Politics of Occupation-Centred Practice E-Book

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• Sprache: Englisch

Seitenzahl: 588

Veröffentlichungsjahr: 2012

Beschreibung

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.

Leseprobe

Contents

Cover

Title Page

Copyright

List of Contributors

Foreword

Acknowledgements

Chapter 1: Introduction

The Meaning of Occupation

The Term ‘Occupation’

So, What Is Occupation?

Occupational Being

Cultural Change and Acceptable Occupations

Occupational Effect

Being with the Others

How this Book is Organized

References

Chapter 2: The Language of Occupation

Language, Cultural Meanings and Nosologies

Language, Occupation and Professional Status

Conclusion

References

Chapter 3: Occupational Literacy

Being Trialogical

Making Sense of the World

Occupational Literacy as a Skill

References

Chapter 4: A Grammar for a Language of Occupation

Comprehension

Language Structures and Occupation

Recognizing Occupation

‘Doingness’

Morphemes

Domains of Symbolic Logic

References

Chapter 5: Towards a Transformational Grammar of Occupation

Human Scale Development Theory

Language and Occupation

Territories of Words

Conviviality

My Baby Took the Train . . .

References

Chapter 6: Narratives of Recognition

Occupational Therapy Stories

Heteroglossia

References

Chapter 7: Narratives and Truths

Features of Narratives

Narrative and Illness

Whose Narrative and Whose Language?

References

Chapter 8: Occupation in a Greek Town: Flowing, Emergent, Flexible across Time and Space

Introduction

Introduction to Melissa

Discussion

Conclusion

References

Chapter 9: Indigenous Ainu Occupational Identities and the Natural Environment in Hokkaido

Ainu Worldview and Traditional Occupations in the Pre-Tokugawa Period: Occupations and Worldview Linked with Nature's Cycles

Ainu Occupational Changes from the Early Modern Period: Domination by Japanese Social Norms and Contempt of the Cycles of Nature

Conclusions

References

Chapter 10: People with Disabilities and Participation: Experiences and Challenges of an Occupational Therapy Practice in the City of São Paulo, Brazil

Participation, Disability in Daily Life and Access to Human Rights in an Urban and Unequal Scenario

Identifying the Rupture of Social Support Networks and the Social Isolation of People with Disabilities in Poor Areas of São Paulo: An Experience of Active Search

The Construction of Participation in the Daily Life of People with Disabilities: Community Alternatives for Intervention

Conclusion

References

Chapter 11: Communities of Writing

Communities, Writing and Publishing

Community Publishing, Occupational Narratives and Occupational Science

Writing and Consciousness

Can Do: Affirmation and Participation

References

Chapter 12: Disability, Sexuality and Intimacy

Overview

Teaching Sexuality and Disability

Theorizing Sexuality and Disability

Research on Policy Context: The First Step in a More Progressive Practice

Sexuality and Disability in Non-Western Societies

Sexual Access

Inclusion of Disabled People as Co-participants in Research, Writing, and Policy-Making

Hope and Jacob

Final Thoughts

Appendix

References

Chapter 13: Models and Human Occupation

Introduction

The Social Status of Modelling

Model Making Defined

Models in Early History

The Value of Modelling to Modellers

Critiques of Modelling

The History, Scale and Nature of the Modelling Market

Conclusion: Models, Competences, Identities, and Representing Human Occupation

References

Chapter 14: Participation, Time, Effort and Speech Disability Justice

Introduction

Participation and Citizenship

Experiences in Time and of Effort

Anger, Advocacy, Responsibility, and Disability Justice

Time and Thought

Conclusion

References

Chapter 15: A Society Founded on Occupation

Occupation and Codependency

The Ownership of Occupation

Occupational Justice

Determining Needs

Choice and Contradiction

The Professionalization of Doing

Occupational Literacy and Occupational Justice

References

Index

This edition first published 2012

© 2012 by John Wiley & Sons Ltd

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Library of Congress Cataloging-in-Publication Data

Politics of occupation-centred practice: reflections on occupational

engagement across cultures / edited by Nick Pollard, Dikaios Sakellariou.

p.; cm.

Includes bibliographical references and index.

ISBN 978-1-4443-3698-6 (pbk.)

I. Pollard, Nick, MSc(OT) II. Sakellariou, Dikaios.

[DNLM: 1.  Occupational Therapy. 2.  Cross-Cultural Comparison. 3. Occupations. 4.  Politics. 5.  Socioeconomic Factors. 6.  Work. WB 555]

362.1′0425–dc23

2012002553

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

List of Contributors

Marta Aoki Occupational Therapist Faculty of Medicine University of São Paulo, São Paulo, Brazil

Mami Aoyama Professor and Associate Dean Faculty of Rehabilitation Sciences Nishikyushu University, Kanzaki, Saga, Japan

Hope Block Board Member Autism National Committee Rhode Island, USA

Pamela Block Associate Professor School of Health Technology and Management Stony Brook University, Stony Brook, New York, USA

Neil Carver Senior Lecturer Faculty of Health and Wellbeing Sheffield Hallam University, Sheffield, UK

Taísa Gomes Ferreira Occupational Therapist Health Science Center Federal University of Santa Maria, Brazil

Sally Foster Senior Lecturer Faculty of Health and Social Sciences Leeds Metropolitan University, Leeds, UK

Sandra Maria Galheigo Senior Lecturer Faculty of Medicine University of São Paulo, São Paulo, Brazil

Sarah Kantartzis PhD Candidate Faculty of Health and Social Sciences Leeds Metropolitan University, Leeds, UK

Devva Kasnitz President, Society for Disability Studies Devvaco Consulting/New Focus Partnerships, USA

Matthew Molineux Director, Allied Health Clinical Education and Training Queensland (ClinEdQ) Brisbane, Australia and Adjunct Research Fellow School of Occupational Therapy and Social Work Curtin University, Perth, Australia

Fátima Corrêa Oliver Senior Lecturer Faculty of Medicine University of São Paulo, São Paulo, Brazil

Jacob Pratt Executive Director Autism Spectrum Differences Institute of New England, Inc. Connecticut, USA

Nick Pollard Senior Lecturer Faculty of Health and Wellbeing Sheffield Hallam University, Sheffield, UK

Linda Rammler Private Practice Consultant Focusing on Autism, Positive Behavior Supports and Inclusion Connecticut, USA

Dikaios Sakellariou Lecturer School of Healthcare Studies Cardiff University, Cardiff, UK

Russell Shuttleworth Senior Lecturer Faculty of Health School of Health and Social Development Deakin University, Geelong Campus, Australia

Foreword

The occupational therapy profession's core concept of occupation ought never to be treated as if its defining characteristic (“meaningful and purposeful activity”) were a property solely of patients or clients as individuals apart from their communal environments. Yet professional care in a clinic or hospital affords few clues to the interpersonal identities and communal lifestyles that occupations support. In this book, editors Nick Pollard and Dikaios Sakellariou lay a scholarly foundation for occupational therapy that treats the cultural, historical and political contexts of daily occupation within a unified worldview.

The book's contributors offer complementary perspectives from occupational therapy, anthropology, disabilities studies, folklore and folk life, and other key fields to promote a common cause. They link narrative (the most potent communicative link between the individual seeking treatment and the occupational therapist) back to wider material and social contexts. Such background contexts are too often merely supposed, or even overlooked, in the press of increasing technical core requirements of an occupational therapy curriculum. To understand how these complementary perspectives on occupation come together, I find it helpful to revisit the founding of the occupational therapy profession in the progressive era, circa 1890 to 1920, in the United States.

It is a truism that cultures are typically invisible to their members until a disruption occurs. For many observers today, global banking has shaped – and now disrupted – lives around the world on an unprecedented scale. Mass demonstrations, revolutions, and cries for democratic reform recall the progressive era, when so many reinventions and reinterpretations of everyday occupations emerged. Under the impact of unregulated industrial capitalism and massive displacements of populations, work and working conditions were redefined. Labourers left rural agricultural settings and small towns. Struggles for survival were drawn more sharply between new forces of ‘labour’ and ‘capital’. New forms of cosmopolitan and pluralistic citizenship and political participation were envisioned and enacted. Traditional arts and crafts were reharnessed variously in movements to restore health and wellbeing, to provide vocational education, and to build utopian socialist communities. The occupational profession as an incorporated entity recognized under New York state laws also emerged this time. This incorporation of the profession, in 1917, marked a shift from an exclusively humanitarian and reformist use of occupations to ameliorate the lives of disabled people. The incorporated profession necessarily had also to become concerned with promoting the profession's own interests as a paid provider of services.

Occupational therapists in the United States, in 2003, adopted the rallying call: We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society's occupational needs. This Centennial Vision issued by the American Occupational Therapy Association anticipates the completion of a hundred years of existence in 2017. The vision is ambitious, optimistic, and expansive. Yet it appears to embody an innocent faith in the background practices of global capitalism that have since brought the world's leading economies to the brink of collapse.

Perhaps an alternative Centennial Vision could be crafted in light of the global economic crisis. Countless families have been displaced from their homes; the value of stocks and savings have been sharply eroded; benefits and pensions are disappearing and thousands upon thousands of jobs have been eliminated on which individuals and families depended to survive with security and dignity. Speaking now just of the United States, the occupational therapy profession aims to gain a greater market share of a highly exclusionary health care system, while quality services become an ever more unaffordable dream for the 15% of the population that is uninsured. Roughly the same percentage of the population in the United States, about 50 million people, cannot put sufficient food on the table to maintain health. A million or more children go to bed at night hungry. The most vulnerable social programmes being cut concern services provided by occupational therapists and other rehabilitation professionals for people with disabilities.

This current volume, Politics of Occupation-Centred Practice: Reflections on Occupational Engagement across Cultures, offers an alternative vision of occupations, one that predates the reduction of occupational approaches into a profession shaped by a fee-for-service medical model. Pollard and Sakellariou restore a view of the occupations of everyday life embedded in their historical and political contexts, pointing us in the direction of cultures as collections of contested discourses and practices. They embody something of the progressive-era vision, when the realm of everyday life and daily labour was indeed being carved up in order to become the specialized, licensed province of competing profession, disciplines and academic societies.

We would not want to go back in time to the excesses and abuses of past. But we must and can encourage occupational therapists to treat the meaning and purpose of occupations in political and cultural contexts. Science and social justice must go forward hand in hand. Now, as a centenary ago, occupation must be reconceptualized in the broadest terms as a restorative dimension to assaults on the survival and communal lifestyles of 99% of the world's population in our own time. Read on!

Gelya FrankProfessorDivision of Occupational Science and Occupational TherapyHerman Ostrow School of Dentistryand Department of AnthropologyUniversity of Southern California

Acknowledgements

To my wife, Linda, and our children, for their patience during the times when I have been working on this project.

Thanks also to the support of my colleagues and students in the occupational therapy team here at Sheffield Hallam University, particularly Neil Carver and Janet Medforth with whom I've shared an office and who withstood my mess.

Nick Pollard

To my family. To Dimitra, Julia and Dean because they are here. To Erimo Okaasan because she greeted the man from Vladivostok. To Vagelio.

Thanks are also due to the School of Healthcare Studies in Cardiff University and in particular to the Department of Occupational Therapy for their support during the development of this and numerous other projects.

Dikaios Sakellariou

The editors would like to thank the proprietors and staff of The Eastend Café, Meriden Street, Birmingham, for their great service during our meetings there.

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 accurately might be characterized as attempts to domesticate the term by assigning it a specific meaning, so as to exercise professional control over an area of human activity in multidisciplinary settings. Occupational therapists have a history of having to assert professional boundaries or reclaiming old professional territories (Whiteford, Townsend, and Hocking, 2000; Wilcock, 2002). Many professions concerned with human activities and health (for example psychology or nursing) continuously negotiate or even contest areas of their practice where role blurring creates problems in delivering care. Sometimes the arguments about definitions have more to do with one or other professional group's dominance over power and resources than abstract meanings (Wilcock, 2002, 2007; Hocking, 2007). As the concept of ‘occupation’ is bigger than its application in occupational therapy it presents a significant issue of classification and methodological appropriateness.

Seen briefly through the windows of an occupational therapy department, what goes on seems superficially simple – sitting down with a group of people and doing a crossword, baking scones, making a cup of tea (see Chapter 2). Anyone could do it – but all too often no-one gets the chance to as, without occupational therapists, the generic support worker is drawn into the tasks of physical care, or only providing activities that are supported by large numbers of clients.

Experientially, understood as components of a narrative in which the person is directly involved, these simple activities can be seen in the context of contributing to life quality. Breines (2004) points out that sometimes mundane activities contribute to occupational complexity in a set of reciprocities between individuals, their environments and their societies. Capturing these phenomena has proved difficult, especially in a way that would be recognized in a research hierarchy defined by biomedical paradigms. Consequently there may be some significant oversights in relation to research on meaningfulness and doing, such as the lack of exploration of the potential of hobbies (despite the anecdotes of Breines, 2004) for wellbeing (Bull, 2009; Burt and Atkinson, 2011; see Chapter 13). One reaction to biomedical dominance was to reconceptualize occupation in a biomedical frame, with activities such as bicycle fretsaw work administered in regulated sessions, but this resulted in a loss of professional identity (Turner, 2002; Hocking, 2007).

To occupational therapists and scientists, occupation is a symbol, a signifier assuming various meanings according to the context in which it appears (for a discussion of ‘signifier’ see Eco, 2000). The profession seems to accept that occupation refers to doing, being, becoming and belonging (Wilcock, 2006), terms that are associated with qualities of wellbeing, and the expression of which can be defined as components of good life quality (Phillips, 2006). Meaningful occupation (however this is defined) symbolizes a life of good qualities (Wilcock, 2007). Occupational therapy literature – if, for example, the covers of OT News are reviewed – frequently includes images of people engaged in activities such as cycling, painting, or gardening. The magazine, as a professional communication to members of the profession, reflects back a vision of itself as being concerned with positive images of people doing things with other people, being creative and active.

In its representation of arts and crafts, occupational therapy is no heroic upholder of a great principle of occupation. For all the splendid intentions of therapists to recapture the moral ground of activity as once described by moral therapy, the result has sometimes been rather hard to identify as having a value at all. Jokes about basket making and occupational therapy still occasionally surface, although they were wearying in the 1960s (Wilcock, 2002) while Mosey (1971) remarked that the idea that it was good for people to do things that they enjoyed seemed to have been abandoned in the 1960s in favour of treatments belonging to other disciplines. Often this has arisen from the political context in which occupational therapists have operated (Hocking, 2007; Wilcock, 2007) – needing to be seen to be doing something, but lacking the real resources, or the power to challenge the lack of resources, or to make a case to do something worthwhile with some of the clients, rather than something worthless and boring with everyone – something that occupies but does not engage. In these situations of occupational absurdity, something that everyone may understand and recognize as an occupation is turned around and made into a therapy –something for ‘doing you good’ rather than something you feel good doing.

We should not overemphasize such criticisms against a professional history that is illuminated with numerous creative, innovative and inspirational examples. All therapists should own a copy of Estelle Breines' Occupational Therapy: Activities for Practice and Teaching (2004) to remind themselves of the value of serious play, the liberation to be gained from simple activities and enjoyments, and the celebration of life qualities combined with clinical assessments and therapeutic intervention. Posture work in the kitchen rolling dough for pastry can be identified in clinical reasoning, but it is also the setting for beginning conversations to investigate wider issues like, for example, whether the pastry should include free range eggs or battery eggs? (e.g. Fearnley-Whittingstall, 2010). The discussion of spatial freedom for chickens can lead to that of occupational justice for people, expressed perhaps for the right to a space in which to keep your own chickens, to become self-sufficient in developing food resources, and in the right of chickens (as well as humans) to do and be. Alternatively, there are many rich narratives to be explored through the experiences of cooking, the handing down of recipes and techniques that allow people to express themselves and their culture through the things they make.

However, as we have already discussed, the experience of doing, being, becoming and belonging is not necessarily an uncomplicated narrative of happy events. To return to the autobiographical narratives of worker-writers, one of the frequent defining characteristics of personal meaning in these accounts concerns the experience of overcoming hardships and dealing with difficulties. Such occupational narratives may also be shaped by such experiences as being a refugee or immigrant (Earl Marshall School, 1993), ill health and disability (Wiltshire, 1985; Irwin, 1995), bereavement, unemployment and conflict (Muckle, 1981; Sitzia and Thickett, 2002) and even imprisonment (Piper, 1995), all of which might be represented as assets in terms of the Kawa model of occupation (Iwama, 2006). Although people generally regard such experiences negatively, they are also a source of resiliency and personal strength, as is suggested in Chapters 9 and 10.

Occupational narratives carry a historical referent to not only who we are, but who we have been, and they anticipate who we will be. The concept of ‘occupation’ is a key to the way society is symbolized through the complex interaction of individual pasts, presents and possibilities and the resulting choices, opportunities, decisions, mistakes, and accidents (Mattingly, 1998; see Chapter 8). Occupation is therefore multidimensional. On one hand it represents an ontological flow developing over time through chronological narrative. Many occupations involve an unfolding process, such as the development of a skill or the creation of an object, in which certain steps of progression cannot be skipped in order to achieve a completed result. On another, while occupation measures time, it also telescopes time because it is through occupation that people anticipate the future and return to the past, as people can demonstrate through the breaks they may make in the telling of a narrative. The story that one person recounts to another is not necessarily linear – sense is made by interrupting chronological order to explain what was anticipated, or to explore earlier events before the current scene being described.

The richness of occupation presents a problem of developing a suitable means to adequately explore it and terms to describe it (Iwama, 2004; Molineux and Whiteford, 2006). Occupational therapists and scientists often generate theoretical terms by merely prefixing existing terms with ‘occupation'. If this labelling endows them with a special meaning, the text that results is replete with jarring occupational concepts. Perhaps these fields of study need a wider range of terms for doing – a language of occupation; the development of a new vocabulary is part of any technical process. For example, a core problem in linguistics is that of classifying and analysing phenomena that are identified from a wide range of other disciplines. To do so requires a specific set of terms, and yet the difficulty with classifying what occurs in language is that it is in a continual state of flux, linked to the continuous social phenomenon of human interaction (Eco, 2000; see Chapter 8). Furthermore, in translating from one language to another, from one set of experiences to another, as in therapist-client interactions, the danger of misinterpretation is always imminent (Pollard and Sakellariou, 2008). An occupational perspective may claim to be holistic but it is only one perspective – and it is heavily influenced by one set of underpinning cultural ideas (Iwama, 2006).

The study of occupation, if it is concerned with people doing, being, becoming and belonging, has generally been constrained by the link to therapy and clinical practices. Although claims are made for occupational therapy's birth in social reform, the early identification with medical rehabilitation which made the practice into a profession (Frank and Zemke, 2008) may have diverted it from the critical engagements to which such origins might have led. As a clinical practice concerned with medical conditions the profession was less concerned with the social history of inequality, which contributed to the distribution and experience of illness and disability. The prescription of interventions for specific conditions is different from the development of practices for social change. Remarkably, given that the profession is based around engagement in activities from art to cooking, crafts to gardening, and forms of social interaction through games and dance to informal socializing, its perspective of occupation has neglected social history and cultural difference. There have been discussions of cultural competency, but little cultural analysis. Art, craft and cooking are seen as therapeutic media, taken out of the wider social context and developed in a clinical milieu. Were the profession to engage more deeply and seriously with these practices, practitioners might be able to advocate them more effectively.

The critical lens that the profession could have turned on human activity has also been denied its own practices. An emergent practice is ripe for investigation as it develops its own institutions and ways of constructing arguments in support of itself, but occupational therapy histories tend to hagiography rather than developing a critical perspective. In most countries where the occupational therapy profession has developed it has acquired a predominantly female membership that seems to replicate itself without admitting greater numbers of men. Such a marked gender imbalance combined with a remit to explore all human occupation suggests certain cultural characteristics amongst this exotic diaspora of 350,000 members that would be worthy of ethnographic or anthropological investigation.

Despite the fact that the profession relies on specialized social forms of language use to convey ideas about practice and other information (Detweiler and Peyton, 1999; Molineux and Rickard, 2003) occupational therapy has not concerned itself with the study of linguistics in relation to the description and interpretation of occupation. This is despite the fact that a key verb in many grammars is the term that equates with ‘doing’ and ‘being’, and the study of etymology may often reveal clues about the way words for doing particular occupations, tools, and familiar plants and animals have evolved in relation to human activity. To understand occupation, therapists need to develop the skills to read occupation and understand the instances where it is enabled or disabled – in effect to develop what Pollard (2008) has defined as ‘occupational literacy’ (see Chapter 3). Such a capacity is not finite but a continuous task of learning as the study of human activity is one of something that is always developing. This exposes a profession to challenges; its area of practice must shift boundaries, be subject to periodical negotiations as one activity eludes its remit and another is substituted, technologies give rise to new things to do, or new ways to do old things, human capacity for activity changes. The definition of what the profession is, and what it might refer to, is broadly constant but not fixed. Occupation is also concerned with territory and property, so it is not only associated with capacity, but prohibitions and proscriptions. The function of language as a means of social control or resistance has been documented (Mayr, 2004) but it has received little attention in occupational therapy and occupational science literature.

Therapists might be forgiven for remarking that they do not have time for all this. Indeed, there are many pressures on professionals' time originating in managerial procedures or the volume of cases – for example, many complain that they do not do the job for which they trained. For what purpose have professionals worked through three or four years of higher education, learning about ideals of practice that are so very different in the real clinical setting?

So, What Is Occupation?

In Chapter 8, Kantartzis, Molineux and Foster illustrate how doing is central to human life. Every day people orchestrate and perform numerous occupations. Some of them are responses to biological needs, such as eating or sleeping; some are socially required or expected (working, paying bills); some maintain the benefits of a social network and others may simply be fun whether alone or shared with others. A certain occupation is often performed for a combination of reasons and functions. To take one example, people engage in paid employment to maintain a social network, respond to social expectations, fulfil personal ambitions, escape poverty, or earn money. Work also gives access to resources, such as training and education opportunities, opportunities for travel, or access to facilities such as computer equipment and workshops. Work places may be located conveniently for other tasks such as collecting children from school, or enabling the worker to work from home. The same occupation can thus have significantly different effects on individuals and communities.

As Chambers Twentieth Century Dictionary (1983 edition) suggests, the meaning of the word ‘occupation’ refers to ownership of territory and the property relations that result. Military occupations are an obvious example. In a military occupation stakeholder involvements concern very different positions. No military occupation is permanent, although it may turn into or become an aspect of colonial possession that lasts hundreds of years and may involve many turns of conflict and cooperation between those who are occupying and those who are occupied (see Chapter 9).

Soldiers may be serving a tour of duty through a belief in defending a national interest, or because they have to fulfil national service obligations. Soldiering may be a vocation for some, and it may be a means to acquire experiences of adventure and travel, the income to obtain education, or purchase a house (Batistelli, 1997; Hedlund, 2011). As an occupation in itself, it is frequently the source of pride in the ability to present oneself smartly, put up with discomforts and stressful conditions, to develop technical and professional capacities. It is often represented as an entire way of life and, as it may encompass the stationing not only of the soldier but families and children in bases abroad with all the support and resources required to sustain social and community life, it can be so. Considerable efforts may be made to maintain the health and wellbeing of troops (Batistelli, 1997; Hedlund, 2011; see Chapter 13).

While soldiers are sending pay home, they are engaged in duties such as establishing law and order, maintaining peace or upholding colonial power, guarding the interests of some people and perhaps oppressing others; they may recognize that the military occupation in which they are engaged has complex outcomes, for example, because the rules of engagement impede them from preventing atrocities or returning fire (Weisaeth, 2003; Dandeker and Gow, 2004). It may limit or exacerbate conflict and the historical effects of the actions they are part of may continue for many years after they have returned home.

Civilians in an occupied area may also recognize very different positions. A military presence may represent a form of order, but it may encourage new forms of disorder, for example creating a market for drugs and prostitution or contraband goods, disrupting opportunities for sustainable work (Barr, 2010). There may be abuses of power that have to be weighed up against the abuses the troops are present to prevent. The troops may be suppressing an old corrupt regime but may not be able to prevent new forms of corruption that develop in the gaps which the former regime has left. When eventually the soldiers leave, as they inevitably must, there is a huge question of the stability of the society they will leave behind them, in which old scores can perhaps be settled.

Often as they are reported in the news such occupations are presented as political issues. It is difficult for outsiders to perceive how these politics are enacted and experienced by the people who pass each other in the street every day, on patrol or trying to go about their business, or follow the multiple objectives of officials, officers, politicians, entrepreneurs, and community leaders who each have their own occupational path to negotiate and whose daily decisions and actions impact on the people around them (Barr, 2010).

Some examples can be found in Gilmour's (1994) account of the life of Curzon, a prominent British politician of the late nineteenth and early twentieth century. Gilmour shows how the human failings and personal conflicts of key groups of powerful political figures and senior civil servants played an important part in determining the nature of some of the most important global conflicts of the later twentieth and early twenty-first centuries. Curzon's career was characterized by enmities where other politicians gave him the impression they were working with him while working against him. These souring friendships and personal disputes possibly exerted influences on the way Britain's colonial policy was carried out. There were, for example, attempts by Curzon's successors to reduce his influence and eradicate some of the projects he developed while Viceroy of India out of personal animosity. He tried to prevent a number of key political decisions because he felt they were made out of ignorance, but other politicians excluded or undermined his contributions. These decisions led to (amongst other things) the partition of India and Pakistan at independence in 1947, the dissolution of the Ottoman empire after the first world war and the formation of several middle eastern nations, including Israel, Syria, Iran and Iraq without proper regard to local ethnic interests. Gilmour notes that Curzon's views may have been borne out by history.

Thus different actors can use occupation for different purposes and occupation can be a means to exercise power, by validating one set of experiences whether this is of one culture, one class, or a perception of normality, over another. This is an unequal process, a long conflict with the odds stacked on the side of those with resources, but the outcome is not inevitable. Power can be evident in many ways, including decision making, agenda setting and manipulation (Barr, 2010). Foucault (2010) considered power as an dynamic, interactive process, and if we take a close look at instances of occupational injustice we will observe the following mechanisms: regulation (including total denial) of access to occupation, coercion for participation in certain occupations, regulation of resources necessary for access to occupation or manipulation and persuasion in exchange for other benefits.

Occupational Being

Doing things is, as Wilcock (2006, 2007) argues, what makes us healthy, or, which may be more important, feel healthy. Occupational therapy literature has discussed (e.g. Breines, 2004) but has rarely researched adult forms of recreation seriously as a contribution to wellbeing. Various forms of hunting and fishing are important in the lives of rural communities, and fishing is one of the most popular leisure activities in the UK, even in urban areas. The issue of poaching has a long history in British culture as an element in the conflict between the gentry and nobility claiming ownership of the land and the things that grow upon it, and those labourers and farmers who lived off the land. The law, in supporting the rights of the gentry to reserve game for their shooting pleasures denied others what they felt was their right to God's bounty (Hopkins, 1986). At the heart of such activities is the occupational and spiritual relationship that people have with the natural and raw environment (Bull, 2009, and see Chapters 8 and 9) and which many poachers clearly viewed as their right: ‘I am not going to be a Serf. They not only Stole the land from the People but they Stocked it with Game for Sport . . .’ (Hawker, 1978: 62, sic). This relationship gave anglers an inner sense of wellbeing and contentment (Bull, 2009) – similar benefits to those obtained from other hobbies such as modelling, which may incorporate a more vicarious relationship with nature through the depiction of landscape (see Chapter 13).

Homo faber as an occupational being expresses a relationship with the world which is not merely vicarious, or a part time interest, or a way of being that is somehow dipped in and out of as if it was a commodity. Hawker's (1978) view of a fundamental right to the land was keenly felt; he was not a solitary example, but one in a long tradition. Hopkins (1986) links the long affray to the mass trespass of the ramblers association in 1932, an event still celebrated in the towns around the Peak District. In this people congregated on the grouse moors between the cities of Sheffield and Manchester to demand rights of way to enjoy the landscape, legal access to which continues to be an issue in England and Wales (Sheffield Campaign for Access to Moorland, 1988; Lowe and Shaw, 1993). Every occupational therapy walking group using the public footpaths exercises the rights won by events set in motion by the Mass Trespass. Similar sentiments concerning rights in relation to class equality and property were evident in the literature of English worker writers (some examples can be found in Morley and Worpole, 2009). Curzon expressed the view that he was merely a custodian of the properties he held, taking a deep interest in restoring them and giving them in his estate to the National Trust (Gilmour, 1994), although, as Hopkins (1986) points out, these arguments are fairly spurious given the effects of the control and power exercised in this relation. The theme of inequalities and health disparities arising from property ownership and land rights are repeated all over the world. Doing, being, becoming and belonging, may produce social transformation; the unequal social order is also a product of occupation.

Cultural Change and Acceptable Occupations

Lorretta Do Rozario (1994) has illustrated the importance of occupation in maintaining culture through key rituals. Archaeologists know that this is a feature of cultural exchange and transition. Pryor (2004) notes British made trade items amongst Native American grave goods, and Roman trade items in Late Iron Age graves in southern England. It is unreasonable to expect people to continue to uphold their traditional standards to satisfy a Western romance of the cultures its influence nearly destroyed, or to describe their failure to do so as a loss. Adopting or refusing these transitions is a right, just as Westerners expect to upgrade their mobile phones to the next generation and match their kitchen appliances to the latest colour scheme, which is progress. Pryor's claim (2004: 438) is that despite a couple of thousand years of considerable cultural change in the British Isles some values may have survived, and one of these is ‘individual freedom’. Although this may have been imparted to many other cultures through the agency of colonial occupation, and to an extent this is what many colonial officials believed they were doing despite frequent failures to respond to the needs of the peoples they governed (Gilmour, 1994; Ferguson, 2004), Pryor asserts that it is an ancient value, one much more rooted in the people despite being suppressed by a succession of elites. The peacekeeping soldiers of various nationalities in Batistelli's (1997) and Hedlund's (2011) studies appear to have similar values and sometimes face similar problems in being able to respond (Dandeker and Gow, 2004).

All cultures change, but the political decision about which occupations are acceptable is an issue of power. Hopkins (1986) connects the rise of poaching as a source of social unrest with the rise of the rural poor. Like Linebaugh's (1991) depiction of the urban poor, he points to the removal of many of the opportunities that people had had to obtain payment in kind through their working practices, and which supplemented their wages. Linebaugh illustrates how eighteenth-century employers had allowed customs whereby a worker might keep spoiled produce or waste materials for their own use in lieu of higher wages, but these practices became criminalized. Consequently the eighteenth-century was a period where new distinctions of property and crime were being established to favour a wealthy elite, but a conflict over freedoms has continued. Much of the 2009 UK parliamentary expenses revelations show a similar difference between wealthy and poor social classes with regard to the expropriation of money from employers. Fiddling expenses is a crime but for many members of the UK parliament making false claims was until recently a way of supplementing their income, widely tolerated – just as labourers in the eighteenth century might acquire surplus or defective goods in the way of their work.

As we have seen, wealth and power have historically been key determinants of the occupational choices that are open to individuals, and social inequality based on relative affluence and poverty is a factor in producing health disparities (Thomas et al., 2010). Due to their disposable income people may be able to afford treatment they have chosen over and above any that a state or more standard service may be able to support. There need not be any moral objection to this, as the individual is merely buying additional services (for a fuller discussion of these points see Tinghog et al., 2010). A meritocratic argument for some of the disparities might be that it is reasonable that people should be encouraged to take responsibilities for reducing the costs of their healthcare to others. If people have the opportunity to eat healthily and exercise then it is their fault if they fail to do so, or if they decide to misuse substances or take other risks that injure their health.

Health and social care is often regarded as a form of commodity. In many countries people with sufficient resources can buy themselves care plans that ensure premium treatment that others cannot access. In such a system people may choose how much of their income they spend on health and receive a service according to the payments they make, but some groups of clients may not have many options, for example when they already have chronic mental health conditions. People who have experienced mental distress over a lifetime may have little economic power. However their condition creates considerable potential costs if they are brought into acute care because their situation is too chaotic for them to remain safely in the community. In the light of this possibility an egalitarian consideration about the distribution of healthcare resources might be that despite their choices everyone should have the same opportunity to access them when needed. It has often proved politically difficult, however, to determine how such equal opportunities can be provided when resources are limited (Tinghog et al., 2010). Many governments are concerned about the rising cost of healthcare to meet people's expectations, not least in recent UK policy (Department of Health, 2006, 2010, 2011).

These concerns about cost place an emphasis on proving the value of services. Occupational therapists have a good fund of anecdotal and experiential knowledge of the benefits many therapeutic activities may have, but have lacked capacity in disseminating the evidence to support these claims (Taylor, 2007). Part of the problem of communicating this lies in the values of occupational therapy itself. If a key part of the goal of the therapist is to empower the client to own their individual achievements it can be difficult to standardize results. The outcome is reflected in what the client, not the therapist, has achieved. Craft activities with their easily realizable goals and capacity for building up strengths and ability in stages lend themselves to these enabling approaches if the client recognizes a purpose in them. However they can be difficult to facilitate in a replicable and generalizable way, and tend to involve small numbers of participants. This makes them difficult to represent in large-scale research studies. They have long been understood in health practices as being good for the soul, but have given way to work reablement or skills training, which is focussed on being better for the economy and for which evidence is stronger because standardized training techniques and measurable tools are being used. They can be assessed in larger numbers enabling randomized control trials (Gibson et al., 2011).

Cost-effectiveness can be difficult to assess. We can determine the cost to one organization delivering healthcare, for example, of long-term mentally clients attending therapeutic sessions that may prevent their condition deteriorating and increasing their dependency on other services, or may reduce the risk of suicide. It is possible that the impact of providing this service reduces potential costs for other organizations running acute or community mental health services, but it may be difficult to ask them to pay towards it because it may be uncertain that the maintenance of relative health is due to this intervention rather than another factor affecting the group. However, there is often no real baseline against which nonevents arising from a policy of maintenance can be measured.

The therapist, who may struggle to identify the cost benefits of running traditional groups or individual programmes may instead become engaged in skills groups. However, a wealthy client can purchase premium occupational therapy treatments which can address the individual needs (perhaps those connected with lifestyle choices) a more cost conscious service may be unable to explore. The present policy of personalization of budgets in the UK has begun to generate a new range of services which service users can buy directly, such as attendance at craft groups for around £30 a session. These initiatives have been presented as a choice (Mandelstam, 2010) but their development is based on a calculation of what can be provided to generate a surplus for the organizations offering them, often operating from the voluntary sector. Thus, these choices are questions of occupation and power; but the question of who decides which occupations (in the form of lifestyles, life roles and health choices) are acceptable are essentially political questions that are determined by policy makers, and tend to be resolved by people who have access to power.

In the UK health professionals and service users are having to adapt to new conditions under which services are being provided. Perhaps these are the conditions that have already been established elsewhere in the world. The global spread of a market-led health philosophy may bring many practical benefits in containing the costs of health care and setting sensible limits to what a society may be expected to provide, but this does not mean that everything about it is right, simply because it is what many other people appear to accept. Many occupational activities are becoming standardized and delimited by these market forces.

Historically, human cultures of all scales reached a point where they were no longer sustainable. Often they used up the resources around them, and came into conflict with other groups, became too reliant on a narrow range of staple foods, or were weakened by diseases, reaching a point where they could not effect further adaptations to events around them (Fernandez-Armesto, 2000). On the other hand Willa Cather's My Antonia (1994 [1918]) set in Nebraska and Albert Facey's (1981) autobiography of settler life in Australia are reminders that the precarious origins of what may seem to their present members to be substantial modern societies and cultures are only a few generations away, only just out of living memory. The current urban interest in bushcraft, the popularity of activities like fishing and horticulture reveal that a relationship with the bounty of the raw landscape and a spiritual connection with nature remains as an important element of human expression of being and doing. The poacher's question concerning which person can really assert a right to the gifts of nature echoes the beliefs of the aboriginal hunter who maintains a symbiotic relationship with the environment, and is again reflected in the angler's experience of fishing (Bull, 2009). There is a tension between these direct personal engagements with the land and nature, and with the alienating forms of engagement that arise through human social development, the accumulation of property and patterns of consumption that reduce the environment, and therefore the things in it, including people, to objects.

Occupational Effect