rts offer individuals opportunities to in activities promote healthy lifestyle, Whereas the other chapters in Part 2 of this book classify leisure service delivery systems in terms of the type of funding they receive (public, private, or commercial), this chapter discusses a program area of leisure services—therapeutic recreation. Therapeutic recreation programs are found in public, private, nonprofit, and commercial organizations. This specialized form of ot- ganized recreation programming involves professionals and organizations that either use recre- ation activities as a means to intervene in people’s lives to accomplish desired ends (therapeutic recreation) or provide recreation opportunities for people who are part of special populations (inclusive or special recreation). Over the last half of the twentieth century, there has been an increased recognition in the potential of recreation as a treatment modality as well as the need to provide inclusive or spe- cial recreation programs for people with disabilities. Persons with disabilities are becoming more vocal about their needs and wants, and society is recognizing that meeting this increased demand is the “right thing to do.” The emerging field of therapeutic recreation services has contributed significantly to these trends as well as grown as a field of professional service be- cause of these trends (Kraus and Shank, 1992). This chapter will chronicle the development of these fields of practice and provide insights into prevailing goals, the available resource base, characteristics of professionals, and orienta- tion to customers. In addition, it will describe various types of programs as well as some of the many challenges for the future that both therapeutic recreation and inclusive special recreation programs may face. 304The Emergence of Therapeutic Recreation as a Profession The use of recreation as a tool to address social problems in the United States can be traced to the late 1800s as social reformers used play and recreation to address the problems and needs that grew out of the Industrial Revolution. For instance, the first playground, the Boston Sand Gardens, was established to meet the play needs of disadvantaged children. Also, many of the first organized camps were designed for and targeted “sickly boys.” Further, the settlement house movement used recreation as a means to ease the transition of immigrants to life in large urban American cities. Sessoms and Stevenson (1981) have written that Adult education, recreation, and social group work all have a common heritage. Each is a product of the social welfare reforms that occurred in our cities and industries at the turn of the nineteenth century. Their founders shared a belief—they were concerned with the quality of life and believed that through the “proper” use of leisure it could be achieved. (p. 2) As public recreation departments grew, the philosophy that views recreation as an end in itself was adopted by most public recreation agencies across the country (Gray, 1969). In other Words, public recreation drifted away from a social welfare model; a basic gap in the contin. uum of recreation services emerged. This gap was filled by professionals who were the forerun- hers to therapeutic recreation specialists today. Thus, the beginning of therapeutic recreation as 4 profession can be attributed to developments that took shape in the early part of the twentieth century and have continued into today. These developments include the need for specialized services for people with special needs, the influx of wounded soldiers from various wars and military conflicts, the emergence of professional organizations, and the number of landmark legislative bills that have become law throughout the twentieth century. The Need for Specialized Services During the early history of the United States those with mental illness and physical disabilities did not pose much of a challenge for communities. Population density was low and most com. munities were predominately rural and agricultural. The few cases of special needs that did be- come evident were addressed on a case by case basis by the family or the community. Fot the most part, communities became involved only when an individual seemed to threaten public safety or had no means of support. For example, in 1694 Massachusetts enacted “An Act for the Relief of Idiots and Distracted Persons.” Under this provision all persons who had special needs and did not have family to take care of them were aided by the state. In 1699, Connecti- cut followed Massachusetts’ lead; other colonies such as New York and Vermont passed simi- lar laws. The responsibility of taking care of those with mental illness when family care was un- available fell to public almshouses. Almshouses typically provided a minimal level of food and shelter to a mixed grouping of able-bodied poor, ill, and disabled persons. An almshouse was in existence in Boston as early as 1662. The physical environs of almshouses were said to have been dungeon-like; the emotional environment was not any more humane. Records show that these places provided bizarre entertainment for the community. Cruel treatment, including the use of chains for restraints, led to the eventual outcry that demanded changes be made in caring for the disabled. Chapter 12 Delivery of Leisure Services: Therapeutic Recreation 305306 Pane he first documented medical institution in the United States was vivant i tal in Philadelphia, which was established in 1751. The services provided at this hospital in- cluded programs for mentally ill persons who had been previously denied treatment. The first United States hospital devoted exclusively to the care of the mentally ill was established in Williamsburg, Virginia, in 1773 to make provisions for the “Support and Maintenance of Td- iots, Lunatics, and other persons of Unsound Minds.” As the United States moved into the 1800s, hospitals and custodial care facilities were constructed for the mentally ill, deaf, blind, mentally retarded, and physically disabled. Private voluntary charity blossomed in the late 1800s to take care of the poor, the ill, the elderly, and the disabled. The first private school to educate severely retarded individuals opened in Massachusetts in 1848. Many of the early re- formers and proponents of the forerunner of modern rehabilitation services are presented in table 12.1. Many of these carly institutions began to offer recreation opportunities in both formal and informal programs. In the case of mental patients, the conviction grew that occupations of various kinds would be helpful in overcoming mental illness and restoring rational func- tioning. As a result, mental patients in the late 1800s were allowed to dance, take part in out- door sports, and use “airing courts,” rocking horses, and other special equipment (Kraus and Shank, 1992) Carter, Van Andel and Robb (1995) have identified a number of developments of the late nineteenth and early twentieth centuries that set the stage for the development of specialized services for a variety of people with special needs. These developments include the following: + Health care reform that emphasized the dignity of all persons and the therapeutic value of ‘humane treatment that included the social and environmental stimulation of recreation activities; + Private and public hospital systems that created the structure for health care providers to experiment with programs and services that included recreation activities as a component of care; and + The playground movement that reemphasized the role that play activities and spaces serve in social and environmental reform. The playground movement also spawned professional ations that supported therapeutic recreation. The Influx of Wounded Soldiers from the World Wars Following the Civil War, the importance of recreation for wounded soldiers was acknowl- edged. Florence Nightingale, in her 1873 text on nursing, “urged nurses to pay attention not only to the patient’s body but also to his mind and morale. She urged that music and convers: tion be encouraged, that beautiful objects be placed in patient wards, that the family be en- couraged to visit and that patients keep small pets. Under her leadership, so-called bedside occupations were introduced in military hospitals to.cheer up injured soldiers” (Kraus and Shank, 1992, p.7), ‘The sudden influx of traumatic and permanent injuries into American society as a result of participation in the World Wars served as a stimulus for the improvement of recreation pro- grams in hospitals and long-term treatment facilities as well as a slow change in attitudes to- ward special populations (Crawford, 1996). Under the leadership of the American Red Cross. the use of recreational activities to treat those who sustained various injuries in military combat during World War I was expanded. Delivering Leisure ServicesTABLE Earcy Rerornmers in Pusiic HEALTH Care AND THERAPEUTIC RECREATION Phillippe Pinel (1745-1826) A French physician who advocated for the humane treatment of persons with mental illness and the economically disadvantaged, Pinel believed these people were capable human beings who deserved to be treated with compassion and dignity. His approach became known as moral treatment and included purposeful recreational activity and work experiences to restore mental and physical heath (Carter, Van Andel, and Robb, 1995), Benjamin Rush (1745-1813) One early reformer addressing the needs of the mentally ill at the end of the 1700s was Benjamin Rush, an influential physician. Rush was a signer of the Declaration of Independence, member of Continental Congress, ‘Surgeon General to the Continental Army during the Revolution, Treasurer of the United States Mint, passionate reformer, brilliant physician, and the first important American psychiatrist. After joining the staff of the Pennsylvania Hospital in 1783, he became the first American physician to develop a comprehensive course of study in mental disease, Rush wrote the frst textbook on mental health in 1812 (Crawford, 1996). Dorothy Dix (1802-1887) ‘The most famous and influential psychiatric reformer of the nineteenth century was Dorothy Dix. A woman who Gedicated her life to the proper care of the mentally ill, her influence spanned three decades (1840s to the 1870s). By the close of her career she had been responsible for founding or enlarging over thirty mental hospitals in the United States and abroad (Crawford, 1996). Florence Nightingale (1820-1910) A British nurse in military hospitals who was a pioneer of modern nursing, Florence Nightingale was a strong advocate for improving the rehabilitation environment of hospitals. She organized classes, reading rooms, and. recreation huts to combat the negative side effects of being a wounded soldier. In 1873, she wrote a book that included guidelines for visitor conversation, promoted the psychological benefits of music and pets, and highlighted the need for variety in both the objects and the color of hospital environments (Avedon, 1974). Paul Haun A physicianvadvocate in the 1940s and 1950s whose writings and presentations supported recreation asa therapeutic modality able to ereate a desitable psychological state within the patient, Haun was a respected leader in the field (Crawford, 1996). Eunice Kennedy Shriver Founder of the Special Olympies movement under the auspices of the Joseph P. Kennedy, J. Foundation in 1968, Shriver helped to spread recreation as formal community movement throughout community-based programs for the ‘mentally retarded and mentally ill (Crawford, 1996). Howard Rusk Physician and intemational authority on physical rehabilitation who believed that both individual and group recreation had a direct and positive relationship upon recovery, Rusk helped to establish the credibility of recreation san adjunctive therapy (Crawford, 1996), As a result of the success experienced by the American Red Cross, in the 1920s and 1930s tecteation services began to appear in other settings such as state mental hospitals (Carter, Van Andel, and Robb, 1995). The Easter Seals Society began providing day and residential camp programs in the 1930s. These types of programs continued to expand, and with the outbreak of World War I therapeutic recreation became an important element in the rehabilitation of wounded soldiers. The increase in therapeutic recreation programs is evident in the over 1,800 recreation leaders the Red Cross trained and employed during World War II (Frye and Peters, 1972). After the War these leaders became the core of young professionals who pushed the field of therapeutic recreation into other community and clinical settings. Chapter 12 Delivery of Leisure Services: Therapeutic Recreation 307308 Pan2 Professional Organizations As the ranks of hospital workers grew in the mid-1940s, several organizations began to emerge. Carter, Van Andel, and Robb (1995) report that the first effort toward professional- ation came from the American Recreation Society (ARS) in 1948 when members laid the groundwork for the establishment of the Hospital Recreation Section (HRS) within ARS Early members of this section represented hospital recreation workers from military, veter- ans, and public institutions. In the early 1950s an organization emerged from within the American Alliance for Health, Physical Education, Recreation and Dance—the Recreation Therapy Section (RTS). Members of this organization felt that HRS was too closely aligned with the community recreation movement and did not adequately represent the recreational therapy perspective. The interests of the membership focused on developing recreation and physical education programs in schools, serving students with disabilities, and adapting physical education pro- grams in integrated schools (Carter, Van Andel, and Robb, 1995). A third organization emerged in 1953 to meet the needs of recreational therapists from state hospitals and schools serving persons with mental illness or mental retardation. The Na- tional Association of Recreational Therapists (NART) became involved in the development of standards for professional education, outlining professional qualifications for clinical prac- tice and defining the role of the profession (Carter, Van Andel, and Robb, 1995). These three organizations (ARS, RTS, and NART) merged in 1966 to form the Na~ tional Therapeutic Recreation Society (NTRS) within the National Recreation and Park As- sociation (NRPA). The combined resources and energies of these three organizations pushed the field of therapeutic recreation to new heights in the areas of credentialing, ac- creditation, and personnel and program standards. In the mid-1980s friction concerning the governance of the organization and the development of a definition and philosophical state- ment for the organization contributed to the formation of a new professional organization— the American Therapeutic Recreation Association (ATRA) (Carter, Van Andel, and Robb, 1995), Although the goals of ATRA are similar to NTRS, the process of pursuing these goals is different. Today, ATRA advocates recreation as a form of treatment, hence recreation ther- apy. This philosophy represents the view of professionals who work in health care settings where “professional services are more likely to be judged by their effectiveness in improving the functional capacity, health status, and/or quality of life of the client” (Carter, Van Andel, and Robb, 1995, p. 58) whereas NTRS has advocated more for community-based recreation services for persons with disabilities. Together, these two perspectives provide a comprehen- sive continuum of services to serve the total person; they are discussed in more depth later in this chapter. Legislation In the latter half of the twentieth century, the concern for the equal rights of all Americans (including those with disabilities) has increased. This concern has been translated into action as legislation pertaining to equal access, and rights to educational and recreational services, has evolved. Legislation affecting the delivery of recreation services to persons with disabili- ties is listed in table 12.2. These laws have led to the passing of the most powerful legislation pertaining to persons with disabilities with the passing of the Americans with Disabilities Act of 1990 (ADA, PL 101-336). ADA is a civil rights law that extends the same protection Delivering Leisure ServicesTABLE 1963 1963 1967 1968 1971 1973 1974 1975 1978 98 1986 1990 LEGISLATION AND OTHER EVENTS AFFECTING RECREATION FoR SPECIAL POPULATIONS. ‘The Bill of ipped. Adopted by the White House Conference on Child Health and Protection, it provided an important endorsement of recreation for disabled children, ‘The Social Security Act. A compilation of laws, including numerous amendments over the last several Years related specifically to the elderly and disabled, it includes provisions for physical education and recreation through formal procedures for review of professional services; establishes func to states for self support services for individuals; and gives grants to states to provide community-based care. Vocational Rehabilitation Act. This Act provided training and research funds for recreation for the ill and handicapped. This was the first recognition by a specific federal agency of the importance of recreation services in rehabilitation, National Outdoor Recreation Plan, PL. 88-29, Directing the formulation and maintenance of a ‘comprehensive nationwide outdoor plan, this plan was completed in 1973 and included an emphasis on compliance with PL 90-480 (see below). Concerns for the handicapped were listed as a priority area Education for Handicapped Children Act, PL. 90-170. This law established the unit of physical education and reereation for handicapped children within the Bureau of Education for the Handicapped: it became the largest federal program for training, research, and special projects related to recreation for special populations. Architectural Barriers Act, PL 90-480, Simply stated, this lav indicates that “any building or facility, ‘constructed in whole or part by federal funds must be accessible (o and usable by the physically handicapped.” Developmental Disabilities Services and Facilities Construction Act, PL 91-517. Developmentally disabled persons are specifically defined and recreation is listed as a specific service to be included as a fundable service in this federal law. Rehabilitation Act, PL 93-112, This Rehabilitation Act was a comprehensive revision of the 1963 Vocational rehabilitation act that included an emphasis on the “total” rehabilitation ofthe individu Rehabilitation Act Amendment, PL 93-516. This law authorized the planning and implementation of the White House Conference on Handicapped Individuals. The final report noted the importance of recreation for individuals with disabilities and called for the expansion of recreation services, as well as an increase in the number of professionally trained individuals employed in the field of recreation. Education for All Handicapped Children Act, PL 94~142. By mandating free and appropriate education for all handicapped children, this law identified physical education as a direct service and recreation as a related service to be offered to those with disabilities. Mainstreaming in the school system is usually viewed 4s an outgrowth ofthis Act providing the legislative leverage for disabled children and their families to gain access to often denietl educational services, Rehabilitation Act, PL 95-602. As with many federal programs, the 1973 Rehabilitation Act and the programas it authorized expired atthe end of five years. In 1978, legislation was introduced to extend and amend the 1973 Act, This renewal called for recreation and leisure services to be a part of the rehabilitation process. Designated by the United Nations as the International Year of Disabled Persons, the theme chosen for 1981 was “the full participation of disabled persons in the life of their society.” Education of the Handicapped Act Amendment, PL. 99-457, This law emphasized the development of ‘comprehensive statewide programs for early intervention services for handicapped infants, toddlers, and families, A multdisciplinary team to develop an individualized family service plan was advocated, Recreation is cited as a related service in this amendment. Americans with Disabilities Act, PL. 101-336. Probably the best known of all the laws protecting those ‘with disabilities, the ADA provides comprehensive guidelines banning discrimination against people with disabilities. Itis an omnibus civil rights statute that prohibits discrimination against people with disabilities in sectors of private and public employment, all public sectors (including recreation), public ‘accommodations, transportation, and telecommunications From D. R, Austin and M. E. Crawford ( ). “Organization and Formation of the Profession” in Therapeutic Recreation: An ‘nsrouction, 2nd ecition, 1996. Copyright © 1996 by Allyn and Bacon. Reprinted by permission, Chapter 12 Delivery of Leisure Services: Therapeutic Recreation 309against discrimination now provided by other federal civil rights laws to people with disabil ties. It is the purpose of the act + to provide a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities; + to provide clear, strong, consistent, enforceable standards addressing discrimination against individuals with disabilities; + toensure that the federal government plays a central role in enforcing the standards established in this act on behalf of individuals with disabilities; and * to invoke the sweep of congressional authority, including the power to enforce the 14th ‘Amendment and to regulate commerce, in order to address the major areas of discrimination faced daily by people with disabilities. Characteristics of Therapeu Recreation: People with Disabilities Today Serious physical and mental disabilities affect an estimated 35 to 40 million Americans and their families, preventing them from taking part more fully in a wide range of life opportunities ranging from education and employment to marital and family involvement, as well as recre- ation participation (Kraus and Shank, 1992). Over 41 million Americans have psychiatric dis- abilities, close to 31 million have arthritis, as many as 23 million individuals have hearing impairments, approximately seven and a half million have mental retardation and over seven million have visual impairments (Seidman and Tremper, 1995). Although many of these dis- abilities are apparent, others are not (see table 12.3 for a brief description of a number of physi- cal and mental disabilities). Disabilities such as HIV, dyslexia, or being subject to seizures are not always apparent. All disabilities (hidden or apparent) are often heightened by society's re~ sponse to people with disabilities and from their own lack of a positive self-concept and confi- dence in meeting societal challenges. “Therapeutic recreation programs and services serve a wide range of individuals. Programs can help individuals in numerous ways to develop skills, contribute to self-concept and aware- ness and, in general, contribute in a positive way to a higher quality of life through the con- structive use of leisure. In discussing the ways in which therapeutic recreation can help people of all ages reach their goals, the National Therapeutic Recreation Society (1993) and Carter, Van Andel, and Robb (1995) have identified how programs can help individuals with varying disabilities. The National Therapeutic Recreation Society offers the following: People with Physical Disabilities. ‘Therapeutic recreation can help people with physical disabilities, sensory impairments, or other health-related benefits to learn new skills and/or modify old ones to compensate for abilities they have lost; practice self-care skills; get involved in community recreation programs; and feel a sense of accomplishment. People with Developmental Disabilities. ‘Therapeutic recreation can help people with mental retardation, cerebral palsy, or other developmental disabilities to develop and use their physical and intellectual abilities to the fullest; develop independence; gain confidence in themselves; and interact with others and participate in community recreation activities. People with Mental Iliness. Taking time to “play” is an important part of good mental health, Therapeutic recreation gives people an opportunity to feel good about themselves and their accomplishments; improve relationships with others; relieve tension; develop healthy coping techniques; and express and communicate their needs. 310 Part2 Delivering Leisure ServicesTABLE DIsaBLING DISEASES aND ConpITIONS Alzheimer’s Disease A progressive, ieversible neurological disorder that results in complete loss of cognitive functioning, followed by loss of physical abilities. Although common in persons over the age of sixty-five, Alzheimer’s disease may appear in individuals in their forties (Carter, Van Andel, and Robb, 1995, p, 538). Alcoholism A.complex, progressive disease in which the use of alcohol interferes with health, social, and {economic functioning. It ranks with cancer and heart disease as a major threat to the nation’s health (Carter, Van Andel, and Robb, 1995). Anorexia ‘A physical and psychological syndrome marked by severe and prolonged inability to eat with marked weight loss. This illness commonly afflicts teenaged girls, and can result in death, Arthritis A joint condition characterized by inflammation, pain, swelling, and other changes varying with the type. It is common late inthe aging process, although it also affects young people (Gunn, 1975), Autism ‘This has been characterized as absorption in fantasy to the exclusion of interest in reality. ‘Mental introversion in which the attention or interest is fastened within one’s ego: a self centered mental state from which reality tends to be excluded (Gunn, 1975). Behavior Disorder ‘A term used to refer to observable general behavior abnormalities; impaired development of internalized controls so that the individual cannot effectively cope with natural and social demands of his or her environment (Gunn, 1975). Bulimia Refers to an insatiable appetite causing excessive eating or bingeing. This is followed by urging, using laxatives, diuretics, strict dieting or fasting, vigorous exercise, andlor self: induced vomiting to prevent weight gain—hence, reference to the disease as the binge-purge syndrome. To be clinically defined as having an eating disorder, a person must have had a ‘minimum of two binge eating episodes a week for at leat three months (Carter, Van Andel, and Robb, 1995). Cerebral Palsy A nonprogressive disorder of movement or posture due to malfunction of or injury tothe brain. Several types of cerebral palsy (spasticity, ahetoisis, rigidity, ataxia and tremors) are a result of the specific location of the brain injury (Carter, Van Andel, and Robb, 1995), Cystic Fibrosis A hereditary disease affecting children involving defective production of enzymes in the pancreas, which Ieave disturbances throughout the body and usually involves the heart (Carter, Van Andel, and Robb, 1995), Developmental Disabilities Disabilities that become evident in childhood and are expected to continue indefinitely constitute a substantial handicap to the affected individual and are attributed to mental retardation, cerebral palsy, epilepsy, or other neurological conditions requiring treatment (Gunn, 1975), Down Syndrome ‘Common form of mental retardation in which the individual has a chromosomal abnormality; characterized by a broad nose, slanting eyes, protruding large tongue, open mouth, square shaped eats, large muscles, broad, short skull, and often congenital heart disease (Goldman, 1987) Epilepsy A central nervous system disorder marked by transient periods of unconsciousness or psychie disturbance, twitching, delirium, or convulsive movements (Carter, Van Andel, and Robb, 1995), Hemiplegia A person who is paralyzed on one half of her or his body (right or left side). Often, hemiplegia isa result of a stroke or brain injury. Hyperactivity Also known as Attention-Deficit Hyperactivity Disorder (ADHD), itis common among school age children who are perceived as extremely active in situations that demand high degrees of ‘composure or compliance (Carter, Van Andel, and Robb, 1995), continued Chapter 12 Delivery of Leisure Services: Therapeutic Recreation 344TABLE CONCLUDED Manic-Depression Multiple Sclerosis Muscular Dystrophy Paraplegia Parkinson’s Disease Quadraplegia Stroke Spina Bifida A major affective disorder characterized by severe mood swings and a tendency to remission and recurrence; sometimes referred to as bi-polar disorder (Gunn, 1975). A neurological disease characterized by periods of exacerbation and remission with progressive degeneration caused by plaques that interrupt transmission of impulses to and from the brain (Carter, Van Andel, and Robb, 1995), A group of progressive disorders evidenced by diffuse weakness of muscle groups. Muscle cells, degenerate and are replaced by nonfunctional fat and fibrous tissue (Carter, Van Andel, and Robb, 1995) ‘The lesion of the spinal cord at or below the second thoracic vertebra resulting in either complete or incomplete loss of sensation and movernent in both legs and the lower trank (Carter, Van Andel, and Robb, 1995). ‘A chronic progressive nervous disease of later life that is marked by tremors and weakness of resting muscles (Gunn, 1975). ‘The condition of all four limbs, both arms and legs being paralyzed or severely limited in ‘movement (Goldman, 1987), CVA—Cerebral Vascular Accident refers to the stoppage of circulation to part of the brain either by the blood vessel bursting or being narrowed enough to deprive the area of blood (Gunn, 1975). A series of spinal cord defects caused by abnormal fetal development, The major types include myelomeningocele (an outpoaching of the spinal cord through the back of the bony vertebral column that has formed incompletely}; meningocele (an outpoaching consisting of only the covering of the spinal cord and not the cord itself); and spina bifida occulta (the failure of the back arch to form—no poaching exists and the bony defect is covered with skin) (Carter, Van Andel, and Robb, 1995). Older Adults with Limitations. Services can help older adults continue to be involved socially; express themselves creatively; maintain independence; and live fully in spite of any limitations they may have. Dependent on Alcohol or Other Drugs. ‘Therapeutic recreation can help people who abuse chemical substances to learn new skills that will enhance their self-esteem; find healthy alternatives to substance abuse; and feel fit and appreciate the value of wellness. At-Risk Youth, and Juvenile and Adult Offenders. ‘Therapeutic recreation can provide healthy outlets for energy and activity—recreation is a way to release tension that can be destructive if it remains bottled up; teach people to cooperate with others—through group activities, individuals can lean to work and play together; and improve self-esteem— people need to feel good about themselves before they can feel good about others. Homeless and Destitute. According to Carter, Van Andel, and Robb (1995, pp. 459-460), therapeutic recreation can serve to assist in“, . . assessment of social and functional capacity to behavioral change and acquisition of coping strategies for daily living . . .” for individuals who are homeless and destitute. Autonomy, control, self: esteem, independent functioning, self-awareness, decision-making, planning, and participation in socially valued roles can be enhanced through therapeutic recreation (Kunstler, 1991), $12 Part2 Delivering Leisure ServicesBarriers to Success in Leisure As can be surmised, to be successfully integrated into society, people with disabilities must overcome a number of barriers both physical and attitudinal (Bedini and McCann, 1992). Physical barriers include inconvenient or inaccessible facilities and programs, transportation barriers, and economic barriers. Attitudinal barriers may be viewed as external (society's atti- tudes toward people with disabilities) and internal (low self-concept). Attitudinal bartiers as- sociated with society’s response to persons with disabilities can be separated into three dis- tinct types: * Negative barriers. These behaviors are usually intentional and obvious. They clearly inform the individual that he or she has less value than individuals without disabilities, An obvious example would be mocking or ridiculing a person with a visible disability, while a more subtle example would be avoiding people with disabilities, * Paternalistic behaviors. Head patting, giving undue ot excessive praise, and providing help when itis not needed are examples of paternalistic behaviors. Unlike negative behaviors, Paternalistic behaviors arise out of a desire to show the person with a disability that you care or that you have a favorable view of a person with a disability. Unfortunately, the message conveyed is that people with disabilities lack competence, maturity, and the capacity for independence. * Apathetic behaviors. People who are apathetic toward individuals with disabilities express no feelings of sympathy, understanding, or caring toward people with disabilities, As a result of these types of barriers, people with disabilities often lack a positive self- concept, which can limit their potential. To assist customers or clients in overcoming these types of barriers, professionals in all areas of recreation must lean to deal with the individual first and the disability second, This adage was exemplified in 1989 by Mark Wellman, a park ranger who is paraplegic, when he climbed a sheer rock cliff in Yosemite National Park. After reaching the top, Wellman said his feat showed that physical disabilities should not stop people from achieving their dreams. He was reported to have said, “I don’t consider myself disabled” (Glastris, 1989, p. 22), Goals and Functions Therapeutic recreation programs serve a variety of different age groups with a wide range of characteristics. As a result, defining therapeutic recreation is often difficult. After a quarter of a century of inquiry and debate, the profession continues to have difficulty defining terms and precisely describing the goals and functions of therapeutic recreation, Evidence of this contin ued disagreement over philosophy, terms, and definitions is illustrated in the existence of both NTRS and ATRA. An excerpt of the philosophical statement of NTRS provides a broad framework for under- standing the goals and functions of therapeutic recreation. This statement identifies the purpose of therapeutic recreation as “to facilitate the development, maintenance and expression of an appropriate leisure lifestyle for individuals with physical, mental, emotional, or social limita- tions. Accordingly, this purpose is accomplished through the provision of professional pro- grams and services which assist the client in eliminating barriers to leisure, developing leisure skills and attitudes, and optimizing leisure involvement” (NTRS, 1982). This view defines ther- apeutic recreation as the provision of leisure services for those people who have some type of limitation, Chapter 12 Delivery of Leisure Services: Therapeutic Recreation 3413.Therapeutic Recreation Service Model seo eoeen Seam pe cate etn Seat teip Principles. an Seen rata ea 314 Pate Leisure Litestyle Role of Special Degree of Control Nature of Intervention (Role of the specialist) Intervention conttoled by Thorapist specialist f (Need of the client) Purpose of Intervention 1 ‘Maximum control by the specialist Improve functional ability i i 1 1 1 i i 1 ‘Treatment asi necessary | antecedent | toleisure | involvement | \ i Degree of Freedom in Participation ‘Obligatory Behavior Constrained Prescriptive Dependent Extrinsically rewarded FO Behavior of the Ciient In accomplishing this purpose NTRS identifies three specific areas of professional services: therapy, leisure education, and recreation participation, These professional services can be seen ona continuum and are presented in figure 12.1 (Peterson and Gunn, 1978, 1984). Therapy is di- rected toward improvement of functional behavior that may impede leisure involvement or using leisure to help participants reach other treatment related goals. Leisure education teaches new recreation and social skills to help expand a person's leisure repertoire or assist in adapting her or his interests and hobbies into a new situation (e.g., a basketball player learning how to play wheelchair basketball after a spinal cord injury). The last component, recreation participation, concems the provision of self-directed leisure participation for individuals with disabilities. Delivering Leisure ServicesSmith, Austin, and Kennedy (1996) point out that when closely examined, it becomes ap- Parent that therapy and leisure education components merge as both deal with facilitating change. This results in leaving only two components in the model presented in figure 12.1— treatment and recreation. Within the treatment mode, therapeutic recreation is a purposeful in- tervention designed to help clients grow and to assist them to relieve or prevent problems through recreation (Austin, 1996). This is what ATRA (1987) emphasizes in its philosophical statement that states “the primary purpose of treatment services, which is often referred to as recreation therapy, is to restore, remediate, or rehabilitate in order to improve functioning and independence as well as reduce or eliminate the effects of illness or disability” (Carter, Van Andel, and Robb, 1995, p. 59). Strong proponents of recreation as therapy often feel that the provision of community recreation for people with disabilities should be the responsibility of community recreation and parks personnel. Viewing therapeutic recreation as purposeful intervention does not diminish the impor- tance of providing recreation opportunities for everyone in society. Such programs, often re- ferred to as special or inclusive recreation programs, are equally important if the continuum of services (presented in figure 12.1) is to be complete. Thus, it is becoming increasingly more important for recreation providers in all areas of the economy (public, nonprofit, and commer- cial operators) to provide recreation services for people with disabilities. As inclusive and special recreation programs grow, there is a need for therapeutic recreation specialists to help organizations meet the diverse needs of all people in the community. Resource Base The resource base or revenue for therapeutic recreation services is diverse. Therapeutic recre- ation services may be found in public organizations (e.g., federal, state, county, and municipal government), private nonprofit organizations (e.g., group homes, advocacy groups), as well as commercial organizations (¢.g,, for profit hospitals, nursing homes). In addition, today’s com- petitive health care environment is encouraging a number of innovative collaborative projects between public, private, and commercial organizations. As a result, funding may be a complex issue for many therapeutic recreation programs, Insurance payments further compound the issue of funding for therapeutic recreation ser- vices. Although third party billing is not a reality for many agencies devoted to therapeutic recre- ation, insurance companies do pay for related services such as therapeutic recreation in in-patient and out-patient care in medically based facilities. Within the funding framework, one constant is clear. Therapeutic recreation specialists need to be creative to continue funding programs at the needed level because the rising costs of medical care are shrinking health care dollars. To remain competitive, therapeutic recreation specialists are constantly looking for oppor- tunities to document the outcomes of their programs (Coveliers, Milliron, Page, and Rath, 1996). Programs are developed with specific benefits, values and goals in mind. For it is only through an underlying commitment to fostering these benefits that they will be achieved. One of the results of such an analysis is identifying the benefits associated with various programs. In many areas of the park and recreation field, professionals are embracing such a benelits-based approach to providing services. Characteristics of Professionals In 1992, there were approximately 30,000 recreation therapists employed throughout the United States. About one half were in hospitals and one third were in nursing homes. Others Chapter 12 Delivery of Leisure Services: Therapeutic Recreation 345316 Pant2 were employed in residential facilities, community mental health centers, adult day-care cen- ters, correctional facilities, community programs for persons with disabilities, and substance abuse centers (Occupational Outlook Handbook, 1995). Due to the diversity of these settings, it is difficult to analyze professionals within therapeutic recreation with a great deal of precision. A profile is starting to emerge, however, regarding the nature of professionals in this sector with regard to educational level and work motivation. Generally, therapeutic recreation professionals have at least a bachelor’s degree in thera- peutic recreation, which is essential for hospital and other clinical positions. In addition to a college degree, certified therapeutic recreation specialists (CTRSs) must have completed an in- ternship under the supervision of a CTRS, passed a cettification exam, and maintained a pro- gram of continuing education as set forth by the National Council for Therapeutic Recreation Certification (NCTRC). In addition to these educational and certification requirements, the Occupational Outlook Handbook (1995) states that “recreation therapists should be comfortable working with people with disabilities and be patient, tactful and persuasive. Ingenuity and imagination are needed in adapting activities to individual needs” (p. 175). Tn an empirical study examining the characteristics of successful youth workers working with youth at risk in American inner cities, McLaughlin (1994) identified the characteristics of leaders who make a difference in the lives of inner city youth. These leaders exemplified the following characteristics: * See potential, not pathology. “The youth of inner cities are not people to be fixed, remediated, or otherwise controlled but as young people with promise, largely ignored, wrongly perceived, and badly served by society at large” (p. 96). + Focus on youth. Successful leaders’ commitment to youth also means that they focus on youth more so than on the organization, program, or activity. + Have a sense of efficacy. Effective youth leaders have a firm conviction that they can and do make a difference in the lives of teenage youth from even the bleakest urban settings. + Believe in giving back. Part of the leaders’ consuming commitment to youth results from their wanting to give back what others gave them as they grew up. All of them see their work as a mission and vocation, not simply a job, or even a career. * Authenticity, Each leader manifests a different personality and programmatic interest to design programs that make a difference. There is no one-size-fits-all program, Successful leaders try to mesh their personal talents with their work. Although many of these characteristics relate specifically to youth leaders, they are also transferable to working with other populations. Focusing on the potential of clients rather than on their problems, focusing on the needs of clients first, seeing work as a mission or vocation instead of a job, and finding a personalized style may all be considered important elements to be successful in working with a variety of clients Types of Therapeutic Recreation Programs/Settings As previously discussed in the goals and functions section, there is a difference between ther- apeutic recreation and special or inclusive recreation, and each stands alone as an important clement in meeting the needs of all members of a community. While distinct, these two enti- ties often overlap. Overlap occurs when a therapeutic recreation program offers a client an Delivering Leisure Servicesaccompanying benefit of a recreative experience, or when a special or inclusive recreation Program serves as an intervention, bringing about a desired therapeutic benefit (Kennedy, Smith, and Austin, 1991). This overlap may also be seen in the variety of agencies that offer both therapeutic recreation programs as well as special/inclusive recreation. Kraus and Shank (1992) and the National Therapeutic Recreation Society (1993) have identified several types of agencies or settings that provide a variety of programs along the continuum presented in figure 12.1, Outpatient Clinics. Outpatient clinics provide a number of therapeutic recreation services and programs. In general, outpatient programs provide services for individuals who do not stay overnight. Length of treatment can vary, as can the number of hours per day that patients are involved in treatment. For example, outpatient programs may be offered to support and treat individuals with substance abuse problems. Such programs may include counseling, information, small group discussion, and a variety of leisure activities and services. Group Homes. A group home is usually thought of as a residential facility that houses twelve or more individuals. These types of residential care units provide therapeutic recreation programs and services such as sports, trips and tours, arts and crafts, aquatics, literary self-improvement. and others, In addition, group homes provide leisure education programs that prepare individuals to live more independently and/or improve their leisure skills. A group home is a controlled, strongly supervised environment. Home Health Care Agencies. Such organizations provide in-home care and associated support services for individuals, For example, the hospice concept found in many communities throughout the United States provides in-home health care and other support services for terminally ill individuals and their families. For example, the Cedar Valley (Towa) Hospice has as its mission a commitment“. . . to providing quality palliative and Support services to help meet the physical, psychological, social and spiritual needs of dying persons and their families, during the patient's illness and throughout bereavement.” Substance Abuse Facilities. There are several different types of settings in which therapeutic recreation services are offered as a part of a substance abuse program. Some of these include acute care hospital programs, residential care, and outpatient services. Programs include self-help, education, counseling, therapy (e.g., milieu, psychotherapy, group therapy, etc.) and others. The purpose of therapeutic recreation in these types of settings is to help individuals finda“. . . healthy means to satisfy needs previously met through drug-taking . . . TR can facilitate new learning related to social and free-time choices, and provide a natural but supportive environment to practice new skills and pursue positive alternative ways of behaving” (Austin and Crawford, 1996, p. 98). Half- Way Houses. This type of facility may be thought of as a treatment site that is located in the community. Half-way houses provide opportunities for re-integration of individuals into community life, while still providing structure and assistance. Therapeutic recreation programs can be offered within the half-way house, or can be organized for half-way house residents using community resources. Vocational Training Centers. These types of settings provide individuals with training and counseling focused on an individual's work or career goals. For example, Goodwill Industries of America provides career training while at the same time offering social skills development, medical management, and leisure education, Vocational training centers are Chapter 12 Delivery of Leisure Services: Therapeutic Recreation 317318 Pate often associated with treatment or rehabilitation programs. Such programs provide opportunities for involvement in action-oriented therapies such as art, dance, music, occupational, and, of course, therapeutic recreation. Camps. There are numerous day and residential camp programs that are targeted specifically for individuals with disabilities. Camp Courageous in the state of Iowa provides opportunities for individuals with a full range of disabilities to participate ina wide variety of therapeutic recreation programs including outdoor adventure, camping, sports, arts and crafts, aquatics, and others. This organization is a nonprofit, year-round, recreational, and respite care facility for individuals with disabilities, Centers for Independent Living. Usually, facilities for independent living are supervised residential facilities for one or more individuals. These arrangements are clustered in several combined units such as an apartment complex. Centers for independent living provide opportunities for individuals to continue their career training, while at the same time engaging in activities for social skill development and leisure education. Following a stay in a half-way house, an individual might transition to a center for independent living. Sheltered Workshops. This type of setting provides a protective environment in which individuals engage in meaningful work experiences and learn job skills. Sheltered workshops may provide therapeutic recreation services as a part of theit support for participating individuals. An example, Adults, Inc. in Waterloo, Towa, uses therapeutic recreation to enhance its clients social and recreational skills. Community Mental Health Centers. Gallagher (1980) refers to a community mental health center as a program that provides partial (day) hospitalization for individuals with Psychiatric disorders. These types of centers may provide in-patient and out-patient services, partial hospitalization, emergency services, consultation, and education. Therapeutic recreation services vary, but usually emphasize community recreational activities such as sports, drama, trips, camping, outdoor pursuits and others. For example, the Merced (California) County Mental Health program offers all of the previously mentioned services as well as conducts a fully developed therapeutic recreation staff by certified therapeutic recreation specialists and aides. Adult Day-Care Centers. An adult day-care center“, . . is a community-based group program designed to meet the needs of functionally impaired adults through an individual plan of care. It is a structured, comprehensive program that provides a variety of health, social, and related support services in a protected setting during any part of the day, but less than 24-hours.. . .” (Bebren, 1986, p. 2). Senior Centers. These types of settings provide opportunities for individuals to pursue leisure activities as a major focal point of their effort. As Austin and Crawford (1996) write, “senior centers provide a place for older adults to come together for socialization, leisure activity and other services” (p. 234). Nearly every community in the United States provides some type of support for such a program. Activities found in these types of programs include current events, literature, trips, genealogy, att, fitness, social recreation, and numerous others. Programs also provide information, referral services, and treatment programs related to the needs of participants. Psychiatric Facilities. Therapeutic recreation programs in psychiatric facilities focus on rehabilitation, education, and participation (Peterson and Gunn, 1984). In these environments, the role of the therapeutic recreation specialist is “. . . to help the individual free himself [sic] from the constraints that are limiting his [sic] personal growth and Delivering Leisure Serviceshealthy choices in behavior . . . typical settings include inpatient, outpatient, partial or day settings, transitional settings, and individualized settings . . .” (Austin and Crawford, 1996, pp. 65-66). Hospitals, Hospitals are housed under various sponsorship such as the Veterans’ Administration, military, public health (federal, state, county, municipal), nonprofit hospitals, sectarian, and proprietary. Many of them offer therapeutic recreation services as, a part of patient rehabilitation, Nursing Homes, Nursing Homes can be described as long-term care facilities for ill or disabled (and often, senior) citizens who can no longer function in the community or reside their own families. Nursing homes are increasingly admitting younger patients who may be profoundly mentally retarded or have head injuries, strokes, or other traumas, and who cannot live independently. Settings Serving Elderly Persons. There are increasing numbers of residential centers for seniors who cannot or choose not to live independently or with their families, do not require intensive nursing or medical care, and meet many of their own needs independently. These types of programs/settings include municipal, county, or state homes for the elderly; residential centers sponsored by sectarian or service organizations; low income housing projects with special units for the aging, and commercially developed retirement centers. In the future, this type of setting may also include senior day-care programs as well as in-home care programs that may be offered to seniors who live in their own homes. Schools or Residential Centers for those with Specific Disabilities, These institutions Permanently house people with physical disabilities (e.g., visually impaired, hearing impaired, orthopedically or neurologically impaired), those with mental retardation, or emotionally ill persons. These centers offer “full service programming” with schooling, recreation, religion, and living skills all a part of the services provided. Penal Institutions and Other Programs for Socially Deviant Persons. These types of institutions include adult penal institutions such as prison, jails, and other detention centers, as well as work camps, reformatories, therapeutic camps, wildemess programs, and special schools for youth who have been committed by the courts for delinquent behavior. In addition, special schools and shelters for emotionally disturbed children and youth, or for those from broken families or families incapable of providing adequate care, are included here. Centers for Physical Medicine and Rehabilitation. Often these types of facilities are found in close proximity to hospital complexes, universities, and/or medical schools and serve as treatment centers for a variety of people who have suffered serious physical injury. Such People are no longer under treatment for the acute phase of their illness or injury and are receiving varied forms of physical, psychological, vocational, and social rehabilitation to facilitate their return to their families and community life. Programs of Voluntary Agencies. A number of national organizations have been established to promote services for specific groups of people with disabilities such as cerebral palsy, orthopedic or neurological disorders, and mental retardation, Special Olympics Intemational and Easter Seals (which provides special camping programs) are {wo examples of the growing number of these types of programs. National youth serving ofganizations are also increasing their programs targeting specific groups of children and adolescents facing specific risks (e.g., gangs, violence, pregnancy, drug abuse). Chapter 12 Delivery of Leisure Services: Therapeutic Recreation 319320 Pane TABLE HEALTH SHiFts—CHaNcEs IN ALL Aspects oF HEALTHCARE Shifts From To Doctor Care Self-Care Treatment Prevention Sole Provider Health Promotion Team Exercise & Fitness Wellness Looking Good Living Well ‘The Years in Your Life The Life in Your Years ‘Source: Trends Action Group, 1993, National Recreation and Park Association Public Recreation and Park Departments. Governmental leisure service agencies on every Jevel—federal, state, and local—have increasingly accepted responsibility for providing recreation for persons with disabilities. In some cases the sponsor may offer segregated activities for customers with severe disabilities, while at the same time encouraging opportunities for fully integrated participation for others. With the emphasis on integration and mainstreaming, and with the support of legislation such as the Americans with Disabilities Act, more emphasis will be placed on creating inclusive recreation opportunities for all Challenges for the Future The 1990s have been a time of tremendous change in health care. Therapeutic recreation spe- cialists in both clinical and community settings are facing a work environment that is constantly changing. On one hand professionals are being asked to document outcomes, respond to the needs of the customer, and provide quality services, while on the other hand they are being asked to deal with budget cuts and staff reductions. Managers and staff everywhere must meet the challenge of doing more, doing it faster and better, and with fewer resources. In a recent study Little, Lankford, and DeGraaf (in press) used a nominal group technique to identify the issues and trends with which therapeutic recreation professionals were most cor cerned. Specifically, participants viewed the related issues/trends of budget cuts, health care re- form, and reduction of staff as the most important changes related to the field of therapeutic recreation. (See table 12.4 for the shifts in approaches to healthcare.) “Lack of awareness of therapeutic recreation by political leadership” and “salary equity of therapeutic recrea workers” also ranked high. Other issues identified included transportation and mobility issues for people with disabilities, the need for staff (and volunteer) training, need for services in de- veloping countries, motivating staff, having less time to assist patients to re-enter the commu- nity, fundraising, promotion of community outings for residential patients, lack of qualified Personnel, deinstitutionalization, the impact of ADA, need for certification, value of TR in gen- eral hospital setting, and the lack of CEU opportunities and funding. As all agencies deal with the rising costs of health care, it will be increasingly important to document the effectiveness of therapeutic recreation in clinical and community settings and to Delivering Leisure Servicesincrease programs and find innovative funding sources and partnerships. For example, home- based recreation services will serve a wide range of populations, especially an increasing num- ber of senior citizens. Home health care in the United States is expanding because it reduces health care costs while assisting individuals to maintain some of their independence. Addressing New/Growing Social Problems CTRSs must continue to serve those outside of the mainstream, It is easy to serve those outside the mainstream in times of affluence, but when resources begin to dwindle a conflict in values can result. For while good times provide increased options and encourage the free play of indi- vidual interests, hard times diminish options and create competition for resources, Professionals in the field of therapeutic recreation must seek out connections with other fields and social ser- vice agencies. Professionals need to build bridges between fields, especially in community ther- apeutic recreation programs. Expanding an agency's role in the community increases political strength for, and public awareness of, the therapeutic recreation profession. Through collabora- tion and partnerships therapeutic recreation can be involved in addressing a variety of new and/or growing social problems that include the following: + AIDS. AIDS affects three groups: those with clinical cases of AIDS, those with AIDS related complex, and those who are infected with the AIDS virus, but are asymptomatic. CTRSs may work with persons with AIDS in a variety of clinical and community settings including hospitals, long-term care facilities, prisons, substance abuse centers and hospices. Because there is no cure for AIDS, individuals will need activities that provide immediate gratification as well as those that assist them in coping with the demands and uncertainty of the disease. Persons with AIDS and related illnesses need opportunities to learn coping and leisure skills that are appropriate to their health status and emotional needs. Challenging questions in working with AIDS patients include the following: What types of knowledge and skills do CTRSs need to work effectively with persons affected by AIDS, ARC, and the HIV virus? How can CTRSs best articulate their potential contributions and collaborate with other health professionals in serving those with AIDS? Can policies and practices be developed to provide equitable and ethical services? What types of TR programs and services will be needed by persons with AIDS (Turner and Keller, 1988)? * Homeless. According to the Department of Housing and Urban Development, homelessness is “a condition of being without a regular dwelling place whereby a person or family lives Outside on the streets, tries to find a public or private shelter at night or sleeps in a makeshift dwelling such as a car or a train station” (Kunstler, 1991, p. 31). Conservative estimates of the number of people homeless in the United States range from 2 to 3 million people (Kunstler, 1991). CTRSs desire to serve those with a variety of disabilities, including those who have any condition that appreciably impairs their ability to make a minimally successful connection with the labor market, and to form mutually satisfactory relationships with family and friends. By this definition, many homeless people are disabled (Kunstler, 1991), * New Poor. Lahey (1991) has identified three groups that arc the hardest hit by today's growing inequity in the health care system who should be of major concern for all recreation professionals. These groups include children living in poverty, the working poor (an alarming number are homeless and without medical insurance), and the frail elderly. For example, child poverty rates in the United States are two to nine times as high as those in other major industrialized nations. In 1994, 15.3 million children were poor, down slightly from 1993, but still the third highest total since 1964 (Children’s Defense Fund, 1996). By Chapter 12 Delivery of Leisure Services: Therapeutic Recreation 324322 Pane strict clinical/medical definitions, these groups would not qualify for services until the difficulty of their situations brings them to the point of hospitalization and short- term intervention. As recreation professionals continue to look for ways to develop Preventative approaches rather than reactive programs, those living in poverty should not be overlooked, * Gangs. Although not a new problem, gang activity has intensified and become more violent in recent years. Homicide is the number one cause of death among African American and Latino 15- to 24-year-old males, and the third leading Killer of Whites in that age group, Approximately 125,000 youth younger than eighteen were arrested for violent crimes in 1994, and while the number of homicides committed by juveniles (ages ten to eighteen) not involving guns has held steady over nearly two decades, the number of gun homicides by Juveniles has almost quadrupled since 1984 (Children’s Defense Fund, 1996), Many of these violent crimes are related to gangs. Recreation professionals have much to offer as communities search out multidimensional solutions to gangs. As society moves toward a more holistic youth development model for deal- ing with young people, recreation professionals must see youth as a resource to be developed rather than as a problem to be fixed. Such an approach to youth development creates programs where youth can acquire a broad range of competencies and demonstrate a full complement of connections to self, others, and the larger communities. Dealing with Technology Keeping current with technological breakthroughs is a constant challenge for therapeutic recre- ation professionals. In trying to incorporate technology into therapeutic recreation services, pro- fessionals must remember to examine new technology to (1) see how it fits into programs, and (2) understand the social ramifications of technology. Therapeutic recreation professionals need to be sensitive to new populations created due to technology. For example, whereas fifteen years ago the majority of brain injured people died Soon after injury, today 95 percent of people with head injuries survive—technology helps keep People alive. An estimated 15 percent of survivors of brain injury are left with permanent deficits that prevent them from returning to their previous school, job, or relationships. Re- sponding to this group of people means providing programs in all areas of the service contin. uum: therapy, leisure education, and recreation. Recreation participation must also be available to those patients who are being main- streamed into the community. One innovative response in the community has been the use of a buddy system, which teams up one individual with a brain injury with an individual who is able-bodied. Since the average age of occurrence for brain injuries is twenty-two years old, so- Cialization and interaction with peers are critical needs for recovering patients. As therapeutic recreation professionals look to the future, the challenges can seem over- whelming. There is opportunity in change, however, and the profession must move for. ward. In the words of Broida (1996), “now is the time for us to mobilize our creativity and meet our professional challenges in positive, proactive ways. We need to communicate our ideas with others so that we all benefit from the expertise of our colleagues. This proba- bly means losing some ego, letting up on the protection of our ‘turf* and having everyone in the ficld commit to move the professional toward the unified goal of better services for out customers” (p. 37). Delivering Leisure ServicesSummary Oliver Wendall Holmes once said, “the great thing in this world is not so much where we are, but in what direction we are moving.” This chapter has documented the movement of society in providing recreation opportunites for everyone, There is still much to be done but the field of therapeutic recreation is moving forward in the right direction. With the increased recognition of the potential of recreation as a treatment ‘modality as well as the increasing need to provide inclusive or special recreation programs for persons with disabilities, the field of therapeutic recreation has grown tremendously. Therapeutic recreation emerged over the last century as a result of a number of different factors including the influx of wounded soldiers from both World War I and World War Il, the emergence of Professional organizations, and a variety of federal legislation. Despite the growth of services for people With disabilities, a number of barriers still exist in truly integrating them back into society. This chapter discusses two types of barriers—physical and attitudinal. Professionals inthe field of therapeutic recreation are constantly advocating for their clients and assisting them in overcoming these barriers. Within the field of therapeutic recreation, there remain two distinct aspects of the profession. The firsts often referred to as therapeutic recreation, which is a purposeful intervention designed to help clients grow and to assist them to relieve or prevent problems through recreation. A second aspect of the Profession, often referred to as inclusive or special recreation programs, provides recreation services for People with disabilities. Yet, with the growth of legislation (like ADA), itis becoming increasingly important for all recreation providers (public, private, nonprofit, and commercial) to provide recreation services for people with disabilities. ‘The growth in services for people with disabilities and increased awareness of society to meet the needs of people with disabilities translate to a bright future for those interested in both therapeutic recreation and inclusive recreation. Yet, many challenges exist ranging from financing and assuring ality in program development to meeting the program needs for new disability groups and growing Social problems. As therapeutic recreation professionals look to the future, the challenges can seem overwhelming; yet, if one looks how far the profession has come, one realizes that anything is possible. Discussion Questions 1. Define therapeutic recreation and inclusive recreation. Why is there a need for both types of services? 2. How do the philosophical statements of NTRS and ATRA differ? 3. What are the barriers people with disabilities face in participating in leisure and recreation? What are three specific things that could be done to make community recreation programs more inclusive? 4. Identify several of the major types of sponsors of therapeutic recreation service (eg, nursing homes) and clarify the role recreation can play in the lives of the population they serve. 5. How did the United States Armed Forces assist in the development of therapeutic recreation programs? 6. As people move more to a wellness approach to medical care, how will the role of therapeutic recreation change? 7. In your own words explain the impact of the ADA on the provision of recreation services. 8. Identify five or more disabling conditions and discuss how therapeutic recreation services can assist individuals improve their quality of life 9. Discuss the emergence of therapeutic recreation as a profession, 10. 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Dubuque, IA: Brown & Benchmark. Staif. 1995. Occupational Ouilook Handbook. U.S. Department of Labor. Washington, DC: U.S, Government Printing Office. Stensrud, C. 1996. The roving recreation specialist in transitional living settings. Parks and Recreation 31 (5), 62-63. Stumbo, N. I., and C. W. Bloom. 1990. The implications of traumatic brain injury for therapeutic recreation services in rehabilitation settings. Therapeutic Recreation Journal 24 (3), 64-79. ‘Trends Action Group (TAG), 1993, Trends being Tracked, Presented at the National Recreation and Park Association National Conference. San Jose, CA. ‘Tumer, N. H., and M. J. Keller. 1988. Therapeutic recreation practitioners’ involvement in the AIDS epidemic. Therapeutic Recreation Journal 22 (3), 12-21. Voight, A. 1983. A National Study of Perceived Motivational Factors and the Degree of Perceived Influence of Supervisors and Subordinates. Unpublished doctoral dissertation, University of Oregon, Eugene. Wilhite, B. 1987. REACH out through home delivered recreation services. Therapeutic Recreation Journal 21 (2), 29-38 Chapter 12 Delivery of Leisure Services: Therapeutic Recreation 325