The Meaning of Occupation: Historical and Contemporary Connections between Health and Occupation

Article excerpt

Introduction

This article builds on an earlier discussion of the development and use of the word occupation throughout Western history. In the earlier discussion (Reed, Smythe, & Hocking, 2012) an overview of the word occupation was presented from a hermeneutic and etymological perspective (etymology is the study of the history of words, their origin and how their form and meaning have changed over time). The aim was to show how different meanings of occupation have built up over the centuries. This article continues the analysis to show how in each new era, circumstances change and shape what counts as occupation. As the profession of occupational therapy developed, occupation became a notion that was named, framed and conceptualised as the domain of a professional group. Up until the establishment of occupational therapy, occupation had not been recognised as a notion that could form the basis of a profession. In this article the history of how occupation became more recognised and formalised will be outlined. The time frame spans the Age of Enlightenment to the current day. A broad outline is presented recognising there is obviously much more than can be recounted. The aim is to bring to the fore how, in the context of occupational therapy, understandings of the notion of occupation have changed and evolved.

Method

As described in the previous article (Reed, Smythe, & Hocking, 2012) a hermeneutic approach based on the work of Gadamer (1960/2004) was employed to explore the history of ideas related to the notion of occupation. Hermeneutics creates the opportunity to explore texts, and to show how ideas have been passed down in language and words. In this review extensive reading through Western sociology, history, philosophy and leisure texts was undertaken along with a search of the professional literature using the CINHAL, Proquest 5000 and Medline databases. Literature published from 1997 to the present was the focus of the database search, literature which described occupation, the link between occupation and health, and contemporary understandings of occupation from an occupational therapy perspective were purposefully sought. A hermeneutic process of analysing the text was undertaken by noticing the words used, how they were brought into play, and the context in which they were used, to highlight what was and what was not spoken about. The questions that guided the analysis were as follows: 'how did occupation show itself in relation to other people?' and 'what influenced the understanding and use of occupation by occupational therapists?'

Analysis of the literature

Over the course of the profession's development occupational therapists have recognised that occupations either positively or negatively influence health. Prior to the existence of occupational therapy, scholars such as Galen (131-201 AD) identified occupations for the maintenance of health. Conversely during the Industrial Revolution those such as Fredrick Taylor and the Scientific Management Movement (Applebaum, 1992) manipulated occupation in such a way that the focus was on the production of items in large quantities, with little or no consideration for those people that were involved in the manufacturing process. This contributed to occupation having a negative impact on workers' health. To show how understandings of occupation have changed and evolved the analysis of the literature is separated into periods of development throughout Western history from the Age of Enlightenment to the current day.

The Moral Treatment Movement

The Moral Treatment Movement, which developed in Europe during the Age of Enlightenment, laid the foundation for the emergence of the profession by recognising the need to occupy people confined to asylums. Brockoven, a psychiatrist, insisted that "the history of moral treatment in America is not only synonymous with, but is the history of occupational therapy before it acquired its 20th century name occupational therapy" (1971, p. 225). The Moral Treatment Movement was founded on the work of Philippe Pinel (1745-1826), a French philosopher and medical practitioner with an interest in mental health and William Tuke (1732-1822) an English merchant-philanthropist who developed principles of Moral Treatment and applied them to the insane in institutions in France and England respectively (Pinel 1806/1962, Tuke 1813/1964). Moral Treatment grew out of the "fundamental attitudes of the day: a set of principles that govern humanity and society; faith in the ability of the human to reason; and the supreme belief in the individual" (Bing, 1981, p. 502). Moral Treatment saw a shift away from the notion that the insane were possessed by the devil. A distinct method of therapy evolved and mental disease came to be seen as the legitimate concern of humanitarians and physicians.

At The York Retreat, an asylum for the insane, in Britain, Tuke (as cited in Foucault 1961/2006) drew on his beliefs as a Quaker and recognised that:

   ... in itself work possesses a constraining power superior
   to all forms of physical coercion, in that the regularity of
   the hours, the requirement of attention, the obligation
   to provide a result detach the sufferer from a liberty
   of mind that would be fatal and engage him in a system of
   responsibilities. (p. 247)

Tuke (as cited in Foucault 1961/2006) was influential in establishing a philosophy of discipline and hard work rather than external control of mental patients. At around the same time as The York Retreat was using occupation to assist in the recovery from mental illness, Pinel (1806/1962) also recognised the value of occupation. He established an environment of work programmes allowing those with a mental illness, previously constrained in chains, to be liberated. Pinel noted that even "the natural indolence and stupidity of ideots (sic), might in some degree be obviated, by engaging them in manual occupations, suitable to their respective capacities" (p. 203).

Across the Atlantic in the United States of America (USA), Thomas Story Kirkebridge implemented a regime of Moral Treatment in The Pennsylvania Hospital for the Insane in 1833. Annual reports detailed that more than 50 occupations were on offer including lectures, gymnastics and magic (Handbook for attendants on the insane, 1896). At the same time scientific trends were beginning to challenge the philosophy of Moral Treatment and the way work was carried out. The decline of Moral Treatment was identified by Peloquin (1998) as being closely related to "a lack of inspired and committed leadership willing to articulate and redefine the efficacy of occupation in the face of medical and social changes" (p. 544).

Vernon Briggs (as cited in Woodside, 1971) described in 1911 how patients' engagement in occupation had a positive effect on their health, based on several occupational initiatives occurring in various sites across the USA. Just prior to this in 1906, Susan Tracy, a nurse and teacher, had developed a course on invalid occupations for nurses (Woodside, 1971). Tracy is credited by some to be the first occupational therapist of the 20th century and a book of her work was published in 1912 (Tracy, 1912/1980). Also occurring at about this time was the work of Adolph Meyer (1866-1950) a psychiatrist, humanist and mental hygienist, who immigrated to the USA from Switzerland. Meyer took on board the educational philosophies of John Dewey and in 1892 professed, "doing, action and experience are being" (as cited in Breines, 1986, p. 46). Meyer held that people could be understood through consideration of the activities that they engage in during their day to day life, for which Meyer demonstrated a mindbody synthesis and supported his view that individuals can only be studied as whole people in action. In 1922, Meyer published a paper entitled 'The philosophy of occupational therapy' and because of this he is often heralded as the philosophical father of occupational therapy. Meyers' accounts showed a critical link between an individual's activities and activity patterns and his or her physical and mental health. Even in the face of adversity such as mental ill health, there was still the potential for people to be engaged in occupation, and that occupation could provide some benefit and relief from their health condition. Despite adversity, the very nature of their Being called them to be connected to others and the world. Wider society, the 'They', prescribed and decided what was acceptable in terms of health, education and income, and it is from this line in the sand that a person measures and compares themselves against what others have achieved or failed to achieve. Thus a person understands himself or herself in their difference from others (Christiansen, 2007; King, 2001).

Arts and crafts

Jane Addams' work at Hull House, where Meyer also had some involvement, led up to the establishment of occupational therapy as a profession. Hull House was a settlement home for new immigrants and was influential in establishing the Arts and Crafts Movement in America. The Arts and Crafts Movement, of which Ruskin and Morris (1883/1915) were leading proponents in the United Kingdom, holds views about work and a simple life, which includes restoration of the human spirit through engagement in honest craftsmanship. Morris (1883/1915) associated the experience of pleasure with skilfully creating an object. He affirmed that:

   ... art is the expression by man of his pleasure in labour. I
   do not believe that he can be happy in his labour without
   expressing that happiness; and especially this is so when he
   is at work at anything in which he especially excels. (pp. 41-42)

These beliefs informed the delivery of services in mental health, tuberculosis sanatoria and physical health settings, and saw manual training as a solution to the problems created during the industrial era. In 1911 Eleanor Clarke Slagle, a social work student, attended a course at Hull House on curative occupations and recreation. She later became the Director of the Henry B. Favill School of Occupations, which is thought to be the first formal school of occupational therapy. Slagle's work, which incorporated ideas from Addams, focused on habit training through meaningful use of time and purposeful activity. Slagle (1922) actively promoted the use of occupation in relation to health when she included the concept that:

   ... for the most part our lives are made up of habit reactions.
   Occupation used remedially serves to overcome some
   habits to modify others and construct new ones, to the end
   that habit reaction will be favourable to the restoration and
   maintenance of health. (p. 14)

World War One and the early 1900s

In Britain, occupation was increasingly recognised as important in the treatment of people with mental disorders and was beginning to be accepted as having value in the rehabilitation of people with physical conditions (Amar, 1920). This was the case especially across Europe, following World War One (1914-1918), where occupation was seen as important to the curative process and the economic future of returning servicemen. It was the British Red Cross that "took a lead in establishing programmes of occupation and entertainment for injured servicemen" (Wilcock, 2002, p. 62). At about this time, occupation was also being used by Sir Pendrill Varrier-Jones as the basis of treatment for people with tuberculosis. Varrier-Jones held the view that the treatment of tuberculosis should not be left to medicine alone and as a result created Papworth Village, a combination of hospital, sanatorium and industries. For Varrier-Jones (as cited in Fraser 1943):

   The true colony consists of a sanatorium, in which all that
   is best in sanatorium treatment is carried out, but with
   the addition of an industrial section where the treatments
   may be prolonged and training in suitable occupation
   begun. To my mind a man engaged in productive work,
   keeping his wife and children, ceasing to be a danger to
   the community, is a more economical proposition than a
   similar person propped up by poor relief, a danger to his
   family and to the community, as well as an unproductive
   unit thereof. (p. 52)

During the 1920s there was growing acceptance of the specific use of occupation as a treatment method, which was coined 'occupational therapy'. Wilcock (2002) points to the spread of occupational therapy as a result of the medical profession endorsing this new profession, which saw the increasing employment of occupational therapists by local authorities as they gradually assumed responsibility for the care of people with disabilities. An additional boost came during the Great Depression of the 1930s, which was a period of high unemployment, one result of which was the general recognition that engagement in occupation was necessary for well-being (Rerek, 1971).

World War Two

Following the ravages of World War Two (1939-1945), occupational therapy was again recognised as a key component in the rehabilitation of injured service people. The view of the use of occupation during this time was that it diverted attention away from the pain and trauma of injury and was used to teach new skills to allow the injured soldiers to have a vocation when they were able to be discharged from hospital (Dudley Smith, 1945). The previous use of craftwork as a therapeutic tool was restricted by both the British Government and a lack of resources. It was during this period that remedial approaches were introduced into the profession as a viable tool in the rehabilitation process.

In the United Kingdom there was ongoing growth and development of the profession following World War Two (Rosser, 1990). During the 1950s the focus of rehabilitation broadened from getting servicemen back to work, to recognising the importance of domestic tasks and independence of those with long term disabilities. Occupational therapy came under increasing pressure from the medical profession to "establish a theoretical rationale and empirical evidence for practice" (Kielhofner, 2004, p. 44). This is perhaps not surprising given the strategic connection that early professional leaders had developed with medicine, which had undoubtedly influenced the assumptions and development of occupational therapy (Hocking, 2007; Wilcock, 2002). At that time it was difficult to measure restoration of the human spirit through craftwork, using research methodologies of the day. As a result the profession began to explain practice in terms of a biomedical perspective, which included reductionist views of the body as a well-oiled machine. This was in contrast to the views of the founders of occupational therapy, such as Meyer, who considered mind-body synthesis to be fundamental in the therapeutic use of occupation. The view of occupation and the connection to health was slowly eroded as the focus of occupation narrowed (Engelhardt, 1977) in response to the challenge to provide evidence of the effectiveness of occupation from a bio-medical perspective. Understandings of occupation appear to have changed during this era as the emerging dominance of the scientific paradigm began to negate and bypass the complex nature of a person who is always situated in context, shaped by place, people, climate and all that is beyond knowing (Heidegger, 1993). The entwined occupation, person and world dynamic was eroded in favour of a rational explanation of occupation based on science. The 'spirit', the indefinable, was lost in theoretical models.

The 1960s and 1970s

As occupational therapy progressed into the 1960s, the focus of practice continued to be based on concepts from medicine which pervaded both physical and mental health. Psychodynamic concepts used by psychiatrists were deemed to be more important in occupational therapy mental health practice than concepts of occupation (Fidler & Fidler, 1978), which led to an emergence of therapeutic communities and group and industrial therapy. In physical health the focus was on "understanding function and dysfunction" in anatomical and neurological terms (Kielhofner, 2004, p. 46). From the bio-medical perspective, occupation was viewed as something that calls on muscle strength, joint flexibility, stamina and changes in behaviour. These were things that could be observed and measured and could therefore provide the empirical evidence that was required to demonstrate the effectiveness of occupational therapy.

As the profession expanded and diversified, there was a call to reinstate the aims and functions of occupational therapy. Wilcock (2002) recalled that during this time "general treatment responsibilities were to assist the recovery of patients from mental or physical illness. Training patients to use returning function or residual ability to gain social and vocational readjustment" (p. 289). The focus on the use of occupation as therapy shifted to centre on function rather than diversion, and fostering independence, responsibility and resettlement in relation to the demands of home or job.

During the 1970s there was a phase of professional self doubt as the philosophical base of the profession was challenged (Kielhofner & Burke, 1977). Shorter hospital stays meant limited opportunities for patients to engage in occupations as they had done in the past and less time for the occupational therapist to build a therapeutic relationship. The influence of the medical profession also saw a move towards increased specialisation by occupational therapists based on their knowledge of medical conditions rather than knowledge of occupation.

Renaissance in the commitment to occupation

In the latter part of the 20th century there was a renaissance in the commitment to occupation as a necessary component of health. Within occupational therapy there was a growth in models of practice such as the Model of Human Occupation developed by Kielhofner (1985). This model was created to be used with any person experiencing problems related to occupation and was concerned with "the motivation for occupation, pattern of occupation, subjective dimension of performance [and the] influence of environment on occupation" (Kielhofner, 2004, p. 148). As the renaissance continued during the 1990s the word occupation was being used more universally. Hagedorn (1995) identified that occupation was the unique element forming the focus and vehicle for occupational therapy. There was also an increase in occupational therapy research as the profession responded to the call to focus on specific occupational themes (Wilcock, 1991). The research themes included studying human occupation, occupational function, occupation for health and the subjective experience of participation in occupation. One consideration highlighted by Hasselkus (2006) that could potentially limit further understandings of occupation by the profession of occupational therapy is its conceptualisation "within a problem framework. We have linked our focus on occupation to a context of disability--making everyday occupation part of the problem" (p. 630). While there was a renewal of ideas during this time about the importance of occupation connected with enabling and empowering people within their own communities and linking self health to occupation, Hasselkus (2006) signalled that there was still the need to consider occupation in its broadest context.

The interest in occupation linked to human life, health and wellbeing is evident in the maturity of occupational therapy. The desire for further knowledge and understanding of occupation led to the development of occupational science. Occupational science distinguishes itself from occupational therapy by being concerned with creating a basic understanding of occupation, without immediate concern for the application of that knowledge. Early advocates of occupational science, such as Zemke and Clark (1996), suggested that the study of occupation would enhance occupational therapists' appreciation of the role of occupation in life and health.

Contemporary understandings of occupation

The notion of occupation in recent literature is presented in a range of ways. This section of the review will focus on descriptions and definitions of occupation and key terms associated with occupation. Occupation has been described by Sundkvist and Zingmark (2003) as a conceptual entity which "includes all things that people do in their everyday life" (p. 40) and by Wilcock (1998) as "all 'doing' that has intrinsic or extrinsic meaning" (p. 257). This certainly gives the sense that occupation is something that is all encompassing, without any bounds. These recent views of occupation are complemented by components of definitions which were brought together in the Journal of Occupational Science Occupational Terminology Interactive Dialogue (2001). The dialogue included a definition from Yerxa, Clark, Frank, Jackson, Parham, and Pierce et al (1989) who considered occupation to be chunks of activity within the ongoing stream of human behaviour, self initiated, socially sanctioned and a complex phenomenon. Similarly, McLaughlin Gray (1997) described occupation as units of activity, classified and named by the culture. According to Sabonis-Chafee (1989) occupation is seen as purposeful activities that fill a person's waking hours and something that is 'more than just doing'. Kielhofner (1995) considered occupation to include action and doing in the physical and social world. This string of perspectives was brought together by Crabtree (1998), who defined occupation as "intentional human performance organised in number and kind to meet the demands of self maintenance and identity in the family and community" (p. 40).

The extent of occupation is also denoted by the American Occupational Therapy Association Commission on Practice (2002), which used the term occupation to "capture the breadth and meaning of everyday life activities" (p. 610); the members of the Commission viewed occupation as the means and outcome of occupational therapy intervention. Likewise, when Wilcock (2003) interviewed occupational science and occupational therapy students, the students simply described occupation as employment, a career path, day-to-day tasks and something that takes up time. In summary, current conceptions of occupation consider it to be central to a person's identity and competence, to influence how a person spends time and makes decisions, to have an element of needing to be endorsed by a person's cultural or social group, and having common components such as groupings of activity. In addition, occupation implies a sense of intentional and purposeful action. An important point made by Sundkvist and Zingmark (2003) is that a consensus has not been reached on the complex meaning of occupation and the discussion, indeed this debate, still continues in the literature (Hammell, 2009; Reed, Hocking, & Smythe, 2011). This supports the discussion by Christiansen (1994) and Law, Steinwender, and Leclair (1998), who recognised the complexity of attempting to understand occupation.

A key point that has been made is that occupation is often socially and culturally sanctioned and defined (Yerxa, Clark, Frank, Jackson, Parham, & Pierce et al, 1989; McLaughlin Gray, 1997), which indicates that different cultural groups will have their own unique understanding of occupation. Darnell (2002) pointed out that occupation, as understood by occupational therapists, is from a Western point of view, that social recognition is important to the value placed on an occupation, and being occupied is socially valued. When considering occupation from the viewpoint of other cultures, it is important to acknowledge that the focus may not necessarily be on productivity, as it is in Western culture. Further the focus of occupation may be to support extended family or to be in balance with nature. The complex nature of the meaning of occupation, which is circumstantial and shaped by the dynamics of the interaction between people, competing demands and possibilities, where the meaning of occupation goes beyond the individual was highlighted by Reed, Hocking, and Smythe (2010). The transactional nature of occupation is also addressed by Dickie, Cutchin and Humphry (2006) who proposed the Deweyan concept of 'transaction' as an alternative perspective for viewing occupation. This is where occupation is no longer seen as something arising from the individual, but should be viewed in its complex totality of the person in context, where the meaning of occupation goes beyond the individual. This seems to suggest that understandings of occupation are much broader than those that are created by the individual, but extends to understandings generated by groups of people. Similar points about the culturally specific nature of occupation are acknowledged by Townsend (1997), in that she agrees that occupations are named to represent purposes and goals, and to express personal and cultural ideas. More importantly she agrees that occupations are named and valued differently in each culture.

Discussion and implications

Understanding is always shaped by our own historical circumstances. We stand "within a tradition [that] does not limit the freedom of knowledge but makes it possible" (Gadamer, 1960/2004, p. 354). Our taken for granted understandings that we have been brought up with, that have become embodied in practice, teaching and scholarship, are often difficult to challenge to see how such understandings have been socially constructed. This paper is an attempt to momentarily break free of the notion that occupation and occupational therapy are generic entities in their own right, determined by the profession itself. Looking back provides evidence of the shaping of understandings of occupation and occupational therapy which have themselves been shaped by the social milieu of the times.

For example, with the Moral Treatment Movement, beliefs about individuals' ability to reason shaped an understanding that mental illness was not the result of an external force. Thus the value of occupation was recognised and initiated in the treatment of people with mental illness. Those underlying beliefs contributed to the establishment of occupational therapy in the early 1900s. This new profession claimed occupation as its domain of concern and built on the growing recognition of the connection between occupation and health. In its formative years occupational therapy was also strongly influenced by the Arts and Crafts Movement, Adolph Meyer, a psychiatrist and mental hygienist, and Eleanor Clarke Slagle who had an interest in habit training. All of those influences came from outside the profession.

With the advent of World War One and Two the use of occupation in the realm of healthcare shifted from being used solely in the treatment of mental health conditions to deal with the alarming rise of physical conditions. Occupation was seen as an important part of treatment to allow injured servicemen to return to the front, or in the case of people with tuberculosis, to regain a level of economic independence. Again, society dictated the need and the purpose. The professions of medicine and psychiatry became highly influential in challenging occupational therapy to provide evidence to show how and why occupation contributed to health outcomes. As a result, the holistic perspective of using occupation therapeutically changed from it being used for diversion or resettlement to being used to increase function in the home or workplace. Engagement in occupation became something that could be manipulated and used for remediation as part of a person's overall rehabilitation programme, to the point where occupation or parts of occupation were prescribed. This meant that much of the value of the experience of participating in occupation was lost. The practitioners themselves would have had little control over this reshaping of their practice, as this would have been determined by the economic imperatives of society at the time.

The rise of professionalism amongst other health professions (Saks as cited in Taylor & Field, 1998) meant occupational therapy had no choice but to meet the challenge of becoming a profession; the alternative was to perish. It followed the other professions in the establishment of 'Schools' of Occupational Therapy and professional bodies. During the 1960s, there was a call by members of the profession to reclaim the aims and functions of occupational therapy. Heidegger (1927/1995) talks of authentic resoluteness, or the times when we see the possibilities of our own being and take a stand. This came in response to the profession being in a phase of uncertainty as a result of the dilution of the understanding of occupation, which had been strongly influenced by biomechanical and psychodynamic paradigms. Occupational therapy scholars were attuned to what was determined to be worthy scholarship. Much of the literature during this time focused on describing and defending practice, and providing evidence for practice based on these dominant paradigms, rather than focusing on understanding occupation from the lived experience. It was not until the 1980s that models of practice with a strong occupational element began to emerge. The resurgence of interest in occupation led to the call to focus research on occupation, particularly the link between occupation and individual and community health. It is interesting to note that in this same era nursing was very intent on articulating the essence of nursing. Part of this move was to distinguish each discipline as 'distinct' in an era of competition for territory in the health domain (Saks, as cited in Taylor & Field 1998). The establishment of occupational science, marking occupational therapy as having a rightful place with the University, created an avenue to lead and show the way for generating a greater understanding of occupation.

Conclusion

Having reviewed the historical and contemporary literature, the question that now arises is 'how is society currently shaping our understandings of occupation, and therefore the mode of practice of occupational therapists?' It is not possible for any discipline in the current context to escape expectations such as using evidence to underpin practice, cost effective service, or proof of useful outcomes. Yet, it behoves the profession to explore who the voices are behind such powerful shapers. The research by Reed et al. (2010) moved beyond the broad societal shapers to hear the voices of the individuals engaged in occupation. The findings of the study revealed the limits of theoretical models of practice that did not appreciate the dynamic, contextual, relational and ever changing understanding of occupation. Our challenge is to once again return to a moment of authentic questioning when, recognising the inescapable shapers, occupational therapists resolutely decide how their practice can most effectively serve society. Shaping itself is a dynamic unfolding in which those being shaped can resist, explore and propose. Let our shaping be in the image of what works for the recipient of occupational therapy. Let us listen to them. Let us take their voice to the table of shapers.

Key points

* Different meanings of occupation have built up over time

* Occupation became a notion that was named, framed and conceptualised as the domain of occupational therapy

* A connection between occupation and health was recognised

* Knowledge of the historical context has the potential to assist with the conceptualisation of current and future practice.

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Corresponding author:

Kirk Reed, DHSc, Head of Department

Department of Occupational Science and Therapy

AUT University

Private Bag 92006

Auckland

New Zealand

Email: kirk.reed@aut.ac.nz

Clare Hocking, PhD, Professor

Department of Occupational Science and Therapy

AUT University

Liz Smythe, PhD, Associate Professor

School of Health Care Practice

AUT University