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Key words
Abstract
Elizabeth Townsend, Ph.D.,
O.T. (C), Reg. N.S., FCAOT is a
Professor and Director of the
School of Occupational Therapy,
Faculty of Health Professions,
Dalhousie University, 5869
University Avenue, Room 215,
Halifax, Nova Scotia B3H 3J5.
E-mail: liz.townsend@dal.ca
Contributors:
J. Pierre Galipeault is the
owner and manager of the
Empowerment Connection.
E-mail: info@empowermentconnection.com
Karen Gliddon is the Adult
Vice Regional Representative
(Ontario) and Hamilton Area
Chapter President of the
Canadian Cystic Fibrosis
Foundation. E-mail: info@
cysticfibrosis.ca
Stephen Little is the former
National Director of Client
Services for the Canadian
Paraplegic Association. E-mail:
info@canparaplegic.org
Cathy Moore is the National
Coordinator of Employment
Services, Canadian National
Institute for the Blind (CNIB)
E-mail: webmaster@cnib.ca
Bonnie Sherr Klein is a disability
activist and educator, as well as
author, speaker and filmmaker.
E-mail: bklein@uniserve.com
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Background.This descriptive paper offers reflections on power and justice associated with
occupational therapys client-centred practice, now described as the practice of enabling
occupation. Framed as a contribution to the sociology of professions, the questions addressed
are: How do power and justice work in occupational therapy today? What vision of power
and justice guides the profession in implementing the client-centred practice of enabling
occupation? Method.The paper opens with an overview of the analytic framework for
reflections.Two sources for reflections are highlighted: the development of the Canadian
guidelines and, client/consumer and occupational therapy perspectives.To illustrate the
discussion of power and justice, two contrasting diagrams are presented, one on late 20th
century power relations and the other on potential power relations. Results. Recommendations for research, education, practice, and guidelines development are offered prior to a
conclusion that acknowledges the dissonance facing occupational therapists who struggle
to focus on occupations in client-centred practice. Practice Implications.The paper offers
insights and strategies for addressing power and justice as issues in implementing the clientcentred practice of enabling occupation.The analysis may be used in raising awareness and
guiding the strategic development of institutional change toward social inclusion and
enabling occupation.
Rsum
Description gnrale. Cet article descriptif propose des rflexions sur le pouvoir et la justice
en relation avec la pratique centre sur le client en ergothrapie, maintenant dcrite comme
la pratique centre sur la promotion de loccupation. Dfinies comme une contribution la
sociologie des professions, les questions abordes sont les suivantes : Comment le pouvoir et
la justice interviennent-ils aujourdhui en ergothrapie? Quelle vision du pouvoir et de la justice
oriente la profession lors de la mise en oeuvre de la pratique centre sur la promotion de
loccupation? Mthodologie. Larticle dbute par une brve description du cadre analytique
utilis pour prsenter les rflexions. Deux sources de rflexions sont mises en relief : llaboration des lignes directrices canadiennes ainsi que les opinions des clients/consommateurs et les
perspectives ergothrapiques. Afin d'illustrer la discussion sur le pouvoir et la justice, deux
diagrammes sont mis en contraste : les relations de pouvoir la fin du 20e sicle et les relations
de pouvoir potentielles. Rsultats. Des recommandations sont mises relativement aux
domaines de la recherche, de lducation, de la pratique et de llaboration de lignes directrices.
Ces recommandations sont suivies dune conclusion qui souligne la dissonance laquelle sont
confronts les ergothrapeutes par rapport la pratique centre sur loccupation, qui se
traduit par une lutte incessante pour promouvoir les occupations dans leur pratique centre
sur le client. Consquences pour la pratique. Larticle propose des rflexions et des stratgies
pour traiter des questions de pouvoir et de justice lors de la mise en oeuvre de la pratique
centre sur la promotion de loccupation. Cette analyse peut tre utilise afin de sensibiliser
les dcideurs et dorienter stratgiquement le changement institutionnel vers linclusion
sociale et la promotion de loccupation.
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Analytic framework
My awareness of power and justice arose through use of the
analytic framework of critical social science (Fay, 1987;
Giddens, 1991; Waitzkin, 1989) and of institutional ethnography, developed by the Canadian sociologist Dorothy
Smith (Campbell & Gregor, 2002; Campbell & Manicom,
1995; Smith, 1987, 1990a, 1990b). Of relevance here, institutional ethnography (IE) grew out of Smiths (1974)
interests to understand, from the standpoint of women,
how and why women experience powerlessness and invisibility as researchers. Since then, IE has been used to critically analyze power and justice related to gender, age, race,
accounting practices, literacy education, and professional
work (Campbell & Gregor, 2002; Campbell & Manicom,
1995).
Briefly summarized, institutional ethnography is a
research theory and method for generating knowledge about
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Guidelines development:
A foundation for reflections
FIGURE 1
Local, interpersonal social relations.
Interpersonal
Power
Power is:
visible & conscious
subjective
local
particular
experienced between people
governed interpersonally
l
na
o
i
t
itu
t
s
In
r
we
Po
Power is:
invisible and unconscious
objectified & embedded in texts
translocal
generalized
experienced in the ways things are done
governed through texts
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coffee pot, a jug of water, and 10 cups. After five
minutes during which Joe and the five others have
been looking out the door without speaking, a pleasant
looking, early 30s, occupational therapist arrives with
a box of papers and pencils. The occupational therapist
invites the six to introduce themselves to each other.
The occupational therapist then describes the group
as an opportunity to talk about life with a mental
illness and share ideas for living outside a hospital.
To reflect on power and justice, one can ask: From Joes
perspective, how does this group display the power or lack
of power of persons with persistent, severe mental illness to
participate in decision making about mental health services
or their lives in society? From the occupational therapists
perspective, how does being facilitator of this group reflect
occupational therapists empowerment or lack of empowerment for "enabling people to identify, choose, and
perform those occupations they find useful and meaningful
in their environment" (CAOT, 1997, 2002, p. 180)?
Canadian guidelines emerged through a history of
national collaborations. Collaboration between Canadian
occupational therapists, other professionals, and health
services personnel in the 1960s and 1970s resulted in
national hospital accreditation guidelines for the structure
of occupational therapy. Structural guidelines defined
features, such as space, facilities, administration and
staffing, required for occupational therapists to work in
medically defined services, such as orthopaedics or paediatrics. The concepts and language in those guidelines
portrayed what occupational therapists, such as Muriel
Driver (1968) and Mary Reilly (1962), referred to as
medicalized, technical practice. Structural guidelines
accepted the taken-for-granted structure of power between
dependent, compliant clients/consumers and expert occupational therapists whose decisionmaking power was
dominant in relations with clients and subordinate in
relations with medicine.
Collaboration between occupational therapists and
government personnel on quality assurance guidelines in
the 1970s and early 1980s lead to the publication in 1983
and 1986 of Canadas first guidelines for client-centred
practice (DNHW, 1983, 1986). Structural guidelines on the
number of occupational therapists, office space, professional
job requirements and documentation would not ensure
that Joe would experience quality occupational therapy in
the group previously described. Moreover, outcomes guidelines could not be defined without knowledge of a quality
occupational therapy process. Therefore, the 1983 and 1986
DNHW publications offered process guidelines, following
Donabedians (1966, 1985) conceptual framework and
language for quality assurance related to the structure,
process and outcome of health services. The 1983
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opportunity to be involved in solving their own problems;
enabling is the basis of occupational therapys clientcentred practice and a foundation for client empowerment
and justice; enabling is the appropriate form of helping
when the goal is occupational performance" (CAOT, 1997;
2002, p. 180).
In general, concepts from previous guidelines about
respect for the individual, holism, a model of occupational
performance, therapeutic use of activity, spirituality and
motivation were included under the broader concept of
human occupation (Kielhofner,
2002; Wilcock, 1998a, 1998b;
Wilcock, 2001) as both the ends
and means of occupational therapy (Gray, 1998; Rebeiro, 1998).
Occupation was displayed in a
new, dynamic Canadian Model
of Occu-pational Performance
(CMOP) as the mechanism for
persons to think, feel and act in
their environment, with spirituality expressed through occupation. Enabling was adopted as an umbrella term for
concepts about an occupational performance process of
practice, a developmental perspective, motivation, the therapeutic relationship, teaching/learning processes, ethics,
health promotion, and empowerment. Enabling is a concept
of participation, and applies to enabling environmental
change as well as enabling individual client participation
(Dunst & Trivette, 1989; O'Donnell, 1993, Polatajko, 2001;
Townsend & Landry, in press). Enabling is also a synergistic,
negotiated collaboration (Gage, 1997) with individual,
group, agency, or organizational clients, concerning participation in occupations in context. An emerging third concept
in 1997 (CAOT) was justice, with greater attention to
population-based clients, these being groups, agencies, and
organizations. Occupational therapys social vision of justice
(Townsend, 1993), now being explored under the concept
of occupational justice (Townsend & Wilcock, 2003; Wilcock
& Townsend, 2000), drew on the 1993 guidelines for clientcentred practice in health promotion and client empowerment.
To follow the guidelines for enabling occupation, the
occupational therapist working with Joe and the group
might voice the professional domain of expertise as being
in occupations, both in evaluating Joes and others everyday life issues, and in involving Joe in occupations that he
says offer both relevance and therapeutic potential for him
as an individual a member of the population who are
occupationally deprived because of a persistent, severe
mental illness. The focus on occupation might drive
changes in the group to go beyond talk to participation in
simulated or real occupations in the hospital and the
community. The occupational therapist might highlight the
use of client-centred, enabling approaches with a mission
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the client/consumer and occupational therapists perspectives below.
Client/consumers perspectives
Client-centred practice works by equalizing clientprofessional power relations in everyday practice and in the
organization of professional and managerial processes
(Cervaro & Wilson, 1999). To recognize the importance of
listening to client/consumer perspectives (Campbell,
Copeland, & Tate, 1998; Peloquin, 1997; Rudman, Cook, &
Polatajko, 1997), five people were approached to talk about
meaningful occupation and enabling approaches. Bonnie
Sherr Klein was selected to update the perspective
expressed in her foreword to Enabling Occupation: An
Occupational Therapy Perspective (Sherr Klein, 1997). The
other four were randomly selected as leaders who could
express perspectives on living with a persistent malady:
mental illness, a physical disability, cystic fibrosis, and low
vision. All invitations were accepted, citing their motivation
to insert client/consumer points of view in a professional
forum. They commented on the following: How might
your opportunities for meaningful occupation be
increased, either you personally or the group for whom you
speak? How and why are your needs for meaningful occupation not met? How could service providers help most to
enable your participation in meaningful occupations?
Speaking about life with a persistent mental illness,
Pierre Galipeault, owner and manager of the Empowerment Conection, talked about consumers desire for more
power to express their perspective on strengths rather than
needs. Prominent concepts about power in Galipeaults
perspective are about policy and attitudinal changes:
If occupational therapists philosophically view
consumers or survivors as they do any other member
of society, as having assets, capabilities and gifts that
they bring to their communities, the focus will be
taken off needs and the relationship between customer
and therapist will be built on hope, trust, strengths and
equal participation. Interestingly, needs become
satisfied through this approach, not by the therapist,
but by the individual through her or his choices. There
are many constraints to shifting to this type of
approach. The entire health care system is founded on
a needs perspective to service delivery. It will require
policy changes, attitudinal changes and increased
involvement of consumer/survivors ... Consumer/
survivors also require the support from and collaboration with professional associations such as the
Canadian Association of Occupational Therapists in
order to achieve any significant reform
He wants to enable change in policy, service systems
planning and education, including professional education.
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Cathy Moore, the Canadian National Institute for the
Blinds national coordinator for employment services,
refers to "misinformation and low expectations." She
reasons that accommodations for children would flow into
employment and other aspects of adult life:
If blind children were expected from the beginning
to be full participants in activities be it play or school
or work then accommodations would be in place.
There would be less special activities and more naturally occurring accommodated everyday activities
misinformation and low expectations on both sides
lead to underdevelopment of the skills and talents a
blind person may possess ... Tools that agencies can
provide which are invaluable are lists of persons
willing to become mentors, databases outlining
successful job accommodations, jobs blind persons are
successfully performing, and resources to assist in the
accommodation of blind persons.
Moores emphasis is on "naturally occurring accommodated everyday activities," rather than "special activities." With a list of "tools" that agencies can provide, she
recognizes that the development of skills and talents
requires multiple strategies, not only individual or group
therapy, a point also made by people with physical
(Campbell, Copeland, & Tate, 1998) and psychiatric
(Deegan, 1997) disabilities.
Bonnie Sherr Klein wrote the foreword to Enabling
Occupation: An Occupational Therapy Perspective (1997) as
well as Slow Dance: A story of stroke, love, and disability
(1998). She spoke about finding the words, images, and
other texts that can transform the power of disability into a
positive force. Her talk about being "transformed" by
participation in art as an occupation echoes occupational
therapists ideas of using occupation as both means and
ends toward empowerment (CAOT, 1997, 2002):
I'm interested to read your description of occupation as the making of meaning, as that is also one definition of art. For the last several years, my occupation
has been an exploration of disability art and culture.
There's an international movement comprised of
artists in all disciplines and with all kinds of disabilities
who are creating visual art, theatre, music, dance, film
out of their own experience. They/we are telling our
own stories, in our own unique ways. The images we
create contradict the dominant cultural stereotypes of
disability (created by well-meaning but non-disabled
people) as passive, tragic, pitiful, and needy. We project
instead authentic, non-sentimental images of the
dynamic, creative, powerful, sometimes funny individuals that we are In my experience, service providers
are excited and challenged by the work we are creating
and can collaborate with us to create these opportunities and push the boundaries of possibilities. For
example, our board and volunteers have included
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A focus on occupations
Some respondents were satisfied with the Canadian Model of
Occupational Performance Model (CMOP) saying that it
offers an "explanation of concepts" (R #10) and "cohesiveness
as a holistic model" (R #14) as indicated below:
The model with the explanation of concepts is helpful
for students to understand how the different aspects
of their study fit together and provides a way in which
research can be discussed to indicate implications
for occupational therapy and occupational science.
(R #10)
One of the great strengths of the Canadian Model of
Occupational Performance is its cohesiveness as a
holistic model (R #14 )
Others, such as R #10, said that the CMOP generates
"discussion and controversy":
It seems to me that everything in the book revolves
around Chapter 3. It is either building up to this
discussion or else indicating how the concepts from
Chapter 3 can be implemented. I continue to think it is
the most helpful because there is still much discussion
and controversy about it I think it is extremely
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important for CAOT to determine the degree of
consensus that occupational therapists hold with
respect to the CMOP. There has been some criticism
but not much Chapter 3 shifted the way in which
the Model of Human Occupation from the US tended
to dominate our thinking to a focus that is more
uniquely Canadian ( R #10)
Respondents, such as R #14 and R #11, believe that more
discussion is needed on the current taxonomy of occupations as self-care, productivity, and leisure in the CMOP:
The one area within the Canadian Model of
Occupational Performance that needs much more
work I think is the taxonomy used for occupation
self-care, productivity, leisure. Although this may serve
to some extent to categorize occupations, it is not even
great for that. It does not serve much function in
analyzing occupational health or performance, or to
identify factors that might determine occupational
health, balance, etc. (R #14)
In self-care, there needs to be more emphasis on rest
and sleep as a foundation for healthy living and as a
health determinant. To take this further, more discussion on health promotion and health determinants is
important The environment is under-represented
in that more discussion is needed on the impact of the
person on the environment and the environment on
the person the interrelationships. The spirit of the
individual needs to be discussed as the foundation of
their story The concepts that people do, think, feel physical, cognitive, affective ... I find that community
partners from inner-city residents to lawyers understand and relate to these concepts. This language gives
OT a place to begin with commonplace communication Leisure needs to connect back more to family,
friends, and community relationships that support a
sense of belonging (R #11)
One respondent noted that, "ICIDH-2 needs to be
introduced and relationships made with the CMOP given
the revised focus" of the ICIDH-2, now called the
International Classification of Function (ICF) (World
Health Organization, 2001).
Spirituality
Continuing inclusion of spirituality in the CMOP remains
controversial, particularly in a world of evidence-based
practice (Unruh, Versnel, & Kerr, 2002). Although spirituality is not an area of occupational therapy competence,
McColl (2000) indicated that in working with occupations,
there is a need to approach clients with "sensitivity to the
presence of spirit" (p.218). Despite or because of the controversies, Canadian occupational therapists have achieved
the power of international recognition for incorporating
the notion of spirituality (Clark Green, 2000).
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Justice
My analysis is that justice in all occupations of everyday life
is both an implicit outcome and an embedded value in the
occupational therapy process of practice (Townsend, 1993).
Injustices of concern to occupational therapists are, for
example, the deprivation of occupation or unwanted
dependence in occupations in disabling environments
(Townsend & Wilcock, 2003; Wilcock & Townsend, 2000).
With complex issues of power
and justice at stake, it is no wonder that occupational therapists
are still asking, almost 20 years
after the first client-centred
practice guidelines were published (DNHW, 1983), What
does client-centred practice
mean (Corring & Cook, 1999)?
Are we truly client-centred
(Rebeiro, 2000)? Why is it so
difficult to do (Wilkins, et al.,
2001)?
Occupational therapists empowerment to organize
services to support the work of enabling occupation
remains a challenge, particularly in the development of
financial strategies "to get funded to do this work" (R #5).
I think the Forces topics [Chapter 2, Context of
Occupational Therapy] all lead to areas of OT involvement and later in the text we need to give some
strategies of how to get funded to do this work
Chapter 5 [Linking Concepts to a Process for
Organizing Occupational Therapy Services] is heavy
going and at a different level of need [entry/advanced]
[the focus] on outcomes is important but getting
through this chapter is difficult. (R #5)
Discussion
Our empowerment as occupational therapists to enable the
empowerment of client/consumers depends on the professions ability to critique its concepts, language, and practice,
and to invite the critique of others (Kinsella, 2001;
Malterud, 1993). In considering the sociology of occupational therapy as a profession, I am grappling with the
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FIGURE 2
Late 20th century power relations client/consumer and occupational therapy.
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FIGURE 3
Potential Power Relations? Client/Consumer and Occupational Therapy.
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Recommendations
Recommendations briefly consider occupational therapy
research, education and practice. In research, analyses of
the age, gender, culture, and ability/disability experiences of
occupational therapists in Canada and elsewhere in the
world might help to locate occupational therapy power
(and lack of power) to clarify concepts and practices
that are appropriate to diverse cultural, economic, and social
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contexts. Research with clients/consumers as partners or
contributors might also prompt our own clarification of the
concepts, language, and practice of enabling occupation.
Concepts of enabling occupation also need to be translated
into the policies, funding, and other governance of institutions, such as health services.
In education and practice, learning and critiquing the
concepts described in guidelines is a beginning. As well,
learning to raise critical reflections about the invisible,
unconscious, and taken-for-granted organization of
everyday practice is an important skill for all students and
practitioners. Awareness of power will enable clients and
occupational therapists to negotiate power, and to press for
their empowerment to enable occupation within health,
education and other institutions. In guidelines development, new collaborations, including clients/consumers, are
needed with a view that future guidelines will require more
than a simple updating. Our professional associations
could foster greater collaboration by inviting client/
consumer critique of our professional priorities and public
advocacy.
clients/consumers, and with occupational therapys continuing struggle for professional empowerment.
For those who want to persist in enabling occupation,
a challenge is to define and refine this professions interests
in the evidence-based practice (Egan, Dubouloz, von
Zweck, & Valerand, 1998), education, research (Egan, 2001)
professional advocacy, and institutional change required
for truly enabling occupation.
Acknowledgements
I am indebted to the five people who contributed client/
consumer perspectives, to the occupational therapists who
responded to the survey on Enabling Occupation: An
Occupational Therapy Perspective, and to reviewers who
helped to refine this paper. Funding to gather perspectives
was provided by the Canadian Association of Occupational
Therapists. Valuable assistance was provided by Jennifer
Smart, Maryanne Sacco-Peterson, Tammy Coles, and Gina
Meacoe.
References
Conclusions
I have used an analytic framework, drawn from institutional
ethnography, to reflect on power and justice in enabling
occupation. Occupational therapy guidelines development,
clients/consumers perspectives on enabling occupation,
and occupational therapists comments on Enabling
Occupation: An Occupational Therapy Perspective (CAOT,
1997) provided foundations for these reflections. From my
perspective as an occupational therapist, and a participant
in Canadian guidelines development, I looked at two
dimensions of power and justice: the power relation
between clients/consumers and occupational therapists
who want to engage in the enabling processes of clientcentred practice; and, occupational therapists own
empowerment to do our own work. Contrasts between late
20th century and future power relations were portrayed.
The 21st century is both a tough and an exhilarating
time for occupational therapists. Questions about power
and justice are often viewed skeptically as being too
political. Yet not addressing power and justice is also
political; we can either remain silently compliant with
client/consumer injustices and our professional lack of
empowerment, or we can take a visible, active stance to
advocate for change. The questions framing this paper
were: How do power and justice work in occupational
therapy today? What vision of power and justice guides the
profession in implementing the client-centred practice of
enabling occupation? An optimistic vision of power
sharing and justice in everyday occupations was contrasted
with todays lack of empowerment and justice for
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