Philosophical Basis Of Occupational Therapy

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10th May 2017 Health And Social Care Reference this

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This paper aims to explore the defining of occupational therapy together with its philosophical basis, discussing the relationship between the philosophy of occupational therapy and practice, including the role of the College of Occupational Therapists (COT) and the Health Professions Council (HPC). This paper is going to be structured in essay form, beginning with a discussion of definitions of occupational therapy and the development of occupational therapy as a profession. Also discussed will be the roles of the COT and HPC with regards to occupational therapy training and practice. The HPC is the regulating body of occupational therapists, as well as fourteen other health professions such as speech and language therapists, biomedical scientists and practitioner psychologists. The HPC’s primary function is to protect the public by dictating standards which the health professions must meet in both their training and practice (HPC, 2010a). The COT (also referred to as the British Association of Occupational Therapists or BAOT) is the professional body for occupational therapists and occupational therapy assistants in the United Kingdom (COT, 2010b).

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It is important to define occupational therapy and have a broad knowledge about the profession as there has been a lot of role blurring and ambiguity with other health professions such as physiotherapists (De Wit et al 2006) particularly since occupational therapy gained interest in the area of psychosocial rehabilitation in the late 1980’s/early 1990’s (Söderback, 2009). This role blurring means occupational therapy as a profession is in danger of being seen as surplus to health authority requirements. With the current economic climate in a state of uncertainty it has been reported that the Government plans to cut funding to the National Health Service by £20bn (Borland, 2010). If frontline staff are being cut, allied health professionals who cannot justify and defend their profession are at risk of being seen as expendable. Alternatively, role blurring can also mean occupational therapists are at risk of being utilised as more than one profession, for example a social worker (Holosko & Taylor, 2006). The COT website clearly states the need for its members acting as ambassadors of the profession (COT, 2010b) implying the need for justification of occupational therapy is widely felt.

This role blurring and ambiguity could be seen as both a cause and effect of the profession lacking a single, clear definition from which all bodies can explain occupational therapy. A single definition that encompassed all merits of the profession could give a clear justification of what therapists do and could be used to support their practice. However, there are many different definitions and newly qualified occupational therapists find it hard to explain to carers what their profession involves (Williams & Richards, 2010). The COT itself changes the definition it releases over the years. The current BAOT definition encompasses the ideas of health and wellbeing obtained through occupation (COT, 2010a). This COT definition has no mention of occupations being meaningful or purposeful which is a core concept in occupational therapy. The idea of giving people meaningless tasks is outdated in modern theories so this definition has limitations. The COT (2009a) released a much broader definition which encompasses a lot more of the theory of occupational therapy and more of the basis in which it is rooted. However, the terms used in this definition are very specific to occupational therapy and if someone outside of the profession were to read it, many of the terms would read as jargon, rendering the definition incomprehensible. On a positive note, this definition does mention fulfilling a persons potential and their quality of life which is an idea central to the philosophy of occupational therapy which many other definitions omit. The Committee of Occupational Therapy for the European Committees (1990) definition talks predominantly of preventing disability and promoting independent function. Even though this definition is fairly broad and encompassing, these two terms rule out a certain number of clients that an occupational therapist could work with. This definition implies that only people whose disability can be prevented and people with the potential to function independently would be assisted by occupational therapy. However this is not the case, occupational therapy has been applied to many areas of severe disabilities such as advanced HIV infection (Parutti et al, 2007).

Other definitions incorporate ideas of competency and satisfaction (Knecht-Sabres, 2010) analyzing qualities of activities (Larson & Von Eye, 2010) and everyday activities and subjective and objective aspects of performance (AOTA, 2002). So with so many differing ideas about what should be in a definition of occupational therapy, what important points should a good definition cover? Reed & Sanderson (1999) outlined the criteria a definition should meet in modern occupational therapy. These included the unique feature of occupational therapy, major goals, outcomes, the population served, a summary of the service programmes and the process in which the service is delivered (Reed & Sanderson, 1999, pp. 6).

One reason occupational therapy may be difficult to define as a profession worldwide is due to the cultural differences. Occupational therapy is important in certain life aspects to a particular population and this may not be generalisable. For example, in Belgium the Fédération Nationale Belge des Ergothérapeutes (FNBE) has a definition which focuses in part on professional occupation, as well as activities of daily living and leisure (FNBE 2010). The Bangladesh Occupational Therapy Association (BOTA) incorporates the ideas of therapeutic exercise, special equipment and special skills training into its definition (BOTA, 2010). The Occupational Therapy Africa Regional Group (OTARG) is largely focused on the rehabilitation of disabled people in Africa (OTARG, 2010) but has recognised the need to apply culturally correct interventions to their clients dependent on what that specific region requires as many of the countries that are part of OTARG are poverty-stricken and there is a significant lack of resources available (Crouch, 2010). These cultural differences are indicative of the breadth to which occupational therapy can be used yet how it can make finding a single definition for the profession practically impossible to pin down.

Finding a definition that utilises all of the concepts inherent in occupational therapy is also difficult due to the fact that the profession is ever changing and evolving. George Barton encapsulated one of the earliest definitions of occupational therapy in its history:

“OT is the science of instructing and encouraging the sick in such labours as will involve those energies and activities producing a beneficial therapeutic effect.” (Barton, 1919, pp.62)

Although this definition was over eighty years ago, much of what was in this definition is still applicable to occupational therapy today, however the profession has been through some major transitions since. The foundations were grounded in a number of historical influences such as the arts and crafts movement, the influence of the Quakers and the mental hygiene movement, amongst others (Reed & Sanderson, 1999). One of the most influential however was the moral treatment movement, borne out of the humanistic frame of reference which introduced the concept of work having a positive effect on health (Söderback, 2009). The first paradigm of occupational therapy reapplied the moral treatment ideals in caring for ill and disabled people. The core beliefs of this paradigm focused on the occupational nature of human beings and the interrelationships between the body, mind and environment (Kielhofner, 2009). Some of the core skills and processes of occupational therapy that are used today could have been inherent in the profession since the very first paradigm such as using activities as therapeutic interventions and assessments of the occupational performance of clients (COT, 2009b). In the late 1940’s occupational therapy was swept into reductionist ideals and a need for a theoretical rationale. This new paradigm is referred to as the mechanistic paradigm and – using the biomedical frame of reference – focused largely on what could be measured quantitatively and scientifically, particularly with; the systems in the body, the neuromotor control and muscuoskeletal performance (Kielhofner, 2009). Some core skills of occupational therapy are rooted in the main ideas of the mechanistic paradigm such as enablement and environmental adaptations (COT, 2009b). Certain stages of the process of occupational therapy could have been developed through the beliefs of the mechanistic paradigm too, in particular the assessment stage which involves assessing clients strengths, weaknesses, environments and support systems. Another stage which could be linked to the mechanistic paradigm is the intervention stage. This involves engaging in activities that have been analysed, graded and sequenced (Larson & Von Eye, 2010) which is also a quantitative and reductionist ideal. The scientific aspect of the paradigm did better establish the profession with the World Federation of Occupational Therapists being inaugurated in Stockholm in 1952 (Söderback, 2009). The mechanistic paradigm, however, lost sight of the origins of occupational therapy; that occupation was central to the profession and that engagement in occupation can be beneficial to health and wellbeing. Mary Reilly, a fundamental figure in the profession in 1962 gave a seminal lecture and definition that was to change the outlook of the profession once again:

“Man, through the use of his hands, as they are energised by his mind and will, can influence the state of his own health.” (Reilly, 1962, pp. 2)

This direct quote encapsulates the change that ended the mechanistic paradigm of occupational therapy and recognised the need to return occupation to the centre of occupational therapy (Molineux, 2004). Following the mechanistic paradigm, a new paradigm emerged which Kielhofner (2009) coined the contemporary paradigm. This paradigm is that in which occupational therapy is practiced today. This focuses on the belief that occupation is central to health and wellbeing and the profession should focus on occupational needs and how neuromotor and musculoskeletal limitations affect a clients occupational performance, as opposed to what the limitations are. This paradigm focuses on the interrelationships between a person, their environment and their occupation (Kielhofner, 2009). There are, however, some new ideas that were not inherent in the original paradigm such as the client-centred frame of reference and the use of client-centred practice. In 1919, Barton wrote that “the patient cannot be trusted to select his own occupation” (Barton, 1919, pp. 20). In the contemporary paradigm, client-centred practice defines the client as having more of a choice and more power in the client-therapist relationship (Sumsion, 2006) and Bartons ideas would not be acceptable. There are three main roles that have been identified as important for occupational therapists; the therapeutic role, the consulting role and the team member role (Söderback, 2009). These roles are fairly modern ideas that are borne out of the beliefs of the latest paradigm.

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The COT became a member of the World Federation of Occupational Therapists in 1952 (WFOT, 2010) when it was first set up during the mechanistic paradigm. The role of the COT is to set professional guidelines which occupational therapists and students must adhere to in practice, with regards to service user welfare, provision of the service, personal and professional integrity, competence, continual professional development and developing the evidence base of the profession (COT, 2010a). The HPC state they protect the public by having professional standards and guidelines that must be met by the professions that they govern (HPC, 2010a). They have a register of all of their health professionals which members of the public can check to make sure any professional working with them is registered, qualified and competent (HPC, 2010b). The HPC also deals with all disciplinary matters and has three different committees for dealing with fitness to practise hearings with registered professionals; the conduct and competence committee, the health committee and the investigating committee (HPC 2010c). As well as protecting the public against incompetent practitioners, the guidelines put in place could also be to protect the profession against scrutiny or disrepute. The COT and HPC are an integral part of practising as an occupational therapist and students are provided with their own copy of the COT Code of Ethics and Professional Conduct to read and digest. However, a big problem of the students of occupational therapy and other professions once qualified is the theory/practice divide; a student can have all the theoretical knowledge needed but lack the ability to effectively apply that knowledge to practice. Core areas in occupational therapy that are limited due to a lack of practice experience include client-centred care, enhanced clinical reasoning skills, the development and use of a therapeutic relationship and a deep appreciation of the person, environment and occupation impact (Knecht-Sabres, 2010). It may be said that this lack of practical experience is due to the strict guidelines of education in the COT. A large body of knowledge has to be understood in order to qualify and register as an occupational therapist. However the COT also have guidelines about how much clinical experience a student needs before they can qualify so they do recognise the need for practice-based learning and incorporate it as much as possible. Once qualified, the COT and HPC guidelines on continual professional development state that a registrant must continue learning and be up to date with policy, guidelines and research. This aims to ensure that practices do not become outdated which would widen the divide between core theory and practice. The Code of Ethics and Professional Conduct (COT, 2010a) being handed out to all students and professionals is a good basis for students to start from before their practice placements, yet it may be hard to practically apply what is in the Code until it is ingrained in ones knowledge of how to apply it in practice. One way suggested in which to bridge the theory and practice divide whilst learning in an institution with limited clinical experience is a good use of reflective practice. Reflecting in action during an intervention as well as reflecting on action (Schön, 1983) can enhance advanced clinical reasoning skills which would help bridge the divide (Knecht-Sabres, 2010).

In conclusion, occupational therapy is a valid and important practice when used in accordance of the Code of Ethics and Professional Conduct and the HPC guidelines. These guidelines are in place to safeguard clients and also the therapists themselves against practicing at an incompetent standard. These guidelines make it possible to further, justify and develop the profession and provide a definition or definitions in which to explain occupational therapy. There are, however, a large amount of standards to consider which one can read but will not become ingrained unless returned to repeatedly or learned and used in context. The true benefit of occupational therapy can get lost amongst the standards and guidelines as they can lead to a lack of clinical experience, a lack of reflecting in-action and perhaps issues of client-centred practice. One example is: if a client wants to work on their planned interventions late but it would interrupt with record-keeping due to time restrictions a therapist would have to refuse as record-keeping is an important part of COT guidelines, but this would not be strictly client-centred practice. Also a clients’ idea of a good quality of life may be different to that of the COT and HPC and it is the responsibility of the therapist to set out guidelines of what is acceptable, regardless of client choice. The profession, as shown in this paper is also ever-evolving and developing. It could be difficult to abide by the standards if the standards themselves are ever-changing. This is where continual professional development is a beneficial practice in overcoming this issue. The COT also sends out free copies of the British Journal of Occupational Therapy and the OT News, enabling all members to keep up to date with modern ideas and research.

This paper aims to explore the defining of occupational therapy together with its philosophical basis, discussing the relationship between the philosophy of occupational therapy and practice, including the role of the College of Occupational Therapists (COT) and the Health Professions Council (HPC). This paper is going to be structured in essay form, beginning with a discussion of definitions of occupational therapy and the development of occupational therapy as a profession. Also discussed will be the roles of the COT and HPC with regards to occupational therapy training and practice. The HPC is the regulating body of occupational therapists, as well as fourteen other health professions such as speech and language therapists, biomedical scientists and practitioner psychologists. The HPC’s primary function is to protect the public by dictating standards which the health professions must meet in both their training and practice (HPC, 2010a). The COT (also referred to as the British Association of Occupational Therapists or BAOT) is the professional body for occupational therapists and occupational therapy assistants in the United Kingdom (COT, 2010b).

It is important to define occupational therapy and have a broad knowledge about the profession as there has been a lot of role blurring and ambiguity with other health professions such as physiotherapists (De Wit et al 2006) particularly since occupational therapy gained interest in the area of psychosocial rehabilitation in the late 1980’s/early 1990’s (Söderback, 2009). This role blurring means occupational therapy as a profession is in danger of being seen as surplus to health authority requirements. With the current economic climate in a state of uncertainty it has been reported that the Government plans to cut funding to the National Health Service by £20bn (Borland, 2010). If frontline staff are being cut, allied health professionals who cannot justify and defend their profession are at risk of being seen as expendable. Alternatively, role blurring can also mean occupational therapists are at risk of being utilised as more than one profession, for example a social worker (Holosko & Taylor, 2006). The COT website clearly states the need for its members acting as ambassadors of the profession (COT, 2010b) implying the need for justification of occupational therapy is widely felt.

This role blurring and ambiguity could be seen as both a cause and effect of the profession lacking a single, clear definition from which all bodies can explain occupational therapy. A single definition that encompassed all merits of the profession could give a clear justification of what therapists do and could be used to support their practice. However, there are many different definitions and newly qualified occupational therapists find it hard to explain to carers what their profession involves (Williams & Richards, 2010). The COT itself changes the definition it releases over the years. The current BAOT definition encompasses the ideas of health and wellbeing obtained through occupation (COT, 2010a). This COT definition has no mention of occupations being meaningful or purposeful which is a core concept in occupational therapy. The idea of giving people meaningless tasks is outdated in modern theories so this definition has limitations. The COT (2009a) released a much broader definition which encompasses a lot more of the theory of occupational therapy and more of the basis in which it is rooted. However, the terms used in this definition are very specific to occupational therapy and if someone outside of the profession were to read it, many of the terms would read as jargon, rendering the definition incomprehensible. On a positive note, this definition does mention fulfilling a persons potential and their quality of life which is an idea central to the philosophy of occupational therapy which many other definitions omit. The Committee of Occupational Therapy for the European Committees (1990) definition talks predominantly of preventing disability and promoting independent function. Even though this definition is fairly broad and encompassing, these two terms rule out a certain number of clients that an occupational therapist could work with. This definition implies that only people whose disability can be prevented and people with the potential to function independently would be assisted by occupational therapy. However this is not the case, occupational therapy has been applied to many areas of severe disabilities such as advanced HIV infection (Parutti et al, 2007).

Other definitions incorporate ideas of competency and satisfaction (Knecht-Sabres, 2010) analyzing qualities of activities (Larson & Von Eye, 2010) and everyday activities and subjective and objective aspects of performance (AOTA, 2002). So with so many differing ideas about what should be in a definition of occupational therapy, what important points should a good definition cover? Reed & Sanderson (1999) outlined the criteria a definition should meet in modern occupational therapy. These included the unique feature of occupational therapy, major goals, outcomes, the population served, a summary of the service programmes and the process in which the service is delivered (Reed & Sanderson, 1999, pp. 6).

One reason occupational therapy may be difficult to define as a profession worldwide is due to the cultural differences. Occupational therapy is important in certain life aspects to a particular population and this may not be generalisable. For example, in Belgium the Fédération Nationale Belge des Ergothérapeutes (FNBE) has a definition which focuses in part on professional occupation, as well as activities of daily living and leisure (FNBE 2010). The Bangladesh Occupational Therapy Association (BOTA) incorporates the ideas of therapeutic exercise, special equipment and special skills training into its definition (BOTA, 2010). The Occupational Therapy Africa Regional Group (OTARG) is largely focused on the rehabilitation of disabled people in Africa (OTARG, 2010) but has recognised the need to apply culturally correct interventions to their clients dependent on what that specific region requires as many of the countries that are part of OTARG are poverty-stricken and there is a significant lack of resources available (Crouch, 2010). These cultural differences are indicative of the breadth to which occupational therapy can be used yet how it can make finding a single definition for the profession practically impossible to pin down.

Finding a definition that utilises all of the concepts inherent in occupational therapy is also difficult due to the fact that the profession is ever changing and evolving. George Barton encapsulated one of the earliest definitions of occupational therapy in its history:

“OT is the science of instructing and encouraging the sick in such labours as will involve those energies and activities producing a beneficial therapeutic effect.” (Barton, 1919, pp.62)

Although this definition was over eighty years ago, much of what was in this definition is still applicable to occupational therapy today, however the profession has been through some major transitions since. The foundations were grounded in a number of historical influences such as the arts and crafts movement, the influence of the Quakers and the mental hygiene movement, amongst others (Reed & Sanderson, 1999). One of the most influential however was the moral treatment movement, borne out of the humanistic frame of reference which introduced the concept of work having a positive effect on health (Söderback, 2009). The first paradigm of occupational therapy reapplied the moral treatment ideals in caring for ill and disabled people. The core beliefs of this paradigm focused on the occupational nature of human beings and the interrelationships between the body, mind and environment (Kielhofner, 2009). Some of the core skills and processes of occupational therapy that are used today could have been inherent in the profession since the very first paradigm such as using activities as therapeutic interventions and assessments of the occupational performance of clients (COT, 2009b). In the late 1940’s occupational therapy was swept into reductionist ideals and a need for a theoretical rationale. This new paradigm is referred to as the mechanistic paradigm and – using the biomedical frame of reference – focused largely on what could be measured quantitatively and scientifically, particularly with; the systems in the body, the neuromotor control and muscuoskeletal performance (Kielhofner, 2009). Some core skills of occupational therapy are rooted in the main ideas of the mechanistic paradigm such as enablement and environmental adaptations (COT, 2009b). Certain stages of the process of occupational therapy could have been developed through the beliefs of the mechanistic paradigm too, in particular the assessment stage which involves assessing clients strengths, weaknesses, environments and support systems. Another stage which could be linked to the mechanistic paradigm is the intervention stage. This involves engaging in activities that have been analysed, graded and sequenced (Larson & Von Eye, 2010) which is also a quantitative and reductionist ideal. The scientific aspect of the paradigm did better establish the profession with the World Federation of Occupational Therapists being inaugurated in Stockholm in 1952 (Söderback, 2009). The mechanistic paradigm, however, lost sight of the origins of occupational therapy; that occupation was central to the profession and that engagement in occupation can be beneficial to health and wellbeing. Mary Reilly, a fundamental figure in the profession in 1962 gave a seminal lecture and definition that was to change the outlook of the profession once again:

“Man, through the use of his hands, as they are energised by his mind and will, can influence the state of his own health.” (Reilly, 1962, pp. 2)

This direct quote encapsulates the change that ended the mechanistic paradigm of occupational therapy and recognised the need to return occupation to the centre of occupational therapy (Molineux, 2004). Following the mechanistic paradigm, a new paradigm emerged which Kielhofner (2009) coined the contemporary paradigm. This paradigm is that in which occupational therapy is practiced today. This focuses on the belief that occupation is central to health and wellbeing and the profession should focus on occupational needs and how neuromotor and musculoskeletal limitations affect a clients occupational performance, as opposed to what the limitations are. This paradigm focuses on the interrelationships between a person, their environment and their occupation (Kielhofner, 2009). There are, however, some new ideas that were not inherent in the original paradigm such as the client-centred frame of reference and the use of client-centred practice. In 1919, Barton wrote that “the patient cannot be trusted to select his own occupation” (Barton, 1919, pp. 20). In the contemporary paradigm, client-centred practice defines the client as having more of a choice and more power in the client-therapist relationship (Sumsion, 2006) and Bartons ideas would not be acceptable. There are three main roles that have been identified as important for occupational therapists; the therapeutic role, the consulting role and the team member role (Söderback, 2009). These roles are fairly modern ideas that are borne out of the beliefs of the latest paradigm.

The COT became a member of the World Federation of Occupational Therapists in 1952 (WFOT, 2010) when it was first set up during the mechanistic paradigm. The role of the COT is to set professional guidelines which occupational therapists and students must adhere to in practice, with regards to service user welfare, provision of the service, personal and professional integrity, competence, continual professional development and developing the evidence base of the profession (COT, 2010a). The HPC state they protect the public by having professional standards and guidelines that must be met by the professions that they govern (HPC, 2010a). They have a register of all of their health professionals which members of the public can check to make sure any professional working with them is registered, qualified and competent (HPC, 2010b). The HPC also deals with all disciplinary matters and has three different committees for dealing with fitness to practise hearings with registered professionals; the conduct and competence committee, the health committee and the investigating committee (HPC 2010c). As well as protecting the public against incompetent practitioners, the guidelines put in place could also be to protect the profession against scrutiny or disrepute. The COT and HPC are an integral part of practising as an occupational therapist and students are provided with their own copy of the COT Code of Ethics and Professional Conduct to read and digest. However, a big problem of the students of occupational therapy and other professions once qualified is the theory/practice divide; a student can have all the theoretical knowledge needed but lack the ability to effectively apply that knowledge to practice. Core areas in occupational therapy that are limited due to a lack of practice experience include client-centred care, enhanced clinical reasoning skills, the development and use of a therapeutic relationship and a deep appreciation of the person, environment and occupation impact (Knecht-Sabres, 2010). It may be said that this lack of practical experience is due to the strict guidelines of education in the COT. A large body of knowledge has to be understood in order to qualify and register as an occupational therapist. However the COT also have guidelines about how much clinical experience a student needs before they can qualify so they do recognise the need for practice-based learning and incorporate it as much as possible. Once qualified, the COT and HPC guidelines on continual professional development state that a registrant must continue learning and be up to date with policy, guidelines and research. This aims to ensure that practices do not become outdated which would widen the divide between core theory and practice. The Code of Ethics and Professional Conduct (COT, 2010a) being handed out to all students and professionals is a good basis for students to start from before their practice placements, yet it may be hard to practically apply what is in the Code until it is ingrained in ones knowledge of how to apply it in practice. One way suggested in which to bridge the theory and practice divide whilst learning in an institution with limited clinical experience is a good use of reflective practice. Reflecting in action during an intervention as well as reflecting on action (Schön, 1983) can enhance advanced clinical reasoning skills which would help bridge the divide (Knecht-Sabres, 2010).

In conclusion, occupational therapy is a valid and important practice when used in accordance of the Code of Ethics and Professional Conduct and the HPC guidelines. These guidelines are in place to safeguard clients and also the therapists themselves against practicing at an incompetent standard. These guidelines make it possible to further, justify and develop the profession and provide a definition or definitions in which to explain occupational therapy. There are, however, a large amount of standards to consider which one can read but will not become ingrained unless returned to repeatedly or learned and used in context. The true benefit of occupational therapy can get lost amongst the standards and guidelines as they can lead to a lack of clinical experience, a lack of reflecting in-action and perhaps issues of client-centred practice. One example is: if a client wants to work on their planned interventions late but it would interrupt with record-keeping due to time restrictions a therapist would have to refuse as record-keeping is an important part of COT guidelines, but this would not be strictly client-centred practice. Also a clients’ idea of a good quality of life may be different to that of the COT and HPC and it is the responsibility of the therapist to set out guidelines of what is acceptable, regardless of client choice. The profession, as shown in this paper is also ever-evolving and developing. It could be difficult to abide by the standards if the standards themselves are ever-changing. This is where continual professional development is a beneficial practice in overcoming this issue. The COT also sends out free copies of the British Journal of Occupational Therapy and the OT News, enabling all members to keep up to date with modern ideas and research.

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