To be able to participate in one’s own life, to do the things we want to do, and to competently perform the activities that form part of our daily, weekly or monthly routines, is a common goal for most people. This not only includes taking part in the basic activities of self-care, such as grooming and dressing, but also extends to our work and leisure activities. It is through doing things that we learn and develop as human beings. The occupational therapy profession believes that being prevented or hindered in some way from participating in the activities that are important to us could adversely affect our health and wellbeing.
Health is a complex term to define because it not only means different things to different people, but is a dynamic process that changes throughout our lives (Seedhouse, 2001). It changes between people of different age groups, different genders, different cultures and different abilities (Wilcock, 2006). With so many different perspectives, it is easy to see why health is a difficult concept to define. The World Health Organisation defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (as cited in Seedhouse, 2001. p41).
This definition shows that health issues are not only concerned with disease and the physical functioning of the body, but also include a person’s state of mind and the environment and communities within which they live. In western society, health is usually linked to autonomy, the more freedom a person has to make choices and to independently participate in life, the greater their health is perceived to be (Seedhouse, 2001). Wellbeing is slightly different to health in that it has wider meaning.
It is a very personal and subjective feeling that a person has about themselves, a feeling of being content or at peace (Crepeau et al, 2009). Feelings of well-being arise when people are satisfied with life, when they are able to participate in and balance the routines that make up the fabric of their lives (Crepeau et al, 2009). To participate is to engage in activity, to be active in daily life, work, family and communities. Each individual engages in activities that are personal to them and to their routines and roles in life.
These meaningful activities are called occupations, and a healthy person is often considered to be someone who is able to competently perform their daily occupations, even despite impairment (Creek, 2003). Occupations are everything people do to occupy themselves, including washing and dressing, enjoying life and contributing to their communities through work and social engagement (Crepeau et al, 2009). These three areas (self-care, leisure and productivity) are called our occupational performance areas and it is through these different areas that people express themselves and develop their own unique occupational identity.
Christiansen (1999) proposed that meaning is what gives rise to occupational identity (as cited in Townsend and Polatajko, 2007). He argued that the link between well-being and engagement in activity could be better understood by examining a person’s occupational identity (Townsend and Polatajjko, 2007) because identity is dictated by an individual’s cultural and social environments, it defines their role in society and gives meaning to the everyday activities that they participate in (Hagedorn, 1995).
Occupations develop in childhood, but change throughout the lifespan, and it is occupation that is the core concept of occupational therapy (Kramer et al, 2003). If there is dysfunction in one of the occupational performance areas it could lead to health issues and a sense of loss of well-being (Crepeau et al, 2009). It is also important to have balance between these areas (Townsend and Polatajko, 2007). In today’s society this is most often seen in relation to the time spent in employed work and the time spent engaging in the rest of life’s activities – work-life balance (Townsend and Polatajko, 2007).
The idea of occupational balance can also be seen in older adulthood when, as a result of age, people lose their roles in life through being unable to perform the activities that make up that role. With the passing of time no longer taken up by meaningful activities these individuals become bored and ultimately depressed, quickly losing their sense of well-being. In the World Health Organisation’s Charter for Health Promotion, it suggests that in order to achieve the state of complete health it describes in its definition, it is necessary for individuals to be able to satisfy their basic needs, realise and achieve their goals, and cope within the changing world around them (Townsend and Polatajko, 2007).
Since these things are achieved through occupation, through doing things, the close link between health and occupation becomes clear (Wilcock, 2001). From an occupational perspective, doing things provides a sense of purpose and fulfilment and leads to a sense of well-being (Crepeau et al, 2009). This link between occupation, health and well-being (i. e. the fact that people are occupational by nature and that engagement in meaningful occupation is essential to health) forms part of the core beliefs and values – the philosophy – of the occupational therapy (OT) profession (Kramer et al, 2003).
OT has its foundations in both philosophy and science, but unlike other medical professions, it was the philosophy that came first (Kramer et al, 2003). Throughout the 19th century, work was seen as something that was not only good for the individual, in place of idleness, but was also good for society (Hagedorn, 1995).
It was during the early 19th century that Philippe Pinel (1809), a physician and scholar, as well as a philosopher, put forward a more humane and compassionate approach to treating the mentally ill (Kramer et al, 2003). His idea was to treat patients with a variety of occupational activities according to their individual taste, and this philosophical movement became known as moral treatment (Kramer et al, 2003). During this time it was observed in psychiatric hospitals across several countries that the patients who were engaged in doing things often made better progress than the patients who didn’t (Hagedorn, 1995).
William Tuke (1813) was a Quaker who also believed in the compassionate and kind treatment of patients with mental illness, and it was through his vision during the era of moral treatment that the philosophy of a client-centred treatment evolved (Duncan, 2011). Dr Adolf Meyer (1922), a noted Swiss psychiatrist working in the USA, built on these ideas through his interest in how occupation impacted on his patients’ lives, and had a significant role in bringing OT across the Atlantic from the USA on his several visits to the UK (Duncan, 2011). He viewed occupational therapy as important because it gave people the opportunity to engage in activities, and this contributed to improved quality of life and an improved sense of well-being (Christiansen and Baum, 1997).
Occupational therapy as we know it today emerged from the American pioneers who came from a variety of professional backgrounds, including psychiatry, medicine, nursing, design, social work and architecture (Hagedorn, 1995). Dr Meyer was one of these pioneers and it was a young graduate from Scotland working for him, Dr Henderson, who, on his return to Scotland, opened the first OT department in the UK in Glasgow in 1919, inspired by the work he did with Meyer (Duncan, 2011).
Patients with neuropsychiatric problems were among some of the first to be treated using occupational therapy, followed later by patients with physical disabilities (Kramer et al, 2003). This move to include physical disabilities coincided with advances in medicine and the need to be able to rehabilitate people who had suffered injuries at war, or industrial accidents at work, and needed to relearn skills that would enable them to continue participating independently in everyday life (Kramer et al, 2003).
By the late 19th and early 20th centuries the philosophies, values and practice of OT had begun to take shape underpinned by a scientific base of research (Hagedorn, 1995). The philosophy of OT that has provided its philosophical roots is reflected in the common beliefs of the OT profession, also known as its paradigm. A paradigm is the shared vision between the members of a profession about its most fundamental beliefs (Duncan, 2011). The contemporary OT paradigm states that occupation is central to life and provides motivation and identity to individuals (Duncan, 2011).
The profession not only believes in the importance of engaging in occupation, but also in individual empowerment, and realises how lack of access to occupations, or choice in occupations, can actually diminish quality of life and may negatively impact on health. When people are denied access to occupation (in prison for example), or are restricted from doing things (through injury or disability), this occupational deprivation and alienation prevents people from balancing their basic social, mental or physical needs, and ultimately deprives them of fulfilling social roles or having purpose in life (Wilcock, 2001a).
This shows the importance of occupational justice, or equal rights and opportunities, in the link between occupation and well-being. Occupational therapy is about assisting people to overcome limitations, or disruptions in ability, to do the things that are important to them (Mayers, 2000). Whether the disruption is temporary or permanent, occupational therapists apply strategies of compensation or adaptation to maintain the roles of daily life (Christiansen and Baum, 2005), and maintain health and a sense of well-being.
Since everything a person does is influenced by many factors both within themselves and within their environment (Duncan, 2011), it makes it difficult for a therapist to decide on an appropriate treatment plan for each individual client. Human beings are complex. They not only differ in their abilities and interests, but live in specific social and cultural environments that vary considerably from person to person (Turpin and Iwama, 2011). Levels of competency and the different physical or mental requirements needed for taking part in one’s occupations also changes across the lifespan (Turpin and Iwama, 2011).
Occupational therapists have therefore developed guides, or models, to help them embrace this complexity (Duncan, 2011). An OT model of practice sets out what a human being needs to be healthy, and is therefore a guide to the practice of occupational therapy (Turpin and Iwama, 2011). It provides a structure for organizing information and thinking about practice in a way that is in keeping with the paradigms of the profession (Turpin and Iwama, 2011).
Models of practice also provide individual occupational therapists with a language they can use to help convey the unique perspective of their profession to others (Turpin and Iwama, 2011), as well as a common language to communicate ideas within the profession. An example of an OT model of practice is the Model of Human Occupation developed by Gary Kielhofner. Also known as MOHO, it is one of the most widely used models in the practice of OT (Kielhofner, 2008). MOHO helps to explain problems that arise in the occupational performance areas due to disability or illness (Duncan, 2011).
In MOHO, humans are viewed as consisting of three interrelated parts: volition (motivation for doing), habituation (roles and routines) and performance capacity (physical and mental abilities) (Kielhofner, 2008). Volition is not simply the motivation to do occupations that meet basic needs for survival. Humans want to engage in activities that are important to them, that they feel competent doing and that satisfy them or give them a sense of well-being (Turpin and Iwama, 2011). MOHO describes these three components of volition as values, personal causation and interests (Kielhofner, 2008).
Kielhofner (2008) divides habituation into two components – habits, which consist of the repeated patterns of behaviour that happen automatically and form part of routine daily life, and roles, the personal identity of a person expressed through the occupations that they choose (Turpin and Iwama, 2011). Performance capacity is the ability to do things and can be divided into two components – objective capacity, which incorporates both the physical and cognitive capacities of the person, and subjective experiences, which refers to how a person views their own performance capacity when participating in occupations (Kielhofner, 2008).
MOHO states that what a person does in their productivity, leisure and self-care is a result of volition, habituation and performance capacity, as well as environmental influences (Kramer et al, 2003). All three of these components, although separate parts of a person, work together, along with the environment, to contribute to our experience of doing (Kielhofner, 2008). The environment is an important factor because it is where all occupations take place. It includes both the physical and social aspects of a person’s life (Kramer et al, 2003).
When an occupational therapist is deciding what treatment plan would best suit their client, all these factors (volition, habituation, performance capacity and environment) need to be considered in order to completely understand the client’s situation (Kielhofner, 2008). Different cultures place different emphasis on different activities, and therefore occupational therapists need to take this into account when planning treatment – people are more likely to be motivated to do activities that have social or cultural relevance to them (Creek, 2010).
The ideas and actions used to structure a treatment plan, or intervention, are referred to as the occupational therapy process (Creek, 2003). The OT process helps to analyse problems and find solutions through a basic sequence that involves collaborating with the client to: gather information regarding their situation and challenges, carry out assessments, identify the needs or problems of the client, set goals, decide on priorities and an action plan, decide how best to proceed, implement the action plan and finally measure the outcome (Duncan, 2011).
The intervention sequence is started when the therapist receives a referral, and the process will often be repeated throughout the course of therapy until the therapist judges the intervention to be complete (Duncan, 2011). The model of practice can be used in several stages of the OT process. In the initial stage of gathering information, for example, it is important for a therapist to find out what motivates the client, what routines or habits make up their daily life and how competent they are at performing them.
All this information is important in that it provides a base from which to measure any differences in outcome once the intervention is complete. This then allows the therapist to revise any action if need be, or set new goals. This particular model also provides the therapist with MOHO-based assessment tools that assist the therapist with information gathering (Kielhofner, 2008). The Model of Human Occupation Screening Tool, or The MOHOST, is one such tool (Kielhofner, 2008).
The MOHOST provides the therapist with a flexible and efficient way to gather information in the first stage of the OT process in order to identify the need for further assessment and to assist in treatment planning (Kielhofner, 2008). Just from this brief introduction to MOHO, we can see how it guides occupational therapists in gathering information relating to a person’s motivation for occupation, the roles and habits that are shaped by their chosen occupations and how well they are able to perform them in their social and cultural environments.
This emphasizes the fact that occupation is the core domain of concern for occupational therapy (Townsend and Polatajko, 2007). By having the client at the centre of OT process, working with them to set goals that will enable them to change or adapt to their environment, and using occupation to bring about these changes are all at the heart of occupational therapy practice. This process leads to improved health as defined by the World Health Organisation, as well as an improved sense of well-being – all achieved through meaningful occupation.
Although the occupational therapy profession has evolved and changed over time in line with current thinking and empirical evidence, it is the perspective that people are inherently occupational beings and can influence their own health and well-being through occupation that has remained unchanged. The fact that an individual’s health is influenced by many factors both within themselves and from the external environment is a holistic view unique to the profession.
The global definition of health has changed from the idea that it is simply the absence of disease to also include a person’s physical, mental and social well-being, as well as their ability to perform their roles in life competently. Occupational therapy, through its use of meaningful occupation, helps people to cope with physical or mental challenges in life, and it is occupational balance that provides health and well-being.
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People living with a physical, mental or cognitive ailment need special care and treatment to recover and maintain work skills and live daily life to its fullest. Occupational therapy does that. Occupational therapy is a healthcare profession which specializes in providing therapeutic help to people that have a physical or cognitive handicap to lead normal lives in terms of maintaining the activities that are essential for their daily living. Occupational therapy is essentially client based. It provides tailor made solutions for each individual. Professional occupational therapists do this by adopting a customized approach for each individual client. The occupational therapist works closely with each client in order to discover their personal preferences and goals and then design activities that could assist them in accomplishing those goals. By nature of their work, occupational therapists collaborate with other social workers such as nurses, speech and physical therapists and even the community.
The Subjectivity of the meaning of Occupation
It is doubtless that human life finds meaning, expression and fulfillment through occupation. Each day, human beings go through essentially the same activities that encompasses the whole gamut of human social and economic interactions as well as recreation. These activities may be classified into those activities that enable us to perform or fulfill our life roles, those that enable us to define ourselves or to express our individuality as well as those that are creative or help us to bring out the potentials of our world for the benefit of all. It is quite true that being deprived of the ability to function in any or all of these domains of activity to a reasonable degree takes away the joy and the beauty of living and limits our humanity essentially. It is in this regard that the work of occupational therapists is essential. However, defining our activities in these three basic domains is rather inadequate on its own because there is a high degree of subjectivity to all of human experiences. For instance, what constitutes a chore or a bore to one person might actually bring pleasure and a profound sense of fulfillment to another.
How do Occupational Therapists Carry out their Work?
Basically, occupational therapists do their work in three co-dependent stages. First of all, they interview the client and work with him closely to determine his life goals. Secondly, they develop customised programs that will enable him to work towards achieving those goals and then periodically they carry out an evaluation to see if those goals are being achieved. They may devise occupational activities to fit in with the client’s preferences or they may customize the environment in order to achieve the desired effect.