Occupation: The Keystone of a Curriculum for a Self- Defined Profession Elizabeth J. Yerxa Key Words: education, occupational therapy * profession’s value system * philosophy The idea of accupation is proposed as the bass for con- structing a curricular renaissance far occupational sherapy in preparation for a new millennium, Implementing an oceupation-centered curriculum could create a more inte- ‘grated profession in whieh practice, ideas, scholarship, and education nuerture and support one another, increasing the autonomy of both the occupational therapy profesion and recipients of its service A practice-oriented rationale for curricular design includes explication of the idea of occu- pation, a view of the person as an occupational being embedded in thas concept, and the choughe proces of occupational therapy. Recommendasions are provided to sreate an insegrated curriculum that will consribute to fuure-oriented practice and a self- defined profession. Elizabeth J. Yerxa, EdD, LHD (Hon), SeD (Hla), OTR, FAOTA, is Distinguished Professor Emerita, Department of Occupational ‘Therapy, University of Southern California, Los Cale ifomnia, (Mailing address: Route 1, 196 Columbine, Bishop, California 93514) This article was accepted for publication October 13, 1997, ee Teis noe the truth that makes you ee. Ics youe powsesion of the power to discover the ruth. (Lewontis 1997, p. 32), distiner profession. A hybrid group of “rehabilca- tion cherapists,” bachelor of science graduates in “allied health," receive most of their training on the job. They provide physical “tchabilicacion’ in large centers owned by megacorporations, Patients are given “therapy” by technicians and computer-oper- ated machines. A formula specifies the number anc extent of treatments according to reimbursement criteria for diagnostic categories. Burgeoning popu- lations of people with chronic impairments cannot find a place in their culture. They become the invis ible, hrow-away people of the 21s¢ century. The public, viewing disablement asa “tragedy.” suppore ccuthanasia for persons with chronic condicions (Proctor, 1988). Occupational therapists are in high demand as autonomous professionals who are advocates for anc alles with persons who have chtonic impairments as well a others who seek a healthy, sacisying life through engagement in occupation. Occupational therapists provide a broad range of individually tai- lored services to enable persons to achieve self-or- ganization and mastery of their environments through their own actions. Recipients of occupa- tional therapy modify their unique nervous systems (Calvin, 1996), learn competence, experience fica op achieve “equality of capability” (Bickenbach, 1993), contribu to their culture, and find satisfac tion in thei daily rounds of actviey, Health is e- conceptualized as possession of a repertoire of skills that enables persons to achieve ther vital goals (Potn, 1993). Recipients of occupational not only survive bue develop skill, respond to chal- lenges, organize their time, and manage their own environments regardless of impairment. Because such persons are visible, participating members of society, public artinuces toward disability change. Impairment is no longer viewed as rendering a life “not worth living” (Proctor, 1988) but a a special class of challenge, one among many facing human beings, The strength of the occupational cherspy profession is connected with the power of those ic ‘nmi hacia nau ofa eseset the year 2050, Which of the following scenaric more likely to occur? * Occupational therapy no longer exists as a separatecannot know which of these scenarios is more likely to occur, However, the probabilities are strong! loaded by lum creates the curriculum we design today. The curricu: hits ability co influence the way graduaces perceive ideas, themselves, the persons they serve, and environments of practice, It may foster an inte grated, strong profession that serves important human needs of, fit emphasizes bod rules of scholarship by writing papers ad. central to occupation, applying their acquire dressing. concey new understanding to the “clinical irritations” arising in practi Lwill explore a practice-oriented rationale for curricu lum design including the idea of occupat of the person as an occupational being, and thougences health (Reilly, 1962, 1966; Yerxa, in press) People are not instinctively or otherwise programmed to move through an itinerary of daily occupations (Yerxa ee al,, 1989). Rather, they make choices (Yerxa, 1967), consciously deciding what they will and will not do. They sequence their choices in time so that, on each day, 2 round of activities is orchestrated ino a sort of routine (Beisser, 1989). The net effect is engagement in a daily blend of occupations, each of which may be experienced and classified, for example, as work, rest, pla, leisure, self cate, of other culeural categories. ‘The experience of individual occupations and their blend shape, in part, a person's perception of the quality of life. Occupations, so orchestrated, mediate adaptation (Yerxa et al., 1989), In occupational therapy we often call occupations the “activities of daily living,” meaning the gamut of activities thar people need and want to do to function effectively in their own environments and cub ture (MacDonald, 1976; Séderback, 1988). The word occupation is derived from the Latin root occupacia meaning “to seize or take possession,” conveying action (Engelhardt, 1977). Occupation is boch organized and acts as an organizer. People are seized by their occupa~ tions (Caikszentmihalyi, 1975). To engage in occupation is to take control, The human seems to be the only organ- iam thae adapts to its envizonmenc by acting on it or by creating a new environment thac is habitable through occupation. As Reilly (1966) observed, occupation that enables humans to become self-sufficient and productive has an economic function. Fulfillment of an occupational role helps connect individuals to cheir culture. Because of the complexity of both occupation and occupational therapy practice, a new synthesis of inter disciplinary knowledge is needed to support che curricu- lum. Reilly (1969) urged the profession to think about what knowledge was “necessary and sufficient” (p. 302) to construct our awn theoretical framework. Tn contrast to medicine’ roots in the natural sciences, the scientific foundation of occupational therapy requires a synthesis of interdisciplinary knowledge organized in a nonreductionistic, systems rk. Some scholars in cour field have called this synthesis “occupational science” (Yerxa er al., 1989}, emphasizing that occupation is a uni- versal phenomenon worthy of serious study. 1 do not expect to discover relevant knowledge in the physical and natural sciences that support medicine and physical cherapy. Rather, salient knowledge is emanating from evolutionary biology (at the macro level of whole organisms), human growth and development, interdisc- plinary beain science, social psychology, anthropology {including the cukure of disability) philosophy, sociology, and even management theory. This emerging knowledge may be organized into different configurations depending The American Journal of Occupational Therayy upon the scholarly interests and skills of particular faculty members and their communities of scholars. View of the Person as an Occupational Being ‘Occupation requires that persons have interests, inten- tions, and the skills to follow them to achieve their pur- poses. People, in all cheir marvelous complexity and diver- sity, engage in occupation “through the use of their hands as energized by mind and will” (Reilly, 1962, p. 2). ‘Therefore, occupation cannot be explained by reducing it to a level of understanding below that of the person, for ‘example, to the level of organs such as muscle and joints. Persons, not synapses or muscles or cognitions, engage in occupation. ‘Reducrionistic thinking is che belief chat i is scienif- cally efficient to reduce all fields of knowledge to one sci- ‘ence whose principles apply to all phenomena (Angeles, 1981). For example, it might propose that all human behavior is ‘nothing but” neurophysiology. Though prac- ticing occupational therapists rarely view people this way, a reductionistic curriculum may erase both occupation and the occupational human from how we explain and develop our practice. Midgley (1995), a philosopher, observed that “...in medicine and especially psychiatry there is often a choice between viewing patients as physi- cal organisms [reductive] of as conscious agents [non- reductive)” (p. 40) (terms in brackets added). This choice can have a profound impact on treatment; in fact, it might decide the patient's entire fate. If reductionistic thinking cannot explain occupation, what sore of think- jing can? In contrast, systems thinking is appropriate for under~ standing complex, living systems. (Our patients are alive, and they ar: certainly complex) Systems thinking enables ‘us to preserve that most important human actribure, the ‘capacity to organize or reorganize oneself (Donald, 1991), ‘We laugh about it, saying, “Tomorrow I'll ec organized!” But as Simon (1969), the Nobel Laureate observed, or- ganic systems have the capacity to reorganize themselves ‘without having to restructure chemselves molecule by molecule, fragment by fragment. When occupational therapists work with people’ interests and purposes, we are tapping into the human system’ capacity co organize itself for example, when we ask, “What are your goals?” ‘Even the patient with che mos serious disability possesses this inherene human capacity for reorganization, and our task is to create the “just right environmental challenge” (Robinson, 1977) to activate it ‘Another characteristic of this fantastically selF-orga- nizing human system is that people exchange informa- tion with their environments. They take in food, ideas, symbols, and expectations, and transmute these into oue- ‘put, a portion of which we call occupation. The environ- 367ment is not only that which currently surrounds the per- son but also includes the past, embedded in memory as history, and che fueure, as projected in imagination (Fra sez, 1982). The occupational human is contextualized. ‘And what of the person? If we cannot reduce the per- son o neurophysiology and say thar we are concerned with 4 person and occupation, how mighe we look at an occupational being? We can do what all good occupation- al therapists do, We can see that @ person is simultaneous- ly a biological organism carrying the organic wisdom of evolution; a conscious agene of the most remarkable com- plexity with an individualized mind (Fraser, 1982); a social being who isa family member; a member of a com- munity and a culcure that eransmies habits and traditions (Young, 1988); a symbolizer who endows value and ‘meaning to all experience including occupation (Bruner, 1990; Fraser, 1982); and finally a spit, which itself seeks a place in che universe (Campbell, 1988). People accomplish complex purposes through their occupations and are simultaneously biological, psycholog- ical, social, culrural, symbolic, and spirieual. This is whae is meant by viewing people hierarchically. Lower levels, such as the biological, are nested in higher levels such as the symbolic. Higher levels depend on the lower for con- tinuity and lower levels are directed by the higher ones (Feibleman, 1969). Bur occupation canncr b= “nothirtg bue” 2 lower level and still be occupation! Systems thinking, enables capture the complexity and. uniqueness of occupation as the tulfillmenr of human purposeful ness by preserving and employing multiple levels of explanation. This way of chinking appears to be on the curring edge af scientific thought as the limitations of reductionism become in- y apparent (Calvin, 199%; Donald, 1991) cuupational therapists co Thought Process of Occupational Therapy Jn Swecen I gained new insigh: about occupational thers pists) thinking. Qccupational therapy students had been sned case stuzies w complete. ‘The faculey members swere disappointed wit) [,SSREINBISM. "| Sores because they seemed as though they had been written by medical stu- dents, not occupacional therapy students. The cases con- hole tained comprehensive content on diagnosis and ogy but virtually noching about the interests, or the daily occupacions of the subjects, The students were emulieing the thought processes of the primary f ulty at thac poine in their education, who were physicians. ‘These learners had not yet seen role models using the tools of thoughe of occupational therapy or heen educated to use chese tools, Thaditional medicine uses diagnostic chinking, Ts purpose is to discover and tat pathology. The basic sci 3.68 ence of medicine is derived from natural science, consist- ing of physics, chemistry, and microbiology, and is ap- plied to cells and specialized organ systems. Occupational therapy has a very differene objective and thought proces. Its goal is to discover and foster the inherent adaptive capacities of people in order that the individual may meet environmental challenges by engag- ing in. occupation that is satisfying co self and contributory to society: Occupational therapists’ thinking emphasizes not the diagnosis and treatment of pathology bue the development of skill thar enables persons to achieve their Purposes and connect with the routines of their culture, Pathology may reverberate through all levels of the hu- ‘man system increasing the degree of challenge co the indi- vidual’s adaptation, Similarly, certain environments such as the Arctic Circle have required people to develop extri- ordinary skills for survival. But the real task of occupa- tional therapists is to discover the strengths and potential of individuals, regardless of the amount and degree of impairment, and enable these to be used to achieve mas- tery (White, 1974), Thus occupational therapists need co tunderstand pathology, not primarily in a diagnostic or acute, curative sense, but as one source of incapacity that may interfere with the achievement of personal goals or fulfillment of social expectations and, in this sense, impair health. The occupational therapy thought process attends to the orchestration of occupations in time and space. The person is not decontextualized, bur embarks upon a de- yelopmental trajectory in multiple environments. Thus, his or her hiscory provides clues co eurrene strengths. Again, disability may create extraordinary challenges 10 such organizations, But one’s use of rime and the timing of ‘occupations make essential coneributions to the ability co manage one’s eavironment and the quahty of daily bie experienced. Occupational therapists ask a vital question: What ow? How can this life be one that is truly worth living co she human by i, who is lelt with incapacity? To answer this question we look at oné of the mosi hundainw characteristics of the human, his or her occupati nature. We view the health and life quality of the pe in the context of his or her capacities as an occupat being, as homo aber, man the fabricator (Arendr, 1° Our knowledge represents continuicy with aniversal kr edge about humankind that emanates from a broad : of sources, including not only science buc the humae and the ares. It is pluralistic and liberal Complexity of Occupational Therapy _ No wonder we have difficulty explaining occupati therapy. It is, at least, a three-part challenge. First Mav 1998, Volare 52, Numixough occupation is something every person engages in, like the goldfish dependent upon water for survival, most perso ‘not consc tional natures. If they think of occupacion a all itis in 2 limited way, monymous with a job or vocation, Secondly, although ‘occupational th din the medical system, that system emple ent way of thinki abour patients and their needs. And thirdly, occupation is a complex phenomenon that involves all levels of the open, living human system in interaction with the envi ronment over a developmental continuum. Ie cannot be reduced to simple cause~effect dyads. that were not as a reason for our chal- py part of occupational therapy is per- lenge, the Wl med by, rather than being done to or for, the patient The therapy consists of the therapist doing whatever is in che environment so that the patient- an produce an adaptive response, accomplishi purposes. The adaptive response ing new skills, fien consists of learn pwledge as a Source of Power ewontin (1997) believed that the power to discover the truth would set us free. T propose that such discovery is lar renal g occupation as the central organt ing idea of the curriculum. This could be done by estab: lishing a community of scholars consisting of faculty membets, students, and members of the clinical commu nity. Each community will study and develop its own unique conceptual framework for the generation and transmission of knowledge about occupation. This cre process will result in a unique cur and research program that contributes to an int profession. A proper balance will need to be sought berween nec essary medical knowledge and the study of occupation (Reilly, 1969). Comparing and contrasting the scientific foundation, traditions, and tools of thought of medicine and occupational therapy will emphasize complementari ty and reaffirm occupational therapy's commitment to persons with chronic impairments, Each educational program needs to develop a cen: tralized resource center for the study of occupation and related ideas. The center will be available to all mem of the community of scholas for the products of scholarship. Ic will legitimize the pro- and serve a8 a repository grams scholarly endeavors and provide a means for thet neorporated into curriculum, resfor research and scholarship chat contribure new ideas and promote the dissemination of knowledge actoss disci- plines within the university and global communities. {In promoring an occupation-centered curriculum 0 support a more integrated profesion, each component of the profession needs to have specific responsibilities that are understood and respected by all. For example, practi- toners would olfer their rich clinical experiences co the brocess of curriculum development while engaging in scholarly dialogue and explering relevane literature with faculty and student colleagues. They might assume pri- ‘mary responuibility for overseeing the clinical phases of education, helping students co develop thoughe-based skills in the real environments of practice while raising ‘questions (“clinical irritations’) requiring new knowledge. + locating resources. A profession that fosters selFinitated, self-directed occupation needs to require its scudents to demonstrate such skills, Graduates, rather than view themselves as rechnicilly proficient and finished,” would see themselves as independent, resourceful thinkers and problem solvers. They would be able not only to colerate luncerainty but aso to we it as an imperus for learning, Studenes would be infected with the need to know, as Reilly suggested in a faculty seminar in 1989, In the occupation-centered curriculum, students ‘would examine the rich history, traditions, and values of ‘occupational therapy, using primary sources whenever possible. Courses might be struccured to examine key concepts explored ar different levels of the open human system (Bertalanffy, 1968; Calvin, 1bution, competence, health, and the quality of daily life experiences, Learning selF-organization and mastery through responding to appropriate environmental challenges will allow persons with chronic conditions to join the main- stream of sociery, enabling them to be viewed as healthy, efficacious, and having the right to equality of capability (Bickenbach, 1993). More persons will achieve their vital goals, exercise choices in their lives, and be active partici- pants in the expected and valued routines of their culture because occupational therapists will understand much ‘more about increasing human capability The occupational therapy profession will exert a stronger and more positive impact on society as a whole. A major issue of the next century will be how persons develop competence and learn co organize their lives in an overwhelmingly complex world (Toffler, 1981). The study of occupation as related to life organization has limitless potential to cast new light on this question. A curriculum centered on occupation will bet describe occupational therapy and differentiate ic om other professions, enhancing our communication with the public. By articulating and further developing our scholarship, occupational therapy could develop new and mutually beneficial collaborative relations with disciplines sharing our humanistic values (Yerxa, 1993). Finally, a curriculum focused on occupation will prepate our stu- dents to take their vision, enthusiasm to know into the unknowa opportuni the world of the 21st century. nféctious need, id demands of {shank Wendy Wood, pup, OTWL. FAOTA, for het insightful editorial ‘comments and asistance. - References: a i, PA. (1981). Dictionary of philphy, New Yor: Arendt, H. (1958), The human condislon, of oxi Chiao Urey Beisser, A. (1989). fying without wings: Penal reflertiont on being disabled. New York: ar . versny Pres Engelhard, H.'T., Je, (1977), Defi The meaning of therapy and the vircues of Journal of Occuparional Therapy, 31, 666-67. Feibleman, J. K. (1965). Theory of integrative levels In J. Cole man (Ed), Pycholag and effrcive bebavier (pp. 456-459). 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Racial Ingiene: Mediine under the Nast, Cambridge, MA: Harvard Universiey Press Reilly, M. (1962). Occupational cherapy can be one ofthe great ‘ideas of 20th century medicine, 1961 Eleanor Clarke Slagle lecture, American Journal of Oxcupatonal Therapy, 16 1-9, Reilly, M. (1960). A psychiatric occupational therapy program 1g model. American Journal of Ceeupational Ther Reilly, M. (1969, The educational process. American Journal of ecupaional Therapy, 23, 299-307. é Sage BMY M0974. Playas exporter ering Bey His, CA ge jinson, A. (1977). Play: The for acquisition of rules for seme a decree Jaelef Ocoee Hage Sh ‘Sion, HA, (1969), The arr of In Simon (Ed.), Tht since of aijeal Ge Sain ‘MA: MIT Press, 4 oS oe ee Gel ie ielbe Beeceerest Socal ae Soockholm Collegeof Feat a 5‘ion, American Journal of Occupational Therapy Yena, FJ, &cSharroe, G. W. (1986), Libeal ats The found Yorn, E-J- Carl F, Frank; Jaos, J Pam, D, Proce, to for accupaond thenpy econ. Ameion Jour of Oop Ds Stein, C. 8 Zemke, R. (1989). An intoducion to vecupadonal tonal Therapy. 40, 83-139, science: A foundation for occupational therapy in the 2ise century. M, (1988). The metronome reisty Cambridge, Mi conpational Therapy in Health Care, 61-17 Harvard University es | Coming in June: Special Issue on Occupation-Centered Research * Health and the Human Spirie for Occupation * Occupacion and Well-Being in Dementia: The Experience of Day Care Staff * Creating Opportunities for Occupation: An Intervention to Promote the Self-Care Independence of Young U P iO) A ile E ‘Children With Special Needs ‘Turn to A/OT for the latestinformation on occupational therapy treatment modalities, aids and equipment, legal and social issues, education, and research, 372 ‘May 1998, Vous 52, Number