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The Evolution of Occupational Therapy

This presentation explores the theoretical basis of the occupational therapy (OT) profession. Major theoretical trends, founding principles and paradigm shifts identify how the profession has evolved over time.

Jennifer Fortuna

on 13 January 2016

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Transcript of The Evolution of Occupational Therapy

The Evolution of Occupational Therapy
The original concepts and values upon which the OT profession was founded are known as the paradigm of occupation. These organizing principles were first articulated by Dr. William Rush Dunton who believed occupation is as necessary to human life as food and drink (Cole & Tufano, 2008). Physicians used occupation as a therapeutic modality in early 20th century medicine; however, they lacked understanding of the therapeutic effect of OT in scientific terms. Dr. Dunton was instrumental in educating the medical community on the therapeutic use of occupation to restore function and health.
Between 1917 and 1920 the number of hospitals in the U.S. doubled creating demand for occupational therapists. In 1922, renowned psychobiologist Adolph Meyer articulated the philosophy of OT in his landmark article titled
Embodying the "Pollyanna Spirit."
Health care trends included habit training (Meyer, 1921) and the Reconstructionist Movement. Habit training involved a full schedule of daily and group recreational activities for patients with mental illness. The goal of treatment was to return to mainstream life. Reconstruction was common for returning soldiers and survivors of industrial accidents. Treatment involved physical reconditioning through occupations, manual labor and encouragement from loved ones. The goal of treatment was to retrain, reeducate and restore physical and mental functions, and to facilitate re-entry into the work force.
In the 1930's, the profession of occupational therapy remained viable despite the great depression. The industrial revolution led focus to the biomechanical model for activity analysis and physical disability. Occupational therapists continued treated patients with physical impairment, developmental disability and chronic mental illness in hospitals, sanatoriums and long-term care institutions. The scientific movement introduced adapted crafting tools. Higher Educational standards now required 18 months of training for entry level OT's. Behavior modification was emerging as a therapeutic approach. Behaviorists such as Watson, Skinner and Pavlov became very well known for their use of the scientific method to study human behavior. Incorporation of human psychology served to reinforce the OT's professional legitimacy and alliance with medicine (Gordon, 2002).
The arrival of WWII brought many changes to social policy including social security income for wounded veterans and funding for vocational retraining programs in physical and mental health settings. The goal of OT was to return restored patients to to competitive employment and independent community living (Cole & Tufano, 2008). Demand for skilled OT and educational programs to train them increased rapidly. In 1947, the first occupational therapy textbook titled,
Willard & Spackman's Principles of Occupational Therapy
was published. Expanded vocational training workshops provided job training with accommodations and close supervision. These workshops provided opportunity to develop the rehabilitative models including activity analysis and adaptation.
The 1960's began with a deinstitutionalization movement fueled by medication to prevent, cure or manage chronic health conditions. The focus of OT practice was helping clients acquire skills for independent living in preparation for the transition to living in the community. Many patients had been in long term care facilities for years which created the need group therapy to assist with reintegration into society. OT groups became the means for learning social skills such as communication, cooperation and respect. In mental health settings, treatment encouraged the patient to actively participate in the therapeutic process of change. The passage of Medicare and Medicaid legislation and The Community Mental Health Act of 1963 was an attempt to ensure health care services would be available to all citizens.

To better
understand the potential usefulness
of the models and
frames of reference
being applied in today's occupational therapy practice, we must first become familiar with
the theoretical history, founding principles and paradigm
shifts of the

The term
occupational therapy
was coined by George Barton in 1914 to describe the healing potential of occupations. The name was chosen to reinforce the future profession's legitimacy and foundation in medical science. From the beginning, a variety of therapeutic occupations were utilized including crafts, music, art, recreation and play. The central role of occupation provides the basis for the original paradigm of occupation, as well as the emerging paradigm utilized in modern day practice.
In 1917, the National Association for the Promotion of Occupational Therapy (NSPOT), later renamed the American Occupational Therapy Association (AOTA) officially founded OT as a profession. The founding members of NSPOT include:
George Barton: Architect, president of NSPOT
William Rush Dunton: Doctor of psychiatry, author
Thomas Kidner: Vocational Secretary, Canadian Military
Eleanor Clarke Slagle: Music, philanthropy, mental health
Susan Tracy: Nurse, educator, author
Susan Johnson: Nurse, educator, craftswoman
Herbert J. Hall: MD, author

Many historical events led to the founding of occupational therapy:
The moral treatment movement of early 19th century.
The industrial revolution led to the arts and crafts movement. Crafts were central to the focus of early OT practice and critical to economic viability of the institution.
The birth of psychotherapy set the stage for OT practice. The mental hygiene movement encouraged engagement in occupation was a key component of treating mental illness.
During WWI, the U.S. military enlisted the National Association for Promotion of Occupational Therapy (NSPOT) to recruit/train 1,200 "reconstruction aides" to rehabilitate wounded soldiers.
Early pioneers of the profession developed a holistic approach to treat both physical and psychological symptoms of war.
In the 1950's, the OT profession came under pressure from the medical model to provide evidence of effectiveness, or in other words proof that occupational therapy led to progress towards treatment goals. During the mechanistic paradigm, OT practice shifted focus away from the central role of occupation to become more consistent with the medical model. Practitioners adopted a biomedical perspective that valued research evidence, anatomy, physiology, and human development over occupation. The new model restricted the OT scope to practices related to skill building for activities of daily living. The medical model proved grossly inadequate to meeting the needs of patients with ongoing mental health and physical conditions.

The 1950's brought continued growth and advances in the fields of medicine and neurology. Occupational therapists worked closely with the field of psychiatry to help patients identify and resolve conflict. Medications such as tranquilizers and mood stabilizers were used to improve the patient's ability to respond to OT. Numerous sensory motor frames emerged including Margaret Rood's sensorimotor therapy model, Jean Ayres' theory of sensory integration, and Berta and the Bobath's neurodevelopmental therapy (NDT). Therapeutic use of self improved communication with patients diagnosed with mental illness. To address the ongoing shortage of trained therapists, the profession began to explore the potential for trained OT assistants (Hopkins, 1978).
The 1980's brought challenges and progress. Managed care demanded accountability and pressured OT to produce evidence of progress towards goals. This was difficult due to lack of standardized assessments to measure occupational performance. Public Law 94-142 called for school-based OT services creating a manpower shortage. New state licensure identified registered occupational therapists (OTRs) and certified OT assistants (COTAs). Theoretical change created chaos for educators/practitioners. Concepts of clinical reasoning, culture, adaptation

and occupational science emerged. In 1989, the AOTA published the
Uniform Terminology
to unite practice.
Scholars argued about how to organize the many frames of reference, theories and models published in the 1980's. Practitioners from various areas of practice united to focus on the concept of occupation. Many occupation-based models were introduced in the 1990's including PEO/PEOP, EHP, and CMOP. Several new FoR's and theories incorporated new developments in neuroscience and brain research. A large number of research studies were published validating the effectiveness of OT and raising recognition within the medical community. The OT job market and need to educate students grew dramatically; however the number of students entering the profession declined when the entry level master's degree was mandated in the late 1990's.
Jennifer Fortuna, MS, OTR/L
In the 2000's, the professional paradigm of OT returned to its roots with focus on the role of occupation to heal and restore function. OT practice moved away from the medical model and into the community. Publication of the Occupational Therapy Practice Framework in 2002 defined OT's domain of concern to

include numerous contexts for occupational performance. Today, OT practice is holistic, client-centered, system's oriented and evidence-based. Services are community-based and client/family centered. Future practitioners will be better informed in research, theory, culture and ethics to promote occupation and improve quality of life of the patients they serve.
The 1970's brought an identity crisis to the field of OT. The scientific movement of the 1950's forced many practitioners to specialize. Over time, major offshoots developed psychiatry, physical disability, pediatrics, geriatrics and hand therapy. Specialization created great diversity amongst practitioners. The AOTA called on contemporary OT leaders to identify common threads through a common frame of reference. Several frames of reference were published to reflect the diversity in OT practice. Kielhofner and Burke (1977) published a comprehensive analysis of OT's conflict with the medical model identifying the need to develop a paradigm of occupation. In the late 1970's, the AOTA attempted to unify practice through publication of the Uniform Terminology document.

Cole, M.B., & Tufano, R. (2008). Applied theories in occupational therapy practice: A practical approach. Thorofare, NJ: Slack Incorporated.

Gordon, D. (2002). Therapeutics and science in the history of occupational therapy. Doctoral dissertation. University of Southern California.

Hopkins, H.L. (1978). A historical perspective on occupational therapy. In H.L. Hopkins & H.D. Smith (Eds.), Willard and Spackman's occupational therapy (5th ed., pp. 3-23). Philadelphia: J.B. Lippincott.

Kielfhofner, G., & Burke, J. (1977). Occupational therapy after 60 years: An account of changing identity and knowledge. American Journal of Occupational Therapy, 31(10), 675-689.

Meyer, A. (1921, 1983). The philosophy of occupational therapy. Occupational Therapy in Mental Health, 79-87.

Quiroga, V.A. (2005). Occupational therapy: The first 30 years 1900-1930. Bethesda MD: American Occupational Therapy Association, Inc.
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