az Chapter 1 Specifying the domain of concern: Occupation as core Helene J. Polatajko Jane Davie | Deb Stewar Noémi Cantin Bice Amoroso Lisa Purdie Daniel ZimmermanCASE 1 Bonnie Sherr Klein: Doing my real work Bonnie Shorr Klein, an accomplished filmmaker, author, and disbilty activists honveriten and spoken extensively bout her recovery ram a debilitating brain Nem tioke, and her experience of belng a disabled person ina word hat realy ready forthe disabled, Inher keynote addres atthe 1995 annual vonarence of the Canedian Assocation of Occupational Therapists, while sees on the theme of Partners in Practice, Bone recounted a partcerly poignant story But fist, the content! Tr August 1987, atthe age of 46, Bone wa nthe mist of Mil Zero: ‘The SAGE Tou, when she suffered two catastrophic strokes coused by hemar- thoging of» congenital malformation i er brain sem She became quadpe ( requied exprator to breathe, and experienced pane attacks and ced in syndome, Having survived an extremely delicate and high-ise ration, Bonnie began along and arduous process of ehabiltation that eed over 3 yours. Bonnie was determined to finish he fim, and during the ary tapes of her rehabiltation she devoted al her weekend o that goal ‘Dating the keynote she recounted Sh would work during my weekend off and return exhausted. {was often, scalded for wearing myself auton the fim. fel asf was cheating on fry rehabltation work... when {was doing my ral work of fimmaking Trova not unt after the fi was ied and released nearly one and a falfyers aftr the stroke that! oozed myself that this was my occupe Tord therapy (as accupational therapy was probably meent tobe) Ie eenuted all my previous skill and experiance, plus many new adopts Tons ft mas going t be useful it reconnected me tothe wide world versie my body, i forced me t come out’ and be seen in public ne ftbvought me validation a a productive pevson, (regained # sense of ‘myse”(CAOT, 2002, p vi Milo Zero: The SAGE Tour wos released in 1988. ete scrces €AOT 202) 1.1 Introduction [As Bonnie Sherr Klein noted, recovery from stroke, enabled by engagement ia sreaningf occupation, s occupational therapy as #8 meant o be. From its very bevinuing cecupatonal therapy has been concerned with occupation and its rele in health and wellbeing. As early as 1919, Dunton established this in his ered ‘Occupation is as necessary to life as food and drink ery human being should have both physical and mental occupations (A should have occupations which they enjoy, or hobbies Sick minds, sick bodies and sick souls may be healed thru oceupation (Dunton, 1919, p10) ‘Comspaton: The core domsn of exnean for acapations heey Be ea| However. as the Ottawa Charter for Health Promotion (WHO, 1986) makes clear the empuusis on health should not be overstated; occupation has value in its own | right as a resource for everyday life To reach a state of complete physical, mental and soctal wel being, an ind vidual or group must be able 10 identify and to realize aspirations, 10 satisfy needs, and to change or cope with the environment, Health is, therefore, seen 15a resource for everyday life, not the objective of living. (WHO, 1986, p. 1) 1.2 The evolution of our occupational perspective: Occupation as the core domain (Over the course of the profession’ history, the concept of occupation has evolved as has the centrality ofits role. In 2001, forthe 75th anniversary issue ofthe Canadian Journal of Occupational Therapy, Poatsko traced this evoltion by reviewing all the issues ofthe joomal from 1933-2001. She concluded that the path has been from the provision of diversional activity, through the use of therapeu- tic activity, to enablement through meaningful occupation. Inivlly occupation was essentially conceptualize informs of work — not necessarily pid work, but work nonetheless, Potatajko's (2001) review noted thatthe term occupational therapy was fist coined by George Barton, an American architect, ‘who championed the idea of curing by means of work. The pervading belief at dhe ‘ime was that work, or occupation, was essential to health, well-being, and happiness ‘Our greatest happiness in life does not depend on the condition of life in which chance has placed us, but is abways the result of good conscience, {g00d health, occupation, and freedom inal jst pursuits (Thomas Jefferson) ‘Thomas Jefferson (1743-1826) stated “itis nether wealth nor splendor; but rangui- ity and occupation which give you happiness." And, more importantly for occupa vional therapy, as the quote from Howland atthe outset of this paragraph suggests the absence of work leads to a general deterioration ofthe human spirit, Accordingly, the inital sim of occupational therapy vas to provide opportunities for ‘ecupational engagement, (a.k.a, work), i order to occupy individuals during their ccanvalescence: "to provide the patient with a well-balanced day, 28 nearly approaching normal as is possible in an institutional set-up” (LeVesconte, 1935, 6). It was assumed that this diversional use of work would not only prevent dete rioeation, but promote recovery instead, The objective [of occupational therapy] Is two-fold Firs, to keep occupied, during atleast part of the long, tiresome period of invaldism, the minds of those who are temporarily swept aside from healthy lving by the ravages of disease and of those who are permanently wable olive normal lives with normal people. Second, to adapt the methods of treatment the needs ofthe individual so that, by active occupation, maimed limbs ana minds may be ‘once more restored fo health (Howland, 1933, p. 4) That occupation has the potential of therapeutic value was a central tenet of practice from the inception ofthe profession in Canada, However, fom the 1940s onward, Sonotying the domino once: Occupation a ate 15a tne curative potential of occupation was no Tonger referred to in terms of occupation rather it was eaptuzed in a number of exer concepts including work (6... Martin, To.) and arts and crafts (-2, Robinson, 1942), The most longstanding among, those was the concept of therapeutic activity, which was given prominence by Howland in his writings in 1944 ‘Occupational therapy is based on the principle that sce voluntary activity is ‘anormal function of every organ and sructue, then, when injury or disease ‘has resulted in om impaired activity, amelioration or recovery may be areatty deste, om the one hand by physical exercise ofthe disabled member, while, ‘onthe other hand, the patient's mn is kept preaceupled with some diver- sional occupation such as at, muse, crafis or recreation (Howland, 1944 pp. 32-33) |With Howland’s statement, the profession was defined in terms of therapeutic use of activity for the next 50 years, There seemed to be no need fora focus on occupation The emphasis on therapeutic use of activity notwithstanding, iterate in the 1950s bbogan Lo describe ever broader roles for occupational therapy. In 1953, Howsack rete thet occupational therapists should assist people in carrying owt their occupa tional roles, By the 1960s, it was suggested that therapists should help their patients ‘purticipate more effectively in out society” (Roberts, 1962, p.5); thatthe ro}e ‘ould go beyond the restoration of function and... seek to help him gxow and develop, to make use of all of his ailtes and thus more effectively realize his potential” (Jantzen, 1963, p. 23); 0 live, not merely exist (Cardwel, 1966), Jn actvitis that are meaningfal to them (ShimeK, 1971), in their own environments (MeKay, 1974). engaged “The evolotion of our perspective on occupation is evident inthe Canadian ltratore a fom the use of diversional aetvity through the therapeutic use of activity, t0 ‘enablement through meaningful engagement in occupation, We now recognize that “ihe vital need served by occupational therapy is man’s need for occupation” (Woodside, 1976, p.12)."The concept of occupation was revived in occupational therapy bythe American occupational therapist Mary Rely (1962), one ofthe most influential writers in the profession in the latter part ofthe lst millennium, Reilly reintroduced the focus on occupation and extended the profession's scope beyond the medical/curative model to an occupational model In 1992, Polatajko suggestee that the profession embrace this accupatonal perspective and name and frame itself ts enabling cccupation. In 1993, Tovmsend, echoing that vision, extended it beyond the individual to include a sovil mission. The 1997 publication of Enabling ‘Occupation: An Occupational Therapy Perspective, entrenched the centrality of ‘ecupation 28 our domain of concer i sang tha, "This primary role of enabling ‘ecupation constitutes a necessary and suliient condition for the practice of occ pational therapy” (CAOT, 1997, p. 30) COeaipate: The core dmsn of coca fr cenypatina thrpy> 1.3 Specification of an occupational perspective: Our language Definitions broadening the role of occupational therapy from occupying the invalid to ‘enabling occupation with diverse clients, the concept of occupation was broadened. 'As defined in Enabling Occupation (CAOT, 19972), the term oeeupation refers mot only to work, puid or unpaid, but to ll manner of human doing be it self-care, productivity or leisure Occupation refers to groups of activites and tasks of everyday life, named, organized, and given value and meaning by individuals and a culture Oceupation is everything people do to accupy themselves, including looking ater themselves (self-care), enjoying life (leisure), and contributing t0 the Social and economic fabric of thei communities (productivity) (CAOT, 1997, p34), ‘Broadening the definition of occupation in Canada was in keeping with international ends, For example, in 1983, Reed and Sanderson defined occupation a, "activities for tasks which engage person's time and energy; specifically sof-cae,productiv- ity and leisure” (p. 247), Christiansen, Clark, Kielhofner, and Rogers (1995) defined ‘occupation asthe ordinary and familie things that people do every day. Kielhofner's (1995) definition specified that occupation included doing culturally meaningful ‘work, play or daily living tasks in the steam of time and inthe contexts of one’s pliyscal and social world. Pechaps the most widely cited definition was that offered by Yerxa and er colleagues (Yerxa et a, 1990) who stated that occupation refers to “Specific chunks of sctvity within the ongoing steam of human behaviour which are named in the lexicon ofthe culture” (p. 1). “These definitions ascribe a meaning to occupation tat isnot only broader than that understood by occupational therapists inthe early days ofthe profession; the mean ing is broader than that nderstood by the general public. In general day-to-day parlance, the primazy understanding ofthe term occupation is “a person's usual or ‘incipal work or business, especially as a means of eaming a living; vocation” (Merriam-Webster, 2003). This day-lo-day parlance notwithstanding, Mecriam Webster (2003) etes asthe fits definition “occupation: an activity in which one ‘engages (pursing pleasure has been his major occupation)” A taxonomic code for occupation ‘Occupational dherapists' rediscovery of the eoncept of occupation does not mean that ‘other concept, in particular the concept of activity, no Tonger have a place inthe profession. Rather, i means that the profession fas to specify the use of these terms tnd their relation to each other (Polatako etal, 2044), Indeed, many of the current ‘definitions of occupation do just that; for example, occupation refers to groups of sotivtis and tasks (CAOT, 1997a, 2002) doing culturally meaningful work, play, ‘or daily living tasks (Kiethofner, 1995) activities or tasks (Reed & Sanderson, 1983); “specific chunks of activity” (Versa etal, 1990, p. 5) Specivng the domino concen: Oscpation a coreivy, and task is not consistently define in absence of consistency, members ar left with considerable conf nner of human doing, regardless ofthe ses of complexity. Por example, acountancy (Hagedor. 2000) report wing “The relationship between occupation, at ome instanoes definitions are contradictory. Inthe ofthe profession and those who read our Iiterature Sion. The term occupation is applied to all ma {Ca 1996, and wex-inking Hanna, 1997 have all been given equ sas 88 therapy literature This situation leaves the profession he awkward position of not yet having an agreed exity of its domstn of concem, With increasing roan vee gccupation in occupational sence and occupational therapy, We may be inne to develop a consistent language fr etsy and clear conmmarizalio with coe pal ther fails, the public, other health professional, service providers, fovernmental agencies, and thind-party payer. ‘ceupations inthe occupational lat risk- ceupatonal therapy is in ‘upon vocabulary to address the comp! “The lack of vocabulary to deseribe our core domain is ot x ne problem for the pro Feta in 1933, Dunlop wrote, "From those early days until dhe present, occupations {pera hus suffered aliostconinuosly from a misunderstanding.” (7 Paine (2001 argues tat itis the lack of specification of ou language, na mer Thar ttas easily undertond by the publ, tht fsa othe disappearance ofthe term sree rom out Hers, She nots tat th tem disp om see ib arent. Except or its continued use in the ile of the profession it was ential does pa the Canadian erature throughout the 1940s, 50s, 6s, 70s and 80s, beg ech tems as activity, ask, work, and fanetion Polak, 2001 replaced b ‘Aremedy for lack of vocabulary i a wxonomy, that to saya clear and consistent ‘tam fr differentting among the levels of ocupaton a the eatonstip of aan each other. A taxonomy is «hierarchical ordering of related concepts dha tethles the specification of concepts and thet placement in ration to each allow- ing for more in-depth understanding (Bloom, Engebat, Furs Hil & Kehoe) aes Keath Bloom, & Masia, 1968). numberof eccupational therapy schol echave popowed that a taxonomy woul allow forthe breakdown ofan occupation aaa ers eves of compleily (Cistiansen & Baum, 1997; Hagedom, 2002; iason, 1996, Levine & Brayley, 1991; Pierce, 2001; Platajko et al. 2004). In Canada, Poatajko and colleagues (Polstajko et al. 2004) propose use of the ‘Tascnomie Code for Occupational Performance (TCOP) to specify the language of ‘rayuton, Developed over ato-year periods through a process involving Ie eaerreews,afinity mapping, scholarly discourse and debate, and evaluation of wee manicablty and eomprehensiveness the code proposes seven levels of om ‘text, Subsequent investigations ofthe validity of the TOP bh from te pe Miectve of ntematonal experts and of novice student oceupaional heaps ‘Poc, Zimmerman, Davi, Poatajko, submited) indicate hat the TCOP i 2 rutin usable insrument 10 categorize the various levels of complexity of oecu- tonal erormance an place them nations beach ther. While the TCO? rarely new and in need of further professional discourse, the TCOP is mie sstong existing clasifieation systems in oseupatioalthorapy, being the ony Om art pec subjee to validation, Thus itis curently the best avaiable method for ‘organizing the language of occupation. ‘cezuoation: Tha cove domain fence fr ocopationa apy ee“The revised TCOP consists of five levels, with exch level having one more dimen: sion of complexity and subsuming all the characteristics ofthe levels below it (ce figare 1.1). Occupation appears atthe top of the hierarchy, As in the rules of taxon- | ‘omy (Bicher, 1975; Bloom et al, 1956; Kesinger, 1979, 1986; Krathwohl et a., | 1964; Reynolds, 1971), occupation subsumes all the levels below it occupations are | composed of ase of activites: composed ofa set of tasks, composed of a set of actions, composed of a set of voluntary movements and mental processes. Using the examples listed above, accountancy isan occupation and report writing is an activ ity, a8 i tea drinking Figure 1.1 The Taxonomic Cod of Occupational Performance! (TCOP) Level of ‘omplenty —Defirition Eaamole | {scooter an raga that bong sac, ° ‘ean by nda a9 Acinty set of asks wth pea ond point ox ovtesme that Franc rapor wring Tusk ——_Asetof actions having an end pent ora spedie Printing the report ‘Adlon Asst ofvoitary movements or antl process tht Folding, erembering ‘im erocogresble and purposetlpatemn auch athe tmeting oF gasping holding, puna, pushing, wring, reali, Nunes Siteine welng: king. ememberng, niin, honing. winking te) Volutary spl volatry sce of mental ation (suchas Flexing. tending rmovanert exon extrsion suction, btn, rotation, Crinetal —supnaton pronation, Silins, mare, stern, 1 en parece eed by cpt, na elect ptmnce compares (ped to oto eto 208% ae, Dai Pan, 2064 As expected ofa taxonomic hierarchy, the number of possibilities increases with each level ofthe TCOP. A the lowest level, thete ate relatively few possibilities (the human is only capable of performing avery finite numberof voluntary movements), hile atthe highest level there are almost limitless possibilities (Wikipedia alone lists ‘over 1,000 occupations) Correspondingly, the lower levels add to the higher levels ‘This makes it possible to predict peeformance in large number of occupations from ‘knowledge of performance on a relatively fewer numberof atvities and, in tun, relatively fewer tasks, actions and voluntary movements, and mental processes Knowing that a person has limited flexion a the hip o poor attention, for example, | allows prediction of performance on a large numberof actions, tasks, atvitis, and ‘ccupstions. The TCOP can, thus, direct practice tothe most appropriate level to maximize occupational enablement. We can communicate the reasoning for choosing | Specivng te domino concen: Osepation coe °oy tasks, aetivities, or oceupations as therapy with our cients to ensure thatthe ee vance of our choiee is not lost on them, as it was on Bonnie Sherr Klein (se> ease 1) ‘he occupational therapist worked with humiliating seriousness. We played shuffleboard, and ping-pong, bus no one explained that they were to practice tour balance and Iwas too Out of 10 understand. Byerything seemed random ‘and irrelevant (CAOT, 1997a, 2002, p. vil) 1.4 Specification of an occupational perspective: Our assumptions [ier saying that “everything seemed random and inelevant” Bonnie Shew Klein ‘continued We dd pre-kindergarten puzzles with large wooden pieces, carnival ames with clown face targets, and uninspired paint-by-number crafs. My parner Tievoted herself to a pre-fabricated wooden nativity scene for Christnas, while ‘made potholders asi happens I was in the middle of making afm (nor potholders} when I had the stoke (CAOT, 1997a, 2002, p. 3). {All professions have some basic assnmptions that, by definition, are not questioned, but rather a held tobe tru. They ae changed only when there is large accumula tion of prevailing evidence to sugges thatthe assumptions are uo longer tenable. “That the earth was the centre of the universe or thatthe world was flat were Ton standing aswmpions held to be true until t was demonstrated otherwise (Some still hold these to be true). Basic assumptions are necessary to guide the art and science of a profession. (Occupational therapy holds « numberof basic assumptions about human eceupation (Gee figure 12), Danton (1919) proclaimed two primary assumptions inhi credo: that occupation isa basic human need; and, that occupation bs the potential to be therapeutic These have guided our art and our science sinee the inception ofthe profession and have led to the articulation of further assumptions as our cecupa tional perspective evolved Fundamental tothe practioe of ecevpains therpy sthe conceal of Thhaman su occupational belngCicok 196, 998,200; Yee al Tree ana: 990, or hr cccpaon ia base ncd Dunn 1919 eee ey Comes and rscrces wo engage in scpatio sa! be sae all ple (Wilcock 1988) cs oesupaton equ fr su Sta hath at we-elng Pi ir, 198; Plato, 1992; Wie. on; unto 1919) prone is ssi when he id hat ocaption a ica foodand dit The sumption of human needs teen etc ocean temp and ecuptona scene Mente acts ef set ose Roger, bRR; Wieck, 006) By extension arything tat a eet abily engage m ecto ts he pti 10 gael Tee aaa vebengof ie indivlual,cve to geventepaoology Fre in ging, @lobmon, 199 Fler & Pde 197), Convent Cceupstion Th cre dain of concern fer occupa erapyFigure 1.2 Base assumptions Base assumptions (Occupation affects heath and wellbeing tcapation a pation gins tian brings = (searing sane by the cre ary Imbalance and negatively affect health, incre depression (Duxbury eta, 1999) 3 stress, and may actualy result in The corollary of the fist assumption isthe seconds that occupation has potent ‘therapeutic value; in the words of Dunton (1919), “sick mings sick bovlies and sick ‘souls may be healed through occupation.” (p.10)."Dis second assumption has pe: ‘yiled in our profession since the beginning and can be seen repeated in our liter ture throughout our history. In 1933, Hovland wrote, “by ative aceupation, maimed Timbs and minds may be once more restored to health” ¢p. 4); and stil ater, Fidler and Fidler (1978) wrote on purposeful action and sef-actualization based om the idea that doing isthe remedy. That occupation should have the by the further assumptions we hold shout it Occupation brings meaning to life. Occupation is deeply seated in human exis tence (Clark, 1993, 2000), 0 much so that in our eulture people identify themselves by what they “do,” making “occupation... dhe erucble in which our identities are formed” (Polatajko, 1998). Occupations conebute o one's social and sel-dentity (CAOT, 19994; Unruh, 2004; Yerxa etal, 1990). Occupations connect ws people (Rowles, 2000) and our past, present, and fare (Laliberte Rudman, Cook, & Polatajko, 1997). They allow us to explore and learn from the environment, to mas- ter skills, to express our individuality, and to sustain life ‘The meanings ascribed to occupation have two sources: the cultre, and, ulti= mately, the individual (CAOT, 1997, 2002). As aa occupational being, the person has interests and intrinsic motivation to choose and engage in particular oceypa- tions (¥erxa, 1998). The motivation to persevere with accupations is influenced by individuals" values, interests, and exercise of choice (Kielhofner, 1997). Ulimately the meaning associated with an occupation is personal and cannot be "understood by observation alane; each occupation is uniguely experienced by the individual engaged in it (CAOT, 19972, 2002), However, humans are “not decon- ‘extualized entities rather, they “act on and interact with a myriad of ‘mens, using occupation” (Yerxa, 1991b, p. 200). According to Yersa, engaging in ‘ceupation enables individuals and groups to participate in society, a8 well as to find meaning through occupations and to place themselves within their own eul ture, Yerxa (1998) reinforced the idea of occupation being context dependentPeople ae sell organizing, responding and adapting to diverse environmental cal Jenges as they engage in occupations throughout ther lifetime, ‘Occupations organize time and bring structure co life it i through engagement in ‘occupations that people bring a htm to their days and organize their time (CAT, 1997, 2002; Kielholner, 1997; Rebeiro, 1998) Prolonged and consistent cups tional engagement ean lea (the formation of habits and routines, which provide (dructare and organization 10 Tite (CAOT, 1997a, 2002; Christiansen & Baum, 1997; Kiethofner, 1997; Polaajko, 1992) However, asthe quote from Sherr Klein (see case 1) indicates, the therapeutic value bf every eccupation is nol the same for every person. The therapeutic potential of ‘ecuptions, and the povter and positive effects of occupation, are greatest whet Shoite and contol ean be exercised, anda sense of accomplishment from perform ance js obtained (Laliberte Rudman, Cook, & Polatajko, 1997), i). Engagement in occupations that ate Inind is apt to see new visions, new hopes and faith. There is something about “imple, effective work withthe hands that makes (humans) ..reators in a ver real sense - makes them: kin withthe great ereatve force ofthe world } From such a basis of dignity and simplicity anything is possible (Hal! & Buck, 1915, pp-57-58) “The idiosyncrasy of occupations points to an important caveat, Not all oveuptions Jend to health, well-being and justice, o have therapeutic value, even if they hold | meaning, organize time, and bring structure to life, Occupations can be “maladaptive.” even harmful, iter tothe individual or society (Golledge, 1998), examples being self abusing behaviour, vandalism, arson, or illegal drug us. Many people ate engaged in risky, unhealthy or even ileal and ict ccupation, which ‘can undermine health, welF-being and justice 1.5 Specification of an occupational perspective: Our Canadian model Tn seting the stage for enabling cecupation, the Canadian Assocation of ‘Occupational Therapists (19974) introduced the Canadian Model of Occupaiona! Performance (CMOP), With the introduction of the CMOP, the CAOT placed CCeaipton The eoe domain ef once for ecapstionl heey