After studying this chapter, the student or practitioner will be able to do the following:
1 Trace the ideas, values, and beliefs that have influenced the development of occupational therapy as a profession.
2 Analyze the development of occupational therapy within the larger context of cultural, social, political, and legislative forces.
3 Explain how some of the opportunities and challenges that physical disabilities practitioners face today are a result of the way the history of occupational therapy has evolved.
Even into the early 20th century, individuals with physical disabilities “were kept at home, out of sight, in back bedrooms, by families who felt a mixture of embarrassment and shame about their presence” (p. 29).17 This detrimental and pervasive reaction to physical disability began to change with the introduction of the medical model. From a medical perspective, disability was seen as a biologic deficit that could be ameliorated with professional treatment. In fact, in the early 20th century, “progressive reformers” were looking to medical professionals to assist individuals with disability to reclaim their place in the community and the workplace.51 It was against this backdrop that the profession of occupational therapy was founded in 1917.
The founders of occupational therapy believed that they could help to rehabilitate individuals with disability through engagement in occupation. They chose the term occupational therapy to reflect this goal, because in 1917 occupation was commonly used to mean “being occupied or employed with, or engaged in something” (p. 682).35 At the time, the founders were aware that such broad terminology could be confusing.14 However, they valued the breadth of the term for the freedom it would give occupational therapists to use a wide range of modalities and approaches, individually tailored to meet each person’s desires and needs.
The founders included William Rush Dunton, a psychiatrist; Herbert J. Hall, a physician; Eleanor Clarke Slagle, a social welfare worker; Susan Johnson, a former arts and crafts teacher; Thomas Kidner and George Barton, both former architects; and Susan Tracey, who was a nurse. They were influenced in their views of occupational therapy by ideas and beliefs prevalent during the latter part of the 19th century and the early years of the 20th century. The ideas that seemed to have most shaped the profession’s early development were reflected in three movements: moral treatment, arts and crafts, and scientific management.
Moral treatment originated in 19th century Europe and was promoted by physicians such as Philippe Pinel of France and Samuel Tuke of England. It represented a shift in thinking from a pessimistic viewpoint that labeled the mentally ill as subhuman and incurable to an optimistic one that viewed the mentally ill as capable of reason and able to respond to humane treatment. The main features of moral treatment included a respect for human individuality, an acceptance of the unity of mind and body, and a belief that a humane approach using daily routine and occupation could lead to recovery.8 Occupations included music, physical exercise, and art39 and agriculture, carpentry, painting, and manual crafts.13
Building on these ideas half a century later, the famous neuropsychiatrist Adolf Meyer proposed that many illnesses were “problems of adaptation” that could be remedied through involvement in curative occupations.31 Dunton and Slagle enthusiastically supported this view, and Meyer’s philosophy of “occupation therapy” was published in the first issue of the profession’s journal. Slagle, who worked with Meyer at Phipps Clinics, developed habit training programs in mental hospitals to reestablish healthy habits of self-care and social behavior.43
The rise of the arts and crafts movement in the 1890s was in reaction to the perceived social ills created by the Industrial Revolution.10 The economy was changing from an agrarian to a manufacturing society, so that what had previously been made by hand was now produced in factories. Proponents of the arts and crafts movement asserted that this resulted in a society of dissatisfied workers who were bored by monotonous and repetitive working conditions.
The use of arts and crafts as a therapeutic medium in occupational therapy (OT) arose from this trend. The arts and crafts approach was based on the belief that craftwork improved physical and mental health through exercise and the satisfaction gained from creating a useful or decorative article with one’s own hands. According to Johnson, the therapeutic value of handicrafts lay in their ability to provide occupation that stimulated “mental activity and muscular exercise at the same time.”24 Different handicrafts could also be graded for the desired physical and mental effects. During World War I, OT reconstruction aides successfully used crafts for the physical and mental restoration of disabled servicemen.41 For treating tuberculosis, Kidner advocated a graduated approach that began with bedside crafts and habit training and proceeded to occupations related to shop work and ultimately actual work within the institution.26
Thus, the ideas from the moral treatment and arts and crafts movements became intertwined as a definition of OT evolved to include treatment of individuals with physical and mental disabilities. In its early years, occupational therapists worked with patients throughout three stages of recovery.26 During convalescence, patients would engage in bedside occupations that primarily consisted of handicrafts such as embroidery and basket weaving. Once patients were able to get out of bed, they would engage in occupations designed to strengthen both body and mind, such as weaving or gardening, and occupations designed to reestablish basic habits of self-care and communication. When they were almost ready to return to the community, patients would engage in occupations that would prepare them for vocational success, such as carpentry, painting, or manual crafts.
Frederick Taylor, a prominent engineer, introduced his theory of scientific management in 1911.46 He proposed that rationality, efficiency, and systematic observation could be applied to industrial management and to all other areas of life, including teaching, preaching, and medicine. Progressive reformers of the period advocated that the ideology of scientific management address societal problems such as poverty and illness. These reformers criticized the noisy, dirty asylum of the 19th century and urged that the image of medical care be transformed into the clean, efficient hospital.23 The idea that knowledge could be developed through research and observation and applied to patient care became an underlying tenet of the science of medicine and ultimately resulted in the development of reliable protocols for surgical and medical interventions.51
The founders of OT were attracted to the idea of a scientific approach to treatment. Barton was particularly taken with Taylor’s time and motion studies and thought they might provide a model for OT research.7 Dunton advocated that those who entered the profession be capable of engaging in systematic inquiry in order to further the profession’s goals.15 Similarly, Slagle urged research in OT to validate its efficacy.43 By 1920 the profession was promoting the notion of the “science” of occupation by calling for “the advancement of occupation as a therapeutic measure, the study of the effects of occupation upon the human being, and the dissemination of scientific knowledge on this subject.”11
However, there is little in the OT literature of the early 20th century to suggest that OT practice was informed by systematic observation. One exception was the Department of Occupational Therapy at Walter Reed Hospital in Washington, D.C., under the direction of psychologist Bird T. Baldwin.6 OT reconstruction aides were assigned to the orthopedic ward, where methods of systematically recording range of motion and muscle strength were established. Activities were selected based on an analysis of the motions involved, including joint position, muscle action, and muscle strengthening. Methods of adapting tools were suggested, and splints were fabricated to provide support during the recovery process. Treatment with this systematic approach was more narrowly focused at times but was applied within the context of what Baldwin called “functional restoration,” in which OT’s purpose was to “help each patient find himself and function again as a complete man [sic] physically, socially, educationally, and economically.”5
Besides advocating a scientific approach to practice, the scientific management ideology emphasized efficiency and a mechanistic approach to medical care. Using the factory analogy, patients were the product, and nurses and therapists were the factory workers. It was assumed that doctors had the most scientific knowledge and therefore should be positioned at the top of the medical hierarchy. Dunton, a physician himself, seemed to support this arrangement: “The occupational therapist, therefore, has the same relation to the physician as the nurse, that is, she is a technical assistant.”12 As the profession evolved, an emphasis on efficiency and deference to medical authority became problematic for the profession. The focus on science and the resulting growth of the medical model were both beneficial and detrimental to OT practice.
The growth of the rehabilitation model began after World War II and peaked with the healthcare industry boom in the 1970s, following the passage of bills establishing Medicare and Medicaid. Although this growth was initially driven by the need to treat the country’s wounded soldiers, care of injured and chronically ill civilians also became a concern.
World War II revived the need for the United States to provide medical care for its wounded soldiers. Many more soldiers survived than in World War I because of recent scientific discoveries such as sulfa and penicillin. The Second World War also highlighted the value of OT services: “Although occupational therapy started during the last World War, it developed slowly [until] now when doctors are finding this aid to the sick and wounded invaluable.”33 A major effort was launched to reorganize and revitalize the Veterans Administration (VA) hospital system. Departments of physical medicine and rehabilitation were created to bring together all the services needed to care for the large number of war injured:
The theory that handicapped persons can be aided by persons who understand their special needs originated during World War II. The armed services established such hospitals for disabled veterans such as the one for paraplegics in Birmingham California (originally built in 1944 in Van Nuys, CA as a cutting edge hospital for soldiers returning from the war, the former hospital is now a high school). They helped the morale and physical condition of the patients so much that others were built for civilians.34
The interdisciplinary approach to care was emulated in the private sector. Demand for medical services increased in the civilian population as the treatment of chronic disability became a priority. Howard Rusk, a prominent voice in the development of rehabilitation medicine, asserted that the critical shortage of trained personnel would impede the country’s ability to deliver services to the “5,300,000 persons in the nation who suffer from chronic disability.”25 He cited OT as one of the essential rehabilitation services. In response to the growing demand for rehabilitation services, Congress passed the Hill-Burton Act in 1946 to provide federal aid for the construction of rehabilitation centers. A proviso of the legislation was that rehabilitation centers must “offer integrated services in four areas: medical, including occupational and physical therapy, psychological, social, and vocational.”52 The passage of legislation establishing Medicare and Medicaid in 1965 put further demands on rehabilitation services to serve the chronically ill and elderly within healthcare institutions, as well as the community.
The creation of a specialty in physical dysfunction within occupational therapy came about as a response to the changing demands of the marketplace and its requirement that specialists possess particular kinds of medical knowledge and technologic skills.20 This new specialty began with an increasing focus on occupations that would promote physical strength and endurance:
The Army is death on the old-time invalid occupations of basket weaving, chair caning, pottery and weaving. These are “not believed to be interesting occupation for the present condition of men in military service,” says an officer from the Surgeon General’s office. The stress now is on carpentry, repair work at the hospital, war-related jobs like knitting camouflage nets, and printing.49
The scientific approach of joint measurement and muscle strengthening that Baldwin pioneered at the end of World War I was adopted and improved upon. Claire Spackman, who along with Helen Willard wrote the profession’s first textbook on occupational therapy, argued that therapists must become skilled in carrying out new treatments based on improved techniques. According to Spackman, the occupational therapists serving people with physical disability needed to be skilled in teaching activities of daily living (ADL), work simplification, and training in the use of upper extremity prostheses. But first and foremost, she asserted, “Occupational therapy treats the patient by the use of constructive activity in a simulated, normal living and/or working situation. … Constructive activity is the keynote of occupational therapy.”44
As the rehabilitation movement helped to establish the importance of OT, it further positioned the profession within the medical model. OT was urged to specialize and separate into two distinct fields, physical dysfunction and mental illness. The head orthopedist at Rancho Los Amigos Hospital in Downey, California, argued that the separation would result in “strengthened treatment techniques” and thus more credibility among the medical profession, which “does not recognize your field as an established necessary specialty.”22 The American Occupational Therapy Association sought closer ties with the American Medical Association in order to increase occupational therapy’s visibility and reputation as a profession dedicated to rehabilitation of the individual through engagement in occupation.
The closer relationship with medicine probably helped the profession gain credibility, at least within the medical model. The positive aspect of the medical model is that it emphasized the importance of the rehabilitation of those with disabilities, and it helped stimulate the development of new scientific techniques. The negative aspect of the medical model is that it presumed that the individual is a passive participant in the process. In response to this view, a new social model was proposed that placed the individual at the center of the rehabilitation process.
The advocacy for disability rights that took hold in the 1970s had its roots in the social and political activism of the 1960s. During the 1960s, disabled people were profoundly influenced by the social and political upheaval that they witnessed. They identified with the struggles of other disenfranchised groups to achieve integration and meaningful equality of opportunity. They learned the tactics of litigation and the art of civil disobedience from other civil rights activists. They absorbed reform ideas from many sources: consumerism, demedicalization, and de-institutionalization (pp. 15-16).16
Like the civil rights and women’s movements, the disability rights movement was rooted in self-advocacy. That is, it was the individuals with disability themselves who were promoting their own cause. Their activism took many forms including lawsuits, demonstrations, founding of a plethora of organizations dedicated to achieving disability rights, and political lobbying for legislation to address inequality and protect rights.
The ideas underlying the disability rights movement were based on a social rather than a medical model. The medical model had provided the predominant view of individuals with disability for much of the 20th century. It placed the medical professional at the center of the rehabilitation process and the patient on the periphery as the person who was being helped by the experts. It categorized individuals according to their medical disability (e.g., the paraplegic or the quadriplegic), and it saw the remediation of that medical condition as the way to eradicate disability. Disability rights advocates rejected this view as too paternalistic, passive, and reductionistic. Instead they advocated a paradigm that put the individual with disability at the center of the model as the expert in knowing what it was like to have a disability.
The social model proposed that disability was created because of environmental factors that prevented individuals from being fully functioning members of society. Physical boundaries prevented individuals from having access to schools, workplace, and home. Social views of individuals as pathetic cripples blocked full participation in life activities. Political and legal interpretations advocated “separate but equal” participation rather than inclusion. The social model argued that disability must be viewed from a cultural, political, and social lens rather than a biomedical one:
This [biomedical] model makes us aware that a complex system of mutually supporting beliefs and practices can impact those with disability by: stigmatizing them as less than full humans, isolating them by policies of confinement or the built environment, making them overly dependent on professionals rather than helping them develop responsible behaviors, robbing them of independent decision making that others enjoy, undermining their self-confidence in their many capabilities, over-generalizing the significance of some impairment, and defining them as tax-eaters rather than tax-contributors (p. 22).45
Aligning itself with the social model, the independent living movement got its start when Edward Roberts was admitted to the University of California, Berkeley, in fall 1963.45 The polio that Roberts had contracted at the age of 14 left him paralyzed from the neck down and in need of a respirator during the day and an iron lung at night. It was arranged that Roberts would stay in Cowell Hospital on the Berkeley campus with his brother Ron providing him personal assistance. Although Roberts was the first, in the following years Berkeley admitted other students with severe disabilities. They formed the “Rolling Quads” and were dedicated to making the campus and environs physically accessible.
Having completed his master’s degree, Roberts, and his fellow Rolling Quads, were invited in 1969 to Washington to help develop a program aimed at retention of students with disability on college campuses. They created the Physically Disabled Students’ Program (PDSP), which included provision for personal assistants, wheelchair repair, and financial aid. In 1972 Roberts became the first executive director of the first Center for Independent Living (CIL), located in Berkeley. Roberts based the CIL on the principles underlying the PDSP:1 “that the experts on disability are the people with the disabilities;3 that the needs of the people with disabilities can best be met by a comprehensive, or holistic program, rather than by fragmented programs at different agencies and offices;4 that people with disabilities should be integrated into the community” (p. 61).37 Since the founding of the first CIL, hundreds of other centers have been developed throughout the country.
Moral Treatment versus the Medical Model
In the 1960s and 1970s, the tension between paradigms within occupational therapy was expressed in terms of moral treatment versus the medical model. A cry arose from some of the profession’s leaders to return to its roots in moral treatment and to forego what Shannon referred to as the “technique philosophy.”42 In his article on what he called “the derailment of occupational therapy,” Shannon described two philosophies at odds with each other. One, he asserted, viewed the individual “as a mechanistic creature susceptible to manipulation and control via the application of techniques”; the other, based on the profession’s early philosophy of moral treatment, emphasized a holistic and humanistic view of the individual.
Kielhofner and Burke described the situation as a conflict between two paradigms.27 Early OT practice, they asserted, was based on the paradigm of occupation that had moral treatment as its foundation. This paradigm provided a “holistic orientation to Man [sic] and health in the context of the culture of daily living and its activities.” Post–World War II practice, they asserted, was based on the paradigm of reductionism, a mode of thinking characteristic of the medical model. This view emphasized the individual’s “internal states” and represented a shift in focus to “internal muscular, intrapsychic balance and sensorimotor problems.” The authors acknowledged that practice based on the reductionist paradigm “would pave the way for the development of more exact technologies for the treatment of internal deficits”; however, they were concerned it “necessitate[d] a narrowing of the conceptual scope of occupational therapy.”27
The claim that early OT practice was based on the humanistic and holistic philosophy of moral treatment is accurate, but it does not tell the full story. As this chapter describes, the founders also valued the medical model and the importance that “science” could play in establishing the profession’s credibility. For example, the Committee on Installations and Advice, directed by Dunton, was formed to scientifically analyze the most commonly used crafts and to match the therapeutic value of each craft to a particular disability.40
How could the founders have supported what came to be viewed in the 1970s as the two opposing views of moral treatment and the medical model? The answer may be that in 1917 when the profession was founded, the models were not considered to be incompatible because the scientific medical model had not fully taken hold. It appears that in the founding years, OT primarily practiced moral treatment and talked about how practice should also be medical and scientific. When early practitioners were asked to treat patients in order to “restore the functions of nerves and muscles” or to make use of “the affected arm or leg,”44 they based their treatment on their belief in the importance of occupation, habit training, and their knowledge of crafts. Once knowledge and technologic advances were sufficient and occupational therapists could actually practice using a scientific, medical perspective, it became apparent that the ideas underlying these two paradigms were in conflict.
The physical disabilities therapist was faced with the problem of how to give treatment that was, on the one hand, holistic and humanistic and, on the other, medical and scientific. Baldwin’s answer in 1919 was to see activities such as muscle strengthening and splint fabrication as techniques that contributed to the larger goal of “functional restoration” of the individual’s social, physical, and economic well-being.6 Spackman’s answer in 1968 was that the occupational therapist should use “constructive activity in a simulated, normal living and/or working situation. This is and always has been our function.”44 She emphasized the teaching of ADL and work simplification and was critical of treatment that consisted of having patients sand or use a bicycle saw with no “constructive activity” involved.
Another answer to the question of differing paradigms was to move outside the medical model. Bockoven urged OT practitioners to set up services in the community based on moral treatment. He said:
It is the occupational therapist’s inborn respect for the realities of life, for the real tasks of living, and for the time it takes the individual to develop his modes of coping with his tasks, that leads me to urge haste on the profession … to assert its leadership in fashioning the design of human service programs. … Don’t drop dead, take over instead!9
Yerxa urged therapists not to rely solely on doctor’s orders:
The written prescription is no longer seen by many of us as necessary, holy or healthy. … The pseudo-security of the prescription required that we pay a high price. That price was the reduction of our potential to help clients because we often stagnated at the level of applying technical skills.54
However, as practice moved into the 1980s, there was much concern that if occupational therapists did as their critics suggested, they would jeopardize reimbursement as well as referrals. They argued that they were being asked to exclude skills and knowledge they believed were valuable in patient treatment, such as exercise, splinting, and facilitation techniques. They further argued that many patients receiving OT services were initially not at the level of motor capability that would enable them to engage in satisfying occupations. It was proposed that adjunctive techniques such as exercise and biofeedback should be considered legitimate when used to prepare the patient for further engagement in occupation.50 A study conducted in 1984 by Pasquinelli showed that although therapists valued occupation, they used a wide variety of treatment techniques and approaches, including facilitation and nonactivity-oriented techniques.36 Both Ayres and Trombly argued that instead of attempting to redirect the focus of OT, the profession should include current clinical practices that had proved effective on an empirical and practical basis.4,50
By the latter decades of the twentieth century, the debate became expressed as the conflict between the rehabilitation model and the social model. Scholars such as Gill18 brought the perspective of the social model of the disability rights advocates to the discussion of what constituted ideal occupational therapy practice.
She argued that the rehabilitation model exempted society from taking any responsibility for its role in creating the climate that restricted the rights and opportunities of the disabled. She urged occupational therapists to examine their practice and make sure that their treatment did not focus solely on the individual’s physical condition.
For rehabilitation to be helpful, it must address the reality of what life is like for disabled persons. If rehabilitation professionals fail to fit their services to the patient’s needs, values, and interests, they fail both the patient and their own professional aspirations. … Without a proper balance of physical treatment and realistic social information, rehabilitation cannot enable patients. … What good are increased range of motion and finger dexterity when a patient’s morale can be crushed by job discrimination or social rejection? (p. 54)18
A study conducted by Pendleton (1990) supported Gill’s concerns. Pendleton found that occupational therapists were much less likely to provide training in independent living skills than physical remediation.38 She defined independent living skills as “those specific abilities broadly associated with home management and social/community problem solving.” She argued that “Mastering such skills could contribute to the achievement of control over one’s life based on the choice of acceptable options that minimize reliance on others. … The result of achieving such control is that the person can actively participate in the day-to-day life of the community” (pp. 94-95).38 She recommended that if occupational therapists are not able to provide sufficient independent living skills training in inpatient rehabilitation centers, they should shift their treatment to community-based programs. Pendleton saw independent living skills as the essence of occupational therapy, and urged therapists to make it one of their priorities.
Longmore, a well-known historian and disability rights activist, emphasized the importance of the issues raised by Gill and Pendleton. Although he acknowledged that disability rights activism has been responsible for numerous pieces of legislation since the 1970s aimed at giving those with disability equal access to all parts of society including schools, work, public places, and transportation, he warned that there is still much to be done. The most important legislation passed during this period included the Rehabilitation Act of 1973, the Individuals with Disabilities Education Act of 1973 (IDEA), and the Americans with Disabilities Act of 1990 (ADA). However, Longmore argued, despite this legislation, people with disabilities continue to experience marginalization and financial deprivation. “Depending on age and definition of disability, poverty rates among disabled people range anywhere from 50 percent to 300 percent higher than in the population at large” (p. 19).29 He worried that most people assume that the ADA has eradicated the major problems for those with disabilities, when in fact “to a surprising extent U.S. society continues to restrict or exclude people with disabilities” (p. 21).29
As previously discussed, disability scholars like Longmore and Gill criticized the main premise of the rehabilitation model: that something is abnormal or lacking in the individual with disability.19,30 The main justification for rehabilitation services is that through the intervention of professionals such as occupational therapists, the client can become more independent and a more useful contributor to society. The problem with this premise is that it assumes that clients want to become more “independent” (as defined by the rehabilitation specialists) and that they cannot fully contribute to society in their current condition. Thus, the rehabilitation model has the unintended consequence of devaluing persons with disabilities and placing the focus of intervention on remediating the disability rather than the social, political, and economic barriers that contribute to it. Kielhofner discussed this problem in the Special Issue on Disability Studies that appeared in the American Journal of Occupational Therapy: “As this paper and others in this special issue illustrate, disability studies raises issues and questions to which there are no easy answers” (p. 487).28 He quotes the disability scholar Abberley, who notes that “OT, despite what may be the best of intentions on the part of its practitioners, serves to perpetuate the process of disablement of impaired people” (p. 487).28
One answer is to create constructs that seek to blend the rehabilitation and social models by redefining disability. The World Health Organization sought to do this in their 2001 International Classification of Functioning, Disability and Health (ICF).53 The ICF provides a classification that considers physical and mental impairments as well as environmental and personal factors, any or all of which may result in activity limitations and participation restrictions.
Based on the conceptual scheme of the World Health Organization, the American Occupational Therapy Association issued the Occupational Therapy Performance Framework (OTPF) in 2002 and its revision in 2008.1,2 It provides a construct that promotes client-centered engagement in occupation as the central focus of practice. This construct addresses issues raised by proponents of moral treatment, as well as the social and medical model. It reclaims the values of moral treatment by its focus on occupation-based treatment that is both holistic and humanistic. It integrates aspects of the medical model by advocating the reduction of functional impairments caused by physical and psychological limitations. Finally, it supports the social model of the disability rights movement by emphasizing the need for client-centered treatment within the context of the social, cultural, and political environment.
Another answer is for occupational therapists to continue to emphasize the therapeutic use of self in all relationships with clients. A focus on the importance of the therapist’s interaction with clients has been an underlying tenet of occupational therapy since its founding and continues today. Indeed, as Taylor et al. found in their survey of 568 occupational therapists, “Most therapists considered therapeutic use of self as the most important skill in occupational therapy practice and a critical element of clinical reasoning” (p. 204).48 By focusing on the client-therapist relationship, the practitioner is more likely to understand the client’s experience as an individual with a disability, and jointly formulate an intervention plan that centers on the client’s goals. When a viable therapeutic relationship is formed, practice is much more likely to be client-centered.
Scholarship focused on the disability experience can add to the profession’s body of knowledge and help to increase our understanding of how occupational therapy can address disability studies concerns. For example, research by occupational therapy scholars like Taylor,47 Neville-Jan,32 and Guidetti, Asaba, Tham21 examines the experiences of those with disabilities through phenomenological and narrative accounts and thereby helps occupational therapists understand disability from the individual’s perspective.
Finally, a knowledge of history can provide a context from which to understand the current challenge to physical disabilities practice. As this history has demonstrated, early treatment in occupational therapy was based on belief in the importance of occupation, habit training, and knowledge of crafts. As scientific knowledge and technology advanced, OT defined a role for itself within the rehabilitation model. This resulted in the emergence of physical disabilities as a specialty within OT. The closer relationship with medicine helped the profession gain credibility. However, the scientific reductionism of the medical model put professional practice at odds with the holistic humanism of moral treatment. Today we discuss this in terms of the tensions inherent in the rehabilitation model versus the social model advocated by disability scholars. Our current challenge is to bridge the rehabilitation and social models wherever possible. Occupational therapy is uniquely qualified to do this because we were founded on two conflicting paradigms—the humanistic and the scientific—and therefore tension between two paradigms is not new for our profession. There have been ongoing discussions since the 1960s on how to bridge the tension between paradigms. These discussions have led the profession full circle, back to its most enduring belief: in the benefits of engagement in occupation. When occupational therapists keep occupation as the central focus, it is easier to find the intersection between the rehabilitation and social models.
As new approaches and techniques are developed in the future, OT intervention that promotes engagement in desired occupations will remain consistent with the philosophical base of the profession and help to further advance occupational therapy as a valued service in physical disabilities practice.
In lieu of a case study, we will demonstrate how we can use our knowledge about occupational therapy’s history to answer a question that is prevalent among students and therapists today: Why do occupational therapists continually have to define occupational therapy to others?
First we should acknowledge that more people than ever do understand occupational therapy. Most of these people are individuals who have received treatment or have had personal contact with someone who received occupational therapy. So each time an occupational therapist successfully engages a client in treatment, he or she is providing a positive definition of occupational therapy. That being said, it can feel as though occupational therapists spend quite a bit of time educating others as to what we do. We can look back to the founding years to understand why this is so. The answer is complex and includes several factors.
The first relates to the profession’s purpose. As this chapter describes, in naming the profession, the founders were looking for a term that was broad enough to encompass all of the things that occupational therapists did. The AOTA in 1923 described occupational therapy in this way: “Occupational Therapy is a method for training the sick or injured by means of instruction and employment in productive occupation. The objects sought are to arouse interest, courage, and confidence: to exercise mind and body in healthy activity; to overcome disability; and to re-establish capacity for industrial and social usefulness.”3 This definition reflects a holistic, humanistic, and all-encompassing view of the individual, the rehabilitative process, and the role of occupational therapy within it. It addresses the mind as well as the body, and social as well as medical goals. The founders ultimately decided that occupational therapy was the term that best reflected the profession’s goals. This is not to say that the founders did not consider the possible negative aspects of the term. It is clear from their writings that they were aware that such a broad term might cause some misunderstanding. However, in the end, they felt that this negative would be offset by the positive of providing occupational therapists with a wide range of freedom to treat each individual in the best way possible.
Second, we must consider that the name was chosen in 1917, and meanings of terms do change over time. For example, children with disabilities were placed in “asylums for the crippled” in the early 1900s. We would never use that terminology today. Fortunately, occupation does not carry such a negative connotation in today’s lexicon, but the term has shifted in meaning. In 1917, occupation was most commonly used to mean an important activity in which one engages. For example, in a novel, one might read about a woman who was searching for an occupation that would satisfy her free time. As the century progressed, the term occupation came to be more closely aligned with the kind of paid work you do, as in “What is your occupation?” When looked at in this light, it is easier to understand any confusion someone today may have about the term, and the continual need for the occupational therapist to educate people about the term’s meaning within today’s context.
Third, we must also consider that the professions that exist today did not exist at the time of occupational therapy’s founding. That is one reason the definition of OT was so broad. At the time of the founding of occupational therapy, society was looking for a profession that could help remediate the wounds and illnesses of returning soldiers and enable them to become productive members of society. Occupational therapy offered that promise. Professions such as social work and physical therapy were still in their fledgling stage and it was unclear which profession would ultimately be involved in the soldiers’ rehabilitation. In addition, art, music, recreation, and vocational therapy had yet to be introduced.
Finally, as has been discussed throughout this chapter, the ideas underlying occupational therapy do not fit neatly into just one theoretic paradigm. Occupational therapy uses an occupation-based, client-centered approach that bridges both the medical and social models, as is evidenced in the Occupational Therapy Performance Framework. Although this sounds good in theory, in practice it means that if occupational therapists are working with people who use a strict medical model (including third parties), there will be misunderstandings about OT’s proper role. This is where occupational therapists must be proactive in describing what we do.
History tells us that occupational therapy has always had a humanistic, holistic approach to viewing its clients and its role, and it cannot be neatly confined to the medical or social paradigms. The blending of these paradigms by the ICF and OTPF finally offers occupational therapy a suitable home. However, these are new ideas and it will take time for them to be accepted. This is one more reason why occupational therapists will not be finished defining what we do any time soon. But is it not a worthy challenge? History would suggest that it is. So the next time you have to define occupational therapy, think of yourself as the latest generation to carry on the proud tradition of defining your goals by what is good for the client rather than what “fits” into the prevailing theoretical model.
1. Name the seven founders of occupational therapy, and list the professional background of each.
2. What ideologies shaped the development of occupational therapy in the late 19th and early 20th centuries?
3. What were the main features of the philosophy of moral treatment?
4. Describe the ideas that were the foundations of occupation as a remedy for mental and physical illness.
5. What provoked the rise of the arts and crafts movement?
6. How did the arts and crafts movement influence occupational therapy?
7. Describe scientific management. How did it influence the development of occupational therapy?
8. When did the rehabilitation model evolve? How did the world wars influence the development of the rehabilitation model?
9. How did physical dysfunction become a specialty?
10. What factors influenced occupational therapy to adopt the medical model?
11. What was the apparent conflict between moral treatment and the medical model?
12. What impact has the disability rights and independent living movement had on occupational therapy?
13. How is the apparent conflict between the medical model and the social model being resolved in occupational therapy practice?
1. American Occupational Therapy Association. Occupational therapy practice framework: domain and process. Am J Occup Ther. 2002;56:69–639.
2. American Occupational Therapy Association. Occupational therapy practice framework: Domain and process, 2nd edition. Am J Occup Ther. 2008;62:625–683.
3. American Occupational Therapy Association, Principles of occupational therapy. Bulletin 4, Bethesda, MD, Wilma West Archives, 1923.
4. Ayres, AJ. Basic concepts of clinical practice in physical disabilities. Am J Occup Ther. 1958;12:300.
5. Baldwin, BT. Occupational therapy. Am J Care Cripples. 1919;8:447.
6. Baldwin, BT. Occupational therapy applied to restoration of function of disabled joints. Washington, DC: Walter Reed General Hospital; 1919.
7. Barton, GE. The movies and the microscope. Bethesda, MD: Wilma West Archives; 1920.
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