Doing, being, and creating a myth

A couple of things have drawn my thoughts to this topic: the first is a post on the Salford University Occupational Therapy Blog called ‘Create your own destiny’ in which they ask how educational institutions should prepare new graduate occupational therapists for the Brave New World of health care in which we work. They suggest we look for opportunities to promote ‘thinking out of the box’ and working from a nonmedical model – but this poses the question of how, in doing this, occupational therapists will manage to still meet the needs of those within a medically-based health care system.

One of the respondents to this post made the point that ‘I believe that occupational therapy is about occupation, health and well being’. I replied with the thought that ‘occupational therapists identify ‘doing’ (occupational performance) as their core domain, and all their clinical efforts are focused on helping ensure that people can ‘do”.

The first poster responded saying ‘Your comment…left me wondering how other health care professional might view their role in relation to enabling people to “do”.’, while another said ‘I think that all health professions would say that they help people to ‘do’, by the very process of working towards people being more healthy and able…So I’m not convinced that this is a good way of defining what an occupational therapist is.”

One person suggested that a solution lies in the need to define occupational therapists contribution more comprehensively by using professional language (ie jargon) to describe the work of occupational therapy….’OTs will gain respect when we begin to use our own therapeutic approaches and our own language to describe the work that we do, instead of borrowing from others and apologising for ourselves.’ and a further response to this was that occupational therapists should do this to ‘highlight our interventions in both medical and social models of care.’

The occupational therapy theory in my vintage was fairly scant, and I clearly and fully acknowledge that I have adopted a lot of psychological theory and research into both my clinical practice within pain management and my model of therapeutic work. However (and you knew I was going to add a ‘however’!), there are so many times throughout my career that people within the occupational therapy profession and other health professional groups have said ‘but you’re still doing occupational therapy’, even though some of the activities I’ve done can barely count as health-related, let alone occupational therapy related!

So, let me recount some of the activities I’ve done that other people have identified as ‘occupational therapy’…

  1. Safe patient handling
  2. Injury prevention
  3. Workplace wellbeing interventions
  4. Injury management case management
  5. Work rehabilitation negotiations between worker and employer
  6. Health and safety management

Quite a wide range, really… and something common to these activities has given people the idea that they’re all ‘occupational therapy’?  I can’t quite see it myself, but more about that later.

Another thread that has drawn me to thinking about ‘what is occupational therapy’ is a paper I read, posted on SomaSimple, a manual therapy forum, by Kelly and McFarlane ‘Culture or cult? The mythological nature of occupational therapy’. (Kelly & McFarlane, 2007).  This is a paper that describes some of the foundations of occupational therapy as similar to beliefs in a religion, that the profession is predicated upon Western beliefs and principles that have not been challenged, and that learning ‘how’ to be an occupational therapist happens as some sort of initiation rite where ‘learnings’ are absorbed by the adherents in some sort of mystical manner.  Using the imagery of myth-making, the authors suggest that occupational therapy can define itself by looking inward and agreeing as a community to what occupational therapy is and does – and that this is ‘truth’, until a newer or better version is adopted by the community of occupational therapists.

Kelly and McFarlane say ‘If we can agree on what occupational therapy is, based on our jointly shared biases, assumptions, prejudices and values, then that interpretation could consequently be considered ‘true’ or ‘valid’ unless, and until, a new interpretation, or myth, is offered that members of that community, or culture, agree is better’. [My emphasis]

Now this paper did several things: it initially got my blood boiling – I’m a scientist, myth makes no sense! Then it got me curious about the place of narrative and storytelling in therapy – reminding me of one therapist who kept on saying ‘it’s all about the process!’  And then my blood started to boil again…are they seriously suggesting that a definition that is consensual amongst a certain group is therefore ‘true’?  What about Copernicus? What about Galileo?  What about witch-burning?  People of the time had a consenual view that made them go to great lengths to harm people who suggested an alternative view – and the consensual view was utterly wrong!

While I agree with some of their paper, which argues that occupational therapy has been predicated upon North American individualistic and independent values and needs to consider broader cultural assumptions –  the suggestion that occupational therapists should embrace ‘creating personal myths for their clients…they conduct clients across thresholds of transformation … that carry them from one stage of life to the next, from separation through transition to re-incorporation’ – this does not sit well with me. This is not what I do in pain management.

Kelly and McFarlane suggest that occupational therapy students are followers of a cult – used, of course, ‘in its traditional sense, and expert practitioners in occupational therapy may then be likened to ‘priests’ or ‘monks’ who possess some secret knowledge thtat cannot be readily explained to others.’ While at the same time they discuss the negative connotations of cults – ‘hero worship’ and ‘gods’ who are the generators of ‘the most popular models and instruments of occupational therapy’.  They contrast the monotheistic and hierarchical religious constructs of Western models with those within the Eastern religious philosophies such as Zen.

They talk of individual therapists ‘creating their own personal myths and follow their individual path to enlightenment’. This to me is quite risky – a constructivist view of the world can lead to individuals identifying ‘what works for me’ without recourse to any evidence base, and opens healthcare up to dogmatism and wonderfully charismatic people ‘selling’ their brand of therapy on the basis of ‘it works for me’.  Unfortunately, basing decisions on what is popular lead to hundreds of people dying from bloodletting and poor hygiene…it definitely was not popular in the early years of surgery to suggest washing hands between patients might be a good idea!

Now one point I really did like was the ‘grand myth’ of occupational therapy being that ‘occupation is essential for health’ and ‘purposeful activity’ may be used to reduce dysfunction and improve individual performance. Kelly and McFarlane state ‘Truth in occupational therapy [ie the place of activity – in my words ‘doing’] is not, therefore, based on scientific facts, but on tenaciously held beliefs.’ Good point – excellent point. The belief/assumption that humans ‘should’ be engaged in activity is implicit throughout all occupational therapy.  And it has not been validated empirically – it’s simply a belief or value that occupational therapists hold, and like every assumption, it needs to be tested in the ‘real world’ or context to determine whether it holds up to scrutiny.  Or at least, that’s my scientific world view.  Otherwise, that belief or value is simply like a religious belief or value that shapes action but in itself doesn’t necessarily improve health.

And this brings me to my original response to the Salford University Occupational Therapy Blog in which I said the I thought occupational therapy was all about ‘doing’ – well, actually I was more precise than that, I said ‘occupational therapists identify ‘doing’ (occupational performance) as their core domain, and all their clinical efforts are focused on helping ensure that people can ‘do’.’

There is merit in this definition of occupational therapy – in fact, you can see it being used in the Kelly and McFarlane paper.  It’s included in the wikipedia definition of occupational therapy ‘“purposeful activity or interventions designed to achieve functional outcomes which promote health, prevent injury or disability and which develop, improve, sustain or restore the highest possible level of independence.”  The Canadian Association of Occupational Therapists defines Occupational therapy as ‘a health profession concerned with promoting health and well-being through occupation. Occupation refers to everything that people do during the course of everyday life (CAOT Position Statement on Everyday Occupations and Health, 2003). The primary goal of occupational therapy is to enable people to participate in the occupations which give meaning and purpose to their lives.’

Personally I don’t subscribe to the idea that everyone ‘must’ carry out purposeful activity in order to be healthy.  I think of the selective relinquishing of household management and self care amongst some Pacific Island people when they become unwell (from a stroke, chronic pain, whatever) – it’s quite OK within their cultural context to do this. Sometimes the ‘therapy’ typically offered within an acute medical setting which aims to promote independence with self cares is simply not appropriate. What I acknowledge within my practice is that if an individual does want to engage in activity (and for me, it’s paid and unpaid work), then I’m able to help them achieve that goal.

So, what does define occupational therapy?
I still think that occupational therapists firmly believe that their role is to help people successfully engage in purposeful activity, or ‘occupational performance tasks’. The assumption is that when an individual can be successful in this, they will be healthy – or happy. Whether this assumption stands up to rigorous scrutiny, I don’t know – and this is something that the occupational therapy profession ‘should’ question or verify using quality empirical data. And further, I don’t know whether this is specific to occupational therapy – aspects of it certainly seem to be (eg the assumption that people should actively choose activity, that their activities shape their roles and ensure they can achieve roles, and that activities are ‘purposeful’ – whatever that means), and yes, there are other helping professions that have similar aims.

Is occupational therapy well-served by the suggestion that ‘special’ language to describe occupational therapy interventions should be adopted? I don’t think so. I think this makes occupational therapy difficult to understand, less well-understood, and much less likely to be respected. I do, however, agree that if occupational therapists want to be respected, the profession must ‘identify clearly what our unique contribution is and could be – and demonstrate this by clear achievement of outcomes’, as one of the respondents to the Salford Occupational Therapy Education blog says. I just haven’t yet found anyone who does ‘identify clearly what our unique contribution is and could be’.

If occupational therapists can translate their activities into language that other professions can understand (and the ‘general public’ too), there might be a chance that people interpret the profession as ‘easy’ and ‘oh we all do that’. At the same time it does make the area of expertise much more readily identified.

I am not sure that reinventing ‘doing’ as ‘engaging in activities of daily living that have personal meaning and value’, , ‘trained to evaluate patients … to determine the impact the disease on their activities of daily living’, the use of productive or creative activity in the treatment or rehabilitation of physically or emotionally disabled people, a profession that enables people to lead meaningful, satisfying lives through participation in occupation, registered health professionals, who use processes of enabling occupation to optimise human activity and participation in all life domains across the lifespan, and thus promote the health and well-being of individuals, groups, and communities makes a lot of difference to the essence of what occupational therapists are interested in enhancing.

Basically, ‘doing’ sums up all of the above however you dress it up.

To summarise – what I’m interested in is helping people achieve their potential despite experiencing persistent pain.  Occupational therapy as a profession has shaped the value that I place on people being able to choose to do things in their lives to fulfil their roles – but it hasn’t given me the tools that I use every day.  The tools I use are founded on evidence from a range of domains that include the biophysical, the psychological and the social.  And this seems to work for me.  And hopefully, the values I bring, along with the tools I use, work for my patients as well.  At any rate, I’ll at least be measuring whether it does.

Kelly, G., McFarlane, H. (2007).  Culture or cult? The mythological nature of occupational therapy. Occupational Therapy International 14 (4), pp188-202.


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