Politics of Occupation-Centred Practice

Reflections on Occupational Engagement Across Cultures

Nick Pollard, Dikaios Sakellariou, Nick Pollard, Dikaios Sakellariou

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118290989
• Edition: 1
• Topic: Medicine
• Subtopic: Occupational Therapy

POLITICS OF OCCUPATION-CENTRED PRACTICE
Reflections on occupational engagement across cultures

Politics of Occupation-Centred Practice: Reflections on occupational engagement across cultures addresses the cultural aspects of occupational identity and draws out the implications for practice, moving beyond the clinical environment to include the occupational therapist's work in the wider community.

It explores the development of individual occupational narratives, community traditions and their roots in everyday experiences, offering a range of examples from distinctive populations to demonstrate approaches to forming sustainable occupational engagements. Chapters span such key areas as 'Experiences of Disaster', 'Social Inclusion', 'Disability and Participation', and 'Sexuality, Disability Cultures and Occupation'.

This cutting-edge text, coordinated by two distinguished researchers and educators in the global field of occupational therapy and science, is designed to meet the needs of students studying the conceptual foundations of occupational therapy, occupational science, role emerging practice, occupational justice, community development and community-based rehabilitation. The book will also be of interest to academics and practitioners exploring new practice contexts created by the drive to address the diversity and inclusion agenda.

Chapter 1

Introduction

Nick Pollard and Dikaios Sakellariou

Although the profession is a hundred years old, in some respects occupational therapy has a short academic pedigree, with the first degree programme in the subject offered in 1947 at the University of Southern California (Gordon, 2009). Although the 1989 Blom-Cooper report (1990) stated the College of Occupational Therapists 1981 diploma was at degree level, the first degree programmes in the UK did not begin until 1986. It was not until 1994 that the profession was all graduate entry (Paterson, 2008). In this short life, occupational therapy has reportedly already been through several paradigm changes (Gilfoyle, 1984) from an initial orientation around craft activities, to activities of daily living, to adaptation, to the idea of occupation as purposeful activity, and perhaps to the emergence of occupational science where the person is recognized as an occupational being. It has produced evidence on its effectiveness and has established a role for itself within the health and social care arena. Yet occupational therapists still have a problem explaining what exactly their profession is about.

Despite the development of an array of frameworks and models for practice there is an evident lack of a unifying conceptual framework that will chart the remit and the goals of the profession and provide a comprehensive overview of its processes. The purpose of such frameworks has been to ensure that professional activities are identifiable in order that payment can be made for occupational therapy services (e.g. American Occupational Therapy Association, 2002) and also that the profession remains relevant to the changing context of practice. An agreed framework might enable the goals and effectiveness of the profession to be communicated across a variety of audiences both within and outside the occupational therapy arena but it would also present challenges. The World Federation of Occupational Therapists has issued position papers and statements acknowledging the right of all people to occupation and the profession's responsibility to facilitate this right has become a reality (WFOT 2004, 2006). There has been a continuing debate about the remit of the profession and links between the underpinning concerns of occupational therapy with meaningful occupation with an assertion of occupation as a human right (Hammell, 2008; Galheigo, 2011). There have been debates concerning the universal applicability of Western concepts of occupational therapy in different cultural contexts (e.g. Iwama, 2006) and challenges to the holism that the profession claims. Hammell (2007, 2010) is amongst those who have challenged whether the profession is really client centred or concerned with its practitioners' own needs, as a critical exploration of the profession's values might suggest (Abberley, 1995).

Developing a clear understanding of what the occupation aspect of occupational therapy refers to might increase the recognition of the profession across different contexts but the same project might generate confusions. The American Occupational Therapy Association (2002) has made several revisions to its practice framework to take account of changes as the context of healthcare develops. Occupational therapy is not yet universally available as a profession. There are many countries where occupational therapists do not yet practise widely and there are many cultural contexts that therapists have yet to encounter. The profession, despite its holistic vision, operates within certain constraints of social class and gender as well as culture (Beagan, 2007; Sakellariou and Pollard, 2008; see Chapter 2) Those therapists who are dually qualified as anthropologists might be interested in the problems generated by the differences in perception observable in applications of a clinical or technical approach to wellbeing and the experiences of those to whom such interventions might be directed (see, for example, Park, 2008). Like Mattingly (1998) we have been concerned with the variety of possible interpretations of occupation and their connection with narratives of experience. This chapter explores some historical and cultural relationships to consider how occupational assumptions may be questioned in relation to power, and some of the implications this may have for the professional position of the therapist.

The Meaning of Occupation

The profession has its origins in an understanding of the need for meaningful and balanced access to occupation (Wilcock 1998, 2002, 2006; Turner 2002) in the sense of people deriving health benefits through purposeful individual and shared activity. While this may seem a fundamental concept, over the history of the profession its focus has shifted away from a broader understanding of occupation to one more connected with work and productivity and then back again to explorations of creativity (Hocking 2007). Thus in occupational therapy the term is not a narrow ‘occupation’ merely related to social function but to a political notion of having choice, participation and sharing in the community, making changes, and requiring ‘social revolution’ (Wilcock and Townsend, 2000: 85) to address issues of disadvantage, from individual through to political and organizational expression (Wilcock, 2007). Wilcock and Townsend apply ‘meaningful occupation’ as a ‘practical means’ for ‘personal and community transformation’ (2000: 85) – that is, for enabling and facilitating individuals in role change through challenging obstacles in the community and environment.

The meaning of occupation has not much been critically explored within the profession's literature. ‘Meaningful’ is an abstract value applied to occupation (see Chapter 8 for a critical discussion of the meaningfulness of occupation – also see Chapters 9, 11, 13 and 14). An occupation might be something that produces change; it could also be something that is concerned with maintenance, and it could also have negative results. Self-destructive behaviours or activities carried out while delusional, for example, are not meaningless. The occupations connected with eating disorders, such as the monitoring of weight or food intake to maintain a distorted body image, are not without meaning to the individual. Group activities such as football violence, communal drug use, or the occupations connected with religious cults might be challenging for other people to understand, but they are not without meaning. For those people who experience them they may be intensely meaningful (Foster, 1984; King, 2001; Klein, 2007). For example, Foster's (1984) discussion of Mormons, Shakers and the Oneida religious communities of the mid-nineteenth century reveals considerable reflection amongst members about the correctness of the paths they were following in responses to social developments around them. Klein's (2007) discussion of khat in the UK Somali community makes comparisons with other societies' use of drugs and notes the suggestion of a traditional aspect in which the drug is taken partly as an expression of cultural heritage, even though in the case of khat usage dates to recent times.

Occupational therapy, as it has only recently begun to grapple with ideas of cultural competency and has rarely engaged with concepts of social class or gender, has tended to assume an uncomplicated link between doing and productivity or perhaps with spirituality. It has not really considered how the meaningfulness of human occupation might be restricted or limited within a dominant ideology, or religious “cult” (Benjamin, 1996 [1921]: 288) of capitalism. Benjamin argued that capitalism was a parasitical development of Christianity and had become a dogma that relied on the same tools of guilt and anxiety to maintain order. The present hegemony represents a capitalist order serving global corporations, and so within this context what people do is determined by a market serving the needs of these organizations to sustain profits.

Despite the widespread idea of Western democracy, much of the social order is determined by the needs of capital, and so is ordered (not necessarily strictly controlled, although at times, for example through the conditions set out by the International Monetary Fund, this may be more evident) from the board room or shareholder meetings. Whether people engage in work, are unemployed, or are able to engage in leisure, their activities are free choices inasmuch as the options available to them are what is offered to them within the limits of what they can afford to do. Other societies might be more influenced by religion, in which what is meaningful is determined by adherence to religious principle. In others the relationship of a people with their environment shapes occupations which are ordained by the availability of natural resources, but the existence of such societies, perhaps as small indigenous groups, is very much on the periphery of global society.

The subservience of global society to capital and the assumption that all engagements have a monetary value of exchange has been questioned. For example, Max-Neef (2010) has devised a matrix of human development needs that cannot be quantified. His argument is that without people there would be no money; indeed much of what may be significant to people (although many of their activities will be underpinned by the exchange of capital through work and spending for leisure) does not involve transactions of monetary value but of occupational value.

On a day-to-day basis, the identification of forms of doing that are meaningful to individuals or to communities might be determined through interwoven and shared narratives. The autobiographical writing by English worker writers (see Chapter 11) produced in the last century showed that many people defined their lives in terms of the work they did, relationships, and the places in which they lived (Ikiugu and Pollard, in press). For example, many of the titles of these autobiographies would include the names of communities (Bailey, 1981; Peckham People's History, 1983; Thompson, 1987) or identify a form of work (Noakes, 1977; Harris, 1978; Beavis, 1980; Noble, 1984). Much of these autobiographical accounts celebrates aspects of work and community, but there are also stories of survival and hardship. While survival might be a particular feature of narratives written about the interwar period (e.g. Beavis, 1980), overcoming literacy difficulties (Shore, 1982), or about racism (e.g. Noble, 1984), there can also be a feature of more recent and prosperous times, for example due to the impact of disability (Irwin, 1995).

The development of this form of autobiographical writing is much concerned with the reflection of individual experience against a background of social change (Vincent, 1981; Morley and Worpole, 2009). In a movement of worker writers and community publishers it was part of a broader counter culture that, during the 1980s and 1990s, was documenting black, Asian, gay, women's, environmental and other expressions of critical consciousness (Woodin, 2009). More often than not, this writing was not expressly oppositional, yet, just like the long tradition of ballads and broadsheets to which it is linked, it contains distinctive perspectives of class, culture and social geography that have been marginalized, suppressed or treated dismissively (Lloyd, 1969, 1978; Morley and Worpole, 2009) (see Chapter 11 – this kind of reflection on meanings of occupation in relation to community narrative is evident in many cultures and Chapters 8, 9, 10 and 14 explore further examples).

Such a link between meaning and occupation carries a very different emphasis from the restorative or recovery oriented approach of a clinical profession. Thus when Mattingly (1998) describes how the therapist may be engaged in a technical solution to disability, yet a client interprets the loss of function she experiences in a personal way, it can be seen that a perspective of doing that comes from a therapeutic position might be very limited. It might fail to respect the expression of identity that the individual possesses outside the clinical setting: a social standing in the community; a network of informal relationships, which may not conform to a hierarchically determined work setting because they have been developed over years of familiarity; social roles derived from going to the local pub or hobby club (see Chapter 13), or which are dependent on the relationships between families (see Chapter 8).

Iwama's depiction of the Kawa or river model (2006) of occupation goes some way to facilitating the recognition of these issues by situating the individual's assets and difficulties in an environmental context, often as the ‘floor’ and ‘banks of the river', which channel the individual's life flow. This model might be one means by which occupational therapists can gradually explain the right of all people to engage in occupations that correspond to their needs and desires and express their own professional responsibility to help make this right a reality, on an individual and community scale. The significance of the Kawa model is that it acknowledges a collective responsibility for occupation. The negotiation of what is to happen has to take account of the experiences that everyone brings into a situation, and questions whose meanings are being made operational (Iwama, Thomson and Macdonald, 2010).

The Term ‘Occupation’

Given the frequency with which the term is used within the profession, ‘occupation’ has been notoriously hard to define in occupational therapy. According to Townsend (1997: 19) ‘occupation is the active process of everyday living’, while the Concise Oxford Dictionary (1999 edition) defines ‘occupation’ as ‘the action, state, or period of occupying or being occupied; a job or profession; a way of spending time’. Significantly the Chambers Twentieth Century Dictionary's (1983 edition) entry on ‘occupation’ emphasizes ‘the act of occupying: possession: [. . .] the time during which a country, etc., is occupied by enemy forces . . .’ This immense scope encompassed by its reference to human activity is an issue of definition, as several authors have recently acknowledged through their discussions of occupation in relation to complexity (do Rozario 1997; Creek, 2003; Molineux and Rickard, 2003; Whiteford, Klomp and Wright St Clair, 2005; Molineux and Whiteford, 2006). Like language, which has many uses and functions and may operate different forms of speech and expression to accommodate these even within a particular tongue, occupation is not one discrete aspect of human life but describes a form of engagement that reaches every area of human activity through its relationship to culture (Wilcock, 1998; Iwama, 2006). In professional literature occupation is described as basic to the experience of wellbeing (Wilcock, 2006). Occupation influences identity formation and is the means through which people perform the requirements of their multiple roles. Among other functions, occupation provides a sense of meaning, a time structure and a daily routine, can be a source of pleasure and of a sense of achievement, promotes interpersonal relationships and helps people to be aware of the capabilities of their bodies (Wilcock, 2006).

Efforts to delineate the meanings of the term accuratel...

Table of contents

• Cover
• Title Page
• Copyright
• List of Contributors
• Foreword
• Acknowledgements
• Chapter 1: Introduction
• Chapter 2: The Language of Occupation
• Chapter 3: Occupational Literacy
• Chapter 4: A Grammar for a Language of Occupation
• Chapter 5: Towards a Transformational Grammar of Occupation
• Chapter 6: Narratives of Recognition
• Chapter 7: Narratives and Truths
• Chapter 8: Occupation in a Greek Town: Flowing, Emergent, Flexible across Time and Space
• Chapter 9: Indigenous Ainu Occupational Identities and the Natural Environment in Hokkaido
• Chapter 10: People with Disabilities and Participation: Experiences and Challenges of an Occupational Therapy Practice in the City of São Paulo, Brazil
• Chapter 11: Communities of Writing
• Chapter 12: Disability, Sexuality and Intimacy
• Chapter 13: Models and Human Occupation
• Chapter 14: Participation, Time, Effort and Speech Disability Justice
• Chapter 15: A Society Founded on Occupation
• Index