Occupational therapy

Not to be confused with Occupational medicine.
Occupational therapy
Intervention
ICD-9-CM 93.83
MeSH D009788

Occupational therapy (OT) is the use of assessment and treatment to develop, recover, or maintain the daily living and work skills of people with a physical, mental, or cognitive disorder. Occupational therapists also focus much of their work on identifying and eliminating environmental barriers to independence and participation in daily activities.[1] Occupational therapy is a client-centered practice that places emphasis on the progress towards the client's goals.[2] Occupational therapy interventions focus on adapting the environment, modifying the task, teaching the skill, and educating the client/family in order to increase participation in and performance of daily activities, particularly those that are meaningful to the client. Occupational therapists often work closely with professionals in physical therapy, speech therapy, nursing, social work, and the community.

The term “Occupational therapy” can often be confusing. It carries the misconception that the profession’s focus is on vocational counseling and job training. The word occupation as defined in Webster’s Dictionary is “an activity in which one engages.” Occupational therapists promote skill development and independence in all daily activities. For an adult, this may mean looking at the areas of self-care, home-making, leisure, and work. The “occupations” of childhood may include playing in the park with friends, washing hands, going to the bathroom, cutting with scissors, drawing, etc[3]

History

Early therapy

The earliest evidence of using occupations as a method of therapy can be found in ancient times. In c. 100 BCE, Greek physician Asclepiades initiated humane treatment of patients with mental illness using therapeutic baths, massage, exercise, and music. Later, the Roman Celsus prescribed music, travel, conversation and exercise to his patients. However, by medieval times the use of these strategies with people considered to be insane was rare, if not nonexistent.[4]

In 18th-century Europe, revolutionaries such as Philippe Pinel and Johann Christian Reil reformed the hospital system. Instead of the use of metal chains and restraints, their institutions utilized rigorous work and leisure activities in the late 18th century. This was the era of Moral Treatment, developed in Europe during the Age of Enlightenment, where the roots of occupational therapy lie.[5] Although it was thriving abroad, interest in the reform movement waxed and waned in the United States throughout the 19th century. It re-emerged in the early decades of the 20th century as Occupational Therapy.

The Arts and Crafts movement that flourished between 1860 and 1910 also impacted occupational therapy. In a recently industrialized society, the arts and crafts societies emerged against the monotony and lost autonomy of factory work .[6] Arts and crafts were utilized as a way of promoting learning through doing and provided an outlet for creative energy and a way of avoiding the boredom that was associated with long hospital stays, both for mental illness and for tuberculosis.

Occupational therapists continue to work in the field of mental health, many universities place a strong emphasis on training students in psycho-social occupational therapy.

Health profession

The health profession of occupational therapy was conceived in the early 1910s as a reflection of the Progressive Era. Early professionals merged highly valued ideals, such as having a strong work ethic and the importance of crafting with one's own hands with scientific and medical principles.[4] The National Society for the Promotion of Occupational Therapy, now called the American Occupational Therapy Association (AOTA), was founded in 1917 and the profession of Occupational Therapy was officially named in 1920.

The emergence of occupational therapy challenged the views of mainstream scientific medicine. Instead of focusing on purely physical etiologies, occupational therapists argued that a complex combination of social, economic, and biological reasons cause dysfunction. Principles and techniques were borrowed from many disciplines—including but not limited to nursing, psychiatry, rehabilitation, self-help, orthopedics, and social work—to enrich the profession's scope. Between 1900 and 1930, the founders defined the realm of practice and developed supporting theories. By the early 1930s, AOTA had established educational guidelines and accreditation procedures [7]

World War I forced the new profession to clarify its role in the medical domain and to standardize training and practice. In addition to clarifying its public image, occupational therapy also established clinics, workshops, and training schools nationwide. Due to the overwhelming number of wartime injuries, "reconstruction aides" (an umbrella term for occupational therapy aides and physiotherapy aides, now known as physical therapists) were recruited by the Surgeon General. Between 1917 and 1920, nearly 148,000 wounded men were placed in hospitals upon their return to the states. This number does not account for those wounded abroad. The success of the reconstruction aides, largely made up of women trying to "do their bit" to help with the war effort, was a great accomplishment. Post-war, however, there was a struggle to keep people in the profession. Emphasis shifted from the altruistic war-time mentality to the financial, professional, and personal satisfaction that comes with being a therapist. To make the profession more appealing, practice was standardized, as was the curriculum. Entry and exit criteria were established, and the American Occupational Therapy Association advocated for steady employment, decent wages, and fair working conditions. Via these methods, occupational therapy sought and obtained medical legitimacy in the 1920s.[4]

Occupational therapy. Toy making in psychiatric hospital. World War 1 era.

The profession has continued to grow and expand its scope and settings of practice. Occupational science, the study of occupation, was created in 1989 as a tool for providing evidence-based research to support and advance the practice of occupational therapy, as well as offer a basic science to study topics surrounding "occupation".[8]

Evolution of the philosophy of occupational therapy

The philosophy of occupational therapy has changed over the history of the profession. The philosophy articulated by the founders owed much to the ideals of romanticism,[9] pragmatism[10] and humanism which are collectively considered the fundamental ideologies of the past century.[11][12][13]

One of the most widely cited early papers about the philosophy of occupational therapy was presented by Adolf Meyer, a psychiatrist who had emigrated to the United States from Switzerland in the late 19th century and who was invited to present his views to a gathering of the new Occupational Therapy Society in 1922. At the time, Dr. Meyer was one of the leading psychiatrists in the United States and head of the new psychiatry department and Phipps Clinic at Johns Hopkins University in Baltimore, Maryland.[14][15]

William Rush Dunton, a supporter of the National Society for the Promotion of Occupational Therapy, now the American Occupational Therapy Association, sought to promote the ideas that occupation is a basic human need, and that occupation is therapeutic. From his statements came some of the basic assumptions of occupational therapy, which include:

These philosophies have been elaborated on over time in order to form the values that underpin the Codes of Ethics issued by each national association. However, the relevance of occupation to health and well-being remains the central theme. Influenced by criticism from medicine and the multitude of physical disabilities resulting from World War II, occupational therapy adopted a more reductionistic philosophy for a time. While this approach led to developments in technical knowledge about occupational performance, clinicians became increasingly disillusioned and re-considered these beliefs.[17][18] As a result, client centeredness and occupation have re-emerged as dominant themes in the profession.[19][20][21] Over the past century, the underlying philosophy of occupational therapy has evolved from being a diversion from illness, to treatment, to enablement through meaningful occupation.[16] This became evident through the development and widespread adoption of the Canadian Model of Occupational Performance.

The two most commonly mentioned values are that occupation is essential for health and the concept of holism. However, there have been some dissenting voices. Mocellin in particular advocated abandoning the notion of health through occupation as obsolete in the modern world and questioned the appropriateness of advocating holism when practice rarely supports it.[22][23][24] The values formulated by the American Occupational Therapy Association have also been critiqued as being therapist centred and not reflecting the modern reality of multicultural practice.[25][26]

Central to the philosophy of occupational therapy is the concept of occupational performance. In considering occupational performance the therapist must consider the many factors that comprise overall performance. This concept is made more tangible using models such as the person-environment-occupation model proposed by Law et al. (1996) and the Person-Environment-Occupation-Performance (PEOP) model developed at the same time by Christiansen and Baum in the United States.[27][28] This approach highlights the importance of satisfactions in one's occupations, broadening the aim of occupational therapy beyond the mere completion of tasks to the holistic achievement of personal well-being.

In recent times occupational therapy practitioners have challenged themselves to think more broadly about the potential scope of the profession, and expanded it to include working with groups experiencing occupational deprivation which stems from sources other than disability.[29] Examples of new and emerging practice areas would include therapists working with refugees,[30] children experiencing obesity,[31] and people experiencing homelessness.[32]

The expanded version of the Canadian model of occupational performance and engagement (CMOP-E) encourages occupational therapists to think beyond just occupational performance and address other modes of occupational interaction such as occupational deprivation, competence, and justice. The broader notion of occupational engagement encompasses all that we do to become occupied and is congruent with how occupational therapists address issues of occupational enablement today.[16]

Enabling occupation

Best practice in occupational therapy seeks to offer effective, client-centered services that enable people to engage in occupations of life. The Occupational Therapy Practice Framework (OTPF) is the core competency of occupational therapy in the United States. The Canadian Model of Client Centered Enablement (CMCE) embraces occupational enablement as the core competency of occupational therapy[16] and the Canadian Practice Process Framework (CPPF)[16] as the core process of occupational enablement in Canada.

Areas of occupation

The American Occupational Therapy Association's practice framework identifies the following areas of occupation:[33]

Process

An occupational therapist works systematically through a sequence of actions known as the occupational therapy process. There are several versions of this process as described by numerous writers, although all include the basic components of evaluation, intervention, and outcomes. Creek[34] has sought to provide a comprehensive version based on extensive research which has 11 stages.

The Canadian Practice Process Framework (CPPF),[16] has eight action points and three contextual elements.

Fearing, Law, and Clark[35] suggested a 7-stage process. A central element of this process model is the focus on identifying both client and therapists strengths and resources prior to beginning to develop the outcomes and action plan.

The Occupational Therapy Practice Framework: Domain and Process (2nd edition) (AOTA, 2008) presents a 3-stage process, and includes interrelated constructs that define and guide practice.

Areas of practice

The role of occupational therapy allows occupational therapists to work in many different settings, work with many different populations and acquire many different specialties. This broad spectrum of practice lends itself to difficulty categorizing the areas of practice that exist, especially considering the many countries and different health care systems. In this section, the categorization from the American Occupational Therapy Association is used. However, there are other ways to categorize areas of practice in OT, such as physical, mental, and community practice (AOTA, 2009). These divisions occur when the setting is defined by the population it serves. For example, acute physical or mental health settings (e.g.: hospitals), sub-acute settings (e.g.: aged care facilities), outpatient clinics and community settings.

In each area of practice below, an OT can work with different populations, diagnosis, specialities, and in different settings.

Occupational therapy during WWI: bedridden wounded are knitting.

Children and youth

In 1951, Joan Erikson became director of activities for the “severely disturbed children and young adults” at the Austen Riggs Center. At that time, “occupational therapy” was used “for keeping patients busy on useless tasks.” Erikson “brought in painters, sculptors, dancers, weavers, potters and others to create a program that provided real therapy.”[36]

Occupational therapists work with infants, toddlers, children, and youth and their families in a variety of settings including schools, clinics, and homes.[37] Occupational therapists assist children and their caregivers to build skills that enable them to participate in meaningful occupations. Occupational therapists also address the psychosocial needs of children and youth to enable them to participate in meaningful life events. These occupations may include: normal growth and development, feeding, play, social skills, and education.[38]

Occupational therapy with Children and Youth may take a variety of forms:[37][38]

The potential for unnecessary treatment of children by occupational therapists does exist in for-profit health care systems: occupational therapists in some affluent areas in South Africa, particularly in the Northern Suburbs of Johannesburg, have been accused by the country's largest private medical aid scheme, Discovery Health, of engaging in over-treatment of children in collusion with schools.[39][40][41][42]

Health and wellness

The practice area of Health and Wellness is emerging steadily due to the increasing need for wellness-related services in occupational therapy. A connection between wellness and physical health, as well as mental health, has been found; consequently, helping to improve the physical and mental health of clients can lead to a general increase in wellness.[43]

As a practice area, health and wellness can include a focus on the following:[43][44]

Mental health

Mental health and the moral treatment movement have been recognized as the root of occupational therapy.[45] According to the World Health Organization, mental illness is one of the fastest growing forms of disability.[46] There is a focus on prevention and treatment of mental illness in populations including children, youth, the aging, and those with severe and persistent mental health issues.[47] More specifically, military personnel and veterans are populations that can benefit from occupational therapy but currently, there is a lack of focus on these populations regarding mental health care.[48] Occupational therapists provide mental health services in a variety of settings including hospitals, day programs, and long-term-care facilities.[49]

Mental health illnesses that may require occupational therapy include schizophrenia and other psychotic disorders, depressive disorders, anxiety disorders, trauma- and stressor-related disorders (post traumatic stress disorder or acute stress disorder), obsessive-compulsive and related disorders such as hoarding, and neurodevelopmental disorders such as autism spectrum disorder, attention deficit/hyperactivity disorder and learning disorders.[50]

Occupational therapists help individuals with mental illness acquire the skills to care for themselves or others including the following:[51]

Within the scope of occupational therapy, there are a variety of assessments that can be used for individuals with mental health conditions.These evaluation tools generally assess occupational performance and participation in a variety of areas.[52]

Use of psychology

The use of psychology in occupational therapy dates back to its beginnings as a profession. Occupational therapy's rather recent start lines up with the majority of psychological studies of the 20th century. The field can date some of its core ideas to Sigmund Freud, using his theories to give an emotional perspective on how the emotions develop and how this affects behavior.[53] Freud's personality theory about the psychic energies he titled the id, ego and superego all reflect on how a chronic unbalance between the three leads to physical and mental illness. This unbalance later affects a person's behavior, which will interfere with their occupations of daily, including simple things as socialization with others, attending a course for leisure, and even managing finances.[54] While the field does not subscribe to the psychosexual development undertones of Freudian personality theory, it does still appreciate how when what one needs to survive (the id component) and the internally engraved mores of one's culture (the superego part) are in conflict, it can lead to a severe handicap when the conscience aspect (or ego) can no longer manage this stress, leading to mental illness .[55]

Along with influence of Freud. Carl Jung has also contributed to some of the psychological perspectives used in occupational therapy today. Like Freud, Jung's theories are primarily about the unconscious's effect on a person's behavior. For the occupational therapist, the unconscious plays a role in how patients will choose to comply with and do certain therapeutic activities. This particularly applies to the influence of art as a form of therapy, which is often used in pediatric facilities; where compliance is often an issue.[53] The usage of therapeutic art techniques, such as molding putty of various compliance, makes something like strengthening the muscles of the hand, look like a playtime rather than an exercise to be carried out. Jung also lent a core belief to the occupational therapist philosophy in his ideals regarding the potential to be able to touch other's souls. This directly correlates with the occupational therapist philosophy that an interpersonal relationship between the therapist and the client is key to helping the patient reach their full potential. The work of Lev Vygotsky was also influential in his theory regarding the Zone of Proximal Development. By utilizing this technique, the therapist can use scaffolding to teach the patient how to resume their prior independence without undermining their autonomy; which can be a potential issue for any therapist.[56] Another way to try and aid a patient in this is the work of Albert Bandura and his social learning theory. By using this far-reaching theoretical perspective, the therapist can model the targeted behavior to be learned and the patient can attempt to copy it. The use of these techniques can combat the common issue of providing too much assistance for a patient so they will avoid failure, but ultimately will not be able to complete the needed tasks without the help of the therapist.[57]

The first time a treatment model for the mentally ill emerged it was created by Johns Hopkins University and titled Habit Training. While it was not created with occupational therapy as its recipient, it still continues as a reminder to the contemporary occupational therapist that their roots began in helping those with primarily mental illness rather than physical disabilities or developmental delays.[58] However, today the same goal as before exists: to treat the entire person, whether the primary problem relates to physical or mental health. This psychological philosophy relates back to the diversity of the field of occupational therapy.

As with the usage of Freud mentioned previously, the use of personality theory most definitely applies to the field of occupational therapy. The occupational therapist Jane Sorenson created the "Wholelife Resume" to cover the areas of expertise in the patient and learn further about how she could expand their overall potential.[53] In her research, she related that ethnicity and stereotype beliefs play a large role in a patient's mental state.[53] By understanding the aspects that make up a person, the occupational therapist can better understand the person's behaviors and value and, therefore, can more affectively use the patient's own belief system to support, develop and enhance their behavioral change that will restore them to former, or even better, health.

Productive aging

Occupational therapists work with older adults to maintain independence, participate in meaningful activities, and live fulfilling lives. Some examples of areas that occupational therapists address with older adults are driving, continuing to live at home, low vision, and dementia or Alzheimer's Disease (AD).[59] When addressing driving, driver evaluations are administered to determine if drivers are safe behind the wheel. Cardiologists must give accurate heart history to DMV and therapists. To enable independence of older adults and injured humans at home, occupational therapists perform fall screens and evaluate all humans functioning in their homes and recommend specific home modifications. When addressing low vision, occupational therapists modify tasks and the environment.[60] While working with individuals with AD, occupational therapists focus on maintaining quality of life, ensure safety, promote independence, and utilize retained abilities.[61]

Rehabilitation

Occupational therapists address the needs of rehabilitation, disability, and participation. Occupational therapists provide treatment for adults with disabilities in a variety of settings including hospitals (acute rehabilitation, in-patient rehabilitation, and out-patient rehabilitation), home health, skilled nursing facilities, and day rehabilitation programs. When planning treatment, occupational therapists address the physical, cognitive, psychosocial, and environmental needs involved in adult populations across a variety of settings.

Occupational therapy with adult rehabilitation, disability, and participation may take a variety of forms:

Travel occupational therapy

Because of the rising need for occupational therapists,[67] many facilities are opting for travel occupational therapists—who are willing to travel, often out of state, to work temporarily in a facility. Assignments may run as short as 8 weeks or as long as 9 months, but typically last 13–26 weeks in length.[68]

Work and industry

Occupational therapists may also work with clients who have had an injury and are trying to get back to work. Testing may be completed to simulate work tasks in order to determine best matches for work, accommodations needed at work, or the level of disability. Work conditioning and hardening are approaches used to restore performance skills needed on the job that may have changed due to an illness or injury. Occupational therapists can also prevent work related injuries through ergonomics and on site work evaluations.[69]

Theoretical frameworks

Occupational Therapists use a number of theoretical frameworks with which to frame their practices. Note that terminology has differed between scholars. Theoretical bases for framing a human and their occupation being include the following:

Frames of reference and generic models

Frames of reference or generic models are the overarching title given to a collation of compatible knowledge, research and theories that form conceptual practice.[70] More generally they can be defined as "those aspects which influence our perceptions, decisions and practice".[71]

Linked to Occupation-Focused Practice Models

Occupational therapy and ICF

The International Classification of Functioning, Disability and Health (ICF) is a framework to measure health and ability by illustrating how these components impact one's function. This relates very closely to the Occupational Therapy Practice Framework, as it is stated that "The profession's core beliefs are in the positive relationship between occupation and health and its view of people as occupational beings".[83] The ICF is also built into the 2nd edition of the practice framework. Activities and participation examples from the ICF overlap Areas of Occupation, Performance Skills, and Performance Patterns in the framework. The ICF also includes contextual factors (environmental and personal factors) that relate to the context in the framework. In addition, body functions and structures classified within the ICF help describe the client factors as described in the OT framework.[84]

Further exploration of the relationship between occupational therapy and the components of the ICIDH-2 (revision of the original International Classification of Impairments, Disabilities, and Handicaps (ICIDH); later becoming the ICF) was conducted by McLaughlin Gray.[85] First, the ICF is an international framework and provides an opportunity for the occupational therapy field to become better known across the globe. Second, the ICF provides occupational therapists with a global language to describe their expertise to the larger international health care community. The ICF uses a positive, holistic language emphasizing skills, capacities, and strengths of an individual rather than focusing on one's deficits and disabilities. This is similar to the outlook of occupational therapists. Third, the ICF includes environmental and personal contextual factors which are incorporated into the theory behind occupational therapy. It is important to take into consideration an individual's personal, environmental, and occupational factors to develop an effective intervention.[86] The last notable application of the ICF to occupational therapy is the recognition of cultural patterns in occupation. Culture has significance on an individual's activities and participation and it is important to keep this in mind when treating an individual.

Although the ICF can be very useful for occupational therapists, it is noted in the literature that occupational therapists should use specific occupational therapy vocabulary along with the ICF in order to ensure correct communication about specific concepts.[87] The ICF might lack certain categories to describe what occupational therapists need to communicate to clients and colleagues. It also may not be possible to exactly match the connotations of the ICF categories to occupational therapy terms. The ICF is not an assessment and specialized occupational therapy vocabulary should not be replaced with ICF terminology.[88] The ICF is an overarching framework for current therapy practices.

Occupational therapists

Certified occupational therapists typically hold Masters or Doctoral degrees in occupational therapy from an ACOTE accredited institution. To practice in the United States, occupational therapists must receive a master's degree and pass a licensing examination to become certified by the National Board for Certification in Occupational Therapy (NBCOT).

The average wages of a permanent occupational therapist is approximately $70,000/year.[89] Most commonly (43%), travel occupational therapists enter the industry between the ages of 21–30.[90] The average annual income for occupational therapy assistants as of 2009 was $33,840. The middle 50% earned between $22,200 and $45,890. Salaries for the lowest 10% were around $33,350, while the highest 10% earned approximately $58,450, with top pay upwards of $65,000.[91]

See also

References

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