Occupational Therapy Defined as a Complex Intervention: A 5-Year Review
Creek, Jennifer, British Journal of Occupational Therapy
Occupational therapy is a profession that assists people of all ages to achieve health and life satisfaction through improving their ability to carry out the activities that they need or choose to do in their daily lives (College of Occupational Therapists [COT] 2006a).
In 1988, the American occupational therapist, Elizabeth Yerxa, argued that the problems seen by occupational therapists are complex, affecting many aspects of an individual, including 'the sensory-motor, perceptual and cognitive systems ... [and] also the psychological, social, symbolic and cultural dimensions of his or her occupational behaviour' (pp5-6). Yerxa (1988) described oversimplification as 'the hobgoblin of theory and practice in occupational therapy' (p5): 'Oversimplification is the process by which inherently complex phenomena are reduced to parts or fragments which are more easily seen, understood and /or controlled' (p5).
During the past three decades, there has been an emerging recognition that organic systems cannot be comprehended fully through reductionist methods of inquiry and traditional scientific analysis, but require new research methods and new ways of understanding (Coffey 1998). This is because organic systems are complex, in that they can be understood only by looking at the relationships between components, not by studying those components separately.
In health care research, the most appropriate method for investigating the effectiveness of health care interventions is often considered to be the randomised controlled trial (RCT). However, some interventions are complex, making it difficult to identify exactly which element of the intervention is having the effect on the client. In 2000, the Medical Research Council produced a guide to the development and evaluation of RCTs for complex interventions to improve health.
In 2001, the South London and Maudsley NHS Trust, in partnership with the COT, commissioned Sarah Cook and Jennifer Creek to write a definition of occupational therapy as a complex intervention for the purposes of research, using the Medical Research Council (2000) guidelines as a framework.
The first step in evaluating a complex intervention is 'to explore relevant theory to ensure the best choice of intervention' (Medical Research Council 2000, p3). The next step is to 'identify the components of the intervention and the underlying mechanisms by which they will influence outcomes' (p3). The aim of the project to define occupational therapy as a complex intervention was to produce a coherently structured description of the components of occupational therapy and how they relate to each other. Secondary aims were to identify the components of occupational therapy intervention, the defining features of occupational therapy and the limits of occupational therapy.
The definition was published in 2003 by the COT (Creek 2003) and made available to members on its website. The document consists of:
* An introduction
* A one-page summary of the definition
* A description of the design and method used
* A description of the visible aspects of occupational therapy practice
* A chapter on the factors that the occupational therapist brings to the therapeutic encounter
* A chapter describing external influences on the occupational therapy process
* A glossary of 142 key terms used in the document.
At the time of publication, it was agreed that the document would have a currency of 5 years, after which time it would no longer represent the most up-to-date thinking on the topic. Five years after publication, the COT undertook a review of the impact that the document had had on the thinking and practice of occupational therapists in the United Kingdom (UK) and elsewhere. They asked one of the original authors of the document, Jennifer Creek, to carry out the review.
The aim of the review was to investigate the impact, if any, that the publication of Occupational therapy defined as a complex intervention (OTDCI) has had on the thinking and practice of occupational therapists. …