note that Mrs Smith owns her own home, which places her within the higher social and economic bracket that Townsend (2003a) refers to in regards to unequal distribution of resources dependant on socio-economic status. However, Mrs Smith does experience occupational deprivation in regards to being hindered from daily activities, such as bathing, due mostly to her lack of confidence to bathe following an accident involving hot water. When asked about her treatment goals, Mrs Smith explained that being able to regain her dignity as an independent person would enable her to more fully participate in life's occupations. Mrs Smith is currently recovering from extensive burns to her body due to being unable to turn off a hot water tap, and not being able to remove herself from a hot bath. Her experience at not being able to independently move herself from a situation as simple as a bath has had adverse affects on Mrs Smith's self-evaluation. The incorporation of Mrs Smith's expectations into the therapeutic process is an example of the occupational therapist focusing on a holistic approach to treatment (Hinojosa & Kramer, 1997; Townsend, 2003a; Zemke, 2004), and including Mrs Smith in the decision making processes. Additionally, Mrs Smith identified wanting to improve her mobility and confidence with personal daily activities (PADL) as other occupations she wished to focus the therapy on. Her mobility issues were mostly concerned with sitting, washing, dressing and walking. It is evident that these occupations are integral to Mrs Smith's concept of her self, and that her occupational deprivation in these areas has affected her self-confidence (Townsend, 2003a). As part of the occupational justice in Mrs Smith's situation it is a positive that the occupational therapist agreed to the client's wish to take a step-by-step approach to her rehabilitation. It is recommended that the occupational therapist use the client-centered approach of the humanistic school of thought, as it emphasises the principles of occupational justice (Christiansen & Townsend, 2003). For example, the inclusion of the client in determining outcomes for therapy, and focusing on the client's sense of self-worth. In contrast, Miss C, a client with learning disability who lives on her own, maintains a healthy confidence and sense of interest in new activities though she is much more marginalized than Mrs Smith. Although her two brothers live nearby, Miss C does not receive the social contact she desires from life, and this appears to be her primary occupational deprivation. Miss C attends a Day Care centre twice a week, and has undertaken computer tutoring whilst at the centre. She also likes to keep herself busy with crafts at home. However, Miss C has expressed the desire to experience new places and activities which she feels she is marginalized from at the moment, by virtue of her disability. Particularly, Miss C wishes to gain more independence over her life in regards to nutrition and cooking, she is presently obese, and has in the past relied heavily on her mother for assistance in the kitchen. Miss C's mother is recently deceased, and this has further isolated her from fully participating in society, in regards to social outings and social interaction. Miss C was fully included in the assessment of her goals for meaningful occupation, which she identified as primarily cooking. She feels her confidence in the kitchen has diminished as her mother is not longer around to assist and instruct when necessary. However, her occupational deprivation appears to be focused on her level of confidence, as observation of Miss C within the kitchen showed that she was quite confident with an assortment of activities. Although, her illiteracy does add to her experiences of occupational deprivation in that she is placed at a health and safety risk in not being able to read cooking instructions, and so fully experience independence in choosing what to cook. And also, her inability to read used-by-dates places her at risk of ill health. The occupational therapist's focus on cooking as a meaningful occupation for Miss C identifies their participation in occupational justice, in that they are enabling Miss C to achieve her own personal goals, and encouraging her agency to become more independent (Whiteford, 2000). However, it does not appear that the occupational therapist has considered the necessity for Miss C to improve her reading abilities, although she is learning to use a computer. Other areas of meaningful occupation for Miss C include leisure activities she takes part in at the Day Care centre. Although Miss C has expressed the desire to further enhance her independent mobility to be able to go to places she has not been to, and to experience activities that will help her stay busy and sociable. Miss S also experiences a learning disability, as well as congenital deformities that are progressively worsening. Although she has at the moment a moderate degree of independence, due to her wheelchair, her disability results in a progressive decline in her ability to care for herself. Her dominant occupational deprivation is the increasing need to rely on others for basic daily living tasks, such as toileting, showering, sleeping and transferring herself from her wheelchair. It is expected that in the near future Miss S will require 24 hour assistance as well as support with activities such as sitting and posture. However, presently, Miss S wishes to focus on meaningful occupations such as independence at cooking, and independent mobility around her home which she is moving to in a few months. Her increasing loss of independence is the dominant occupational deprivation fro Miss S. The intervention selected for Miss S was the Frames of Reference (FoR, Turner et al, 2000). It is a highly appropriate therapy in that it attends to sensorimotor, cognitive-perceptual, and social and personal aspects of Miss S's life. It is a theory that also acknowledges her potential for development and adaption to her continually changing circumstances. Also, the theory engages the client in active participation of the therapeutic process, and supports the ideal of differences in levels of functioning being valid to experiences of wellbeing, regardless of their level of functioning. However, the theory is grounded in a medical model approach and so has a tendency to reduce occupational issues, segmenting issues of occupational deprivation rather than taking a holistic approach (Christiansen & Townsend, 2003). It is recommended that the occupational therapist more fully incorporate occupational justice by way of focusing on the personal goals and expectations of Miss S in regards to the directions of her therapeutic treatment. As future occupational therapists students need to develop an action plan that incorporates a primary goal of maintaining occupation as a central theme (Christiansen & Townsend, 2003; Townsend, 2003b). As such, the focus needs to be on a client-centered approach that incorporates occupational justice to fully enable and empower the client, educate the public, and encourage debate with colleagues as to the principle goals of our discipline. Possible positive actions could include: Become an active member of the British Occupational Therapists Association. Develop a vision statement that incorporates the rights of the therapist, clients and society as a whole. Maintain an ethical approach to the practice of occupational therapy. Maintain knowledge of current trends and debates within the discipline of occupational therapy. Cultivate an awareness and respect for issues pertaining to occupational deprivation, apartheid and justice. Gain work experience with professionals across a wide variety of contexts and occupations. Promote client participation in setting therapeutic goals, decision-making and identification of their needs and expectations for outcomes. Encourage and empower clients to recognize their agency in the therapeutic process. Encourage clients to recognize their rights to meaningful and purposeful occupation. Undergo continual evaluation of personal practices and intervention processes to ensure the highest level of service to myself, my colleagues, my clients and society as a whole. Maintain continual annual evaluation. In conclusion, the concept of occupation has continued since the inception of occupational therapy as a discipline. However, contemporary practice sees an emergence of the concept as a dominant factor in the practice of the science. As such, students of occupational therapy are encouraged to re-engage with the philosophy of their discipline, and to reflect on their understandings of humans as occupational beings, and of occupation as meaningful and purposeful activity that incorporates biopsychosocial aspects of daily living. Issues of occupational apartheid and occupational deprivation inform the therapist of how best to attend to the client's experiences and expressions of meaning in regards to their occupations. Occupational justice requires that the therapist once again focus on occupation during rehabilitation, and to empower and enable the client to more fully engage in the decision-making processes that comprise occupational therapy. References Blair, S E (2000) The centrality of occupation during life transitions. The British Journal of Occupational Therapy, 63(5): 231-237. Christiansen, C & Townsend, E (2003) Introduction to occupation: The art and science of living. Prentice Hall: New York. Fisher, A G (1998) Uniting practice and theory in an occupational framework. American Journal of Occupational Therapy, 52(7): 509-521. Hammell, K W (2004) Dimensions of meaning in the occupations of daily life. Canadian Journal of Occcupational Therapy, 71(5): 296-305. 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British Journal of Occupational Therapy, 64(8): 412-417. Yerxa E J (1998a) Occupation: The keystone of a curriculum for a self-defined profession. American Journal of Occupational Therapy, 52(9): 770-773. Yerxa, E J (1998b) Health and the human spirit for occupation. American Journal of Occupational Therapy, 52(6): 412-418. Zemke, R (2004) The 2004 Elanor Clarke Slagle Lecture: Time, space, and the kaleidoscopes of occupation. British Journal Occupation Therapy, 58(6): 608-620. Read More