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The research questionThe research question was:‘What are clients’ and the therapists’ perceptions of client-centred practice inoccupational therapy in the UK’?To understand the importance and influence of client- centred practice within theprofession of occupational therapy and its impact on practice, the therapist and theclient, the history and background to this way of working requires exploration. Thischapter will provide that context by considering the following key components: thehistory of the profession; the background and development of client centred practice;the relevance of outcome measures; and the part my own professional role had inquestioning the relevance of client-centred practice. Arising from this context theresearch design was developed to address the research question, examine practiceissues and explain the factors relevant to professional development, clinical practiceand future research.Defining Occupational Therapy:The profession of occupational therapy has acquired a multiplicity of definitionsduring the years since the first training school was opened in the UK in Bristol in1930. One of the earliest definitions by McNary in 1947 described it as;“any activity, mental or physical, medically prescribed and professionallyguided to aid a patient recover from disease or injury” (Hopkins 1993 p.3).The World Federation of Occupational Therapy (WFOT) lists 37 definitions whichhave been developed by national member organisations to reflect their practice3

(Duncan 2006). When Duncan (2006) reviewed these definitions he found that therewas a consensus regarding the core elements of Occupational Therapy (OT), namelythe connection of occupation with the therapeutic perspective. In 2010 the council ofWFOT published a ‘Statement on Occupational ) which affirmed for the memberorganisations, the scope, practice, education and focus of occupational therapyworldwide (WFOT 2010). The statement opens with;“Occupational Therapy is a client-centred health profession concerned withpromoting health and well being through occupation” (WFOT 2010 p4)In the UK, the Council of the COT acknowledged that defining occupational therapywas complex (Creek 2003) and adopted a shorter definition in January 2004 which islisted as the current COT UK definition on the World Federation of OccupationalTherapists website, it reads:“Occupational therapy enables people to achieve health, well being and lifesatisfaction through participation in occupation” (COT 2004 p1)This definition underpins the framework of this research with a focus on the coreskills of enablement through participation with occupation. Core skills are the expertskills shared by occupational therapists irrespective of their field or level of practice(see below). The College of Occupational Therapists (COT) in the UK defined theprofession’s core skills (Table 1.1) as built around occupation and activity whilstrecognising that these complex skills are composed of many component sub skillswhich include cognition and group leadership (COT 2009a).4

Table 1.1Core Skills of Occupational TherapyCore SkillDescriptorCollaboration withBuilding a collaborative relationship with the client thatthe clientwill promote reflection, autonomy and engagement in thetherapeutic processAssessmentassessing and observing functional potential, limitations,abilities and needs including the effects of physical andpsychosocial environmentsEnablementenabling people to explore, achieve and maintainbalance in their activities of daily living in the areas ofpersonal care, domestic, leisure and productive activitiesProblem solvingidentifying and solving occupational performanceproblemsUsing activity as ausing activities to promote health, well being and functiontherapeutic toolby analysing, selecting, synthesising, adapting, grading,and applying activities for specific therapeutic purposesgroup workplanning, organising and leading activity groupsEnvironmentalanalysing and adapting environments to increaseadaptationfunction and social participationCreek 2003 p365

The focus of occupational therapy practice, which appears deceptively simple, is thedoing of everyday activities or occupations; its complexity is in understanding thefactors that influence and shape these activities by constructing interventions whichenable the client to achieve mutually agreed goals. Duncan (2006) explained that thekey skill of the occupational therapist is to bring an occupational perspective to thetherapeutic context, taking into account a person’s ability and identity. Occupationaltherapists work with clients’ strengths and address areas of occupational dysfunction,in other words activities of everyday living with which the client struggles as a resultof illness, disease or trauma. Occupational therapists work with all age groups acrossa variety of settings for example; physical and mental health hospitals andcommunities, prisons, rehabilitation units, private health and the voluntary sector anddeal with a wide range of social, medical and environmental problems. The skill ofthe occupational therapist lies in the accurate assessment of a person’s abilities anddeficits and the construction of a planned graduated intervention plan, using activityor occupation to remediate function and increase independence. Key to thisapproach is the use of occupation or activity and the centrality of the individual withinthe therapeutic context (Duncan 2006).Historical roots of Occupational Therapy:Appreciating the history of occupational therapy adds to an understanding of currentapproaches and theories which influence how occupational therapy practice hasbeen shaped. The title of the profession links the practice directly to occupation. Thehistorical basis for health through occupation can be traced back to the OldTestament. In 30 B.C. Seneca recommended employment as a treatment for mentalagitation and in the classical period of the Ancient Greeks and Romans, the remedial6

and health promotional effects of occupation were noted as essential to humanhappiness (Haworth & McDonald 1946). Occupation has been central to humanexistence throughout time and remains pivotal today in terms of health and wellbeing, with lack of health reducing the ability of the individual to engage in occupation(Reed 1993). During the 19th century the issues of health and occupation wereexplored in many writings in English society, but those which had the greatestinfluence on occupational therapy were related to the philosophy of humanism andthe social values of humanitarianism, which were also the basis of the moraltreatment and the arts and crafts movements (Reed 1993).The moral treatment movement was the vision of the Quaker, William Tuke, (Tuke1813 cited by Borthwick et al 2001) who founded the York Retreat in England in1796. This movement set out to treat patients with mental illness using work andoccupation rather than confinement. It was a humane revolution that had a huge andlasting influence on the practice of psychiatry as it aimed to provide acompassionate, homely environment for people afflicted by loss of reason (Reed1993). Based on the Quaker principles of spiritual equality for all human beings andwith an emphasis on creating an environment which encouraged the individual totake personal and social responsibility, the moral treatment movement recognisedthe importance of useful occupation as a form of treatment contributing to themaintenance of health (McDonald et al 1972).This principle is also at the heart of thepatient-centred philosophy which is central to occupational therapy today (Duncan2011).The arts and crafts movement, spearheaded by John Ruskin the English philosopherand William Morris an artist and architect (Reed 1993), emerged in the latter half of7

the 19th century. This movement, when translated into education and therapyprovided two approaches; one approach became known as diversional therapy andthe other as occupational training. The former became dominant in occupationaltherapy practice in psychiatry whilst the latter was prevalent in occupational therapypractice for people with physical disabilities (Reed 1993).Modern day Occupational Therapy:Occupational therapy as it is known today was formally recognised in 1917 with theestablishment of the National Society for the Promotion of Occupational Therapy inthe USA. Prior to that, programmes of occupation are known to have been inexistence in the early part of the twentieth century (Haworth & McDonald 1946). Agroup of professionals from a broad range of backgrounds founded the NationalSociety, an organisation which later became the American Occupational TherapyAssociation and was influential in the development of the profession (Duncan 2006).However one individual who had a significant impact on the development ofoccupational therapy was Dr Adolph Meyer (1886 -1950), who was born inSwitzerland but spent his professional career in America, eventually becoming theDirector of the Johns Hopkins University Medical School. During his career Meyerrecognised the importance of instincts, habits, interests and experiences in people’slives. Consequently he developed an interest in the impact occupation had on hispatients and employed Eleanor Clark-Slagle (a founder member of the NationalSociety), who had trained in occupational therapy, to work with him. Meyer presentedthe first organised model of occupational therapy in 1921 in a lecture ‘The philosophyof occupational therapy’ (Reed 1993 p29). Even at this very early stage in thedevelopment of the profession, the core themes of occupation, a sense of doing and8

the relationship with the client were evident. Meyer described human organisation ashaving a particular rhythm of work, play, rest and sleep which needed balancing(Meyer 1922). He believed the only way of achieving this balance was by ‘actualdoing and actual practice’ (Meyer 1922 p6) recognising the value to the individual ofoccupation and the satisfaction of achievement and completion of work activities. Healso acknowledged the individuality of the therapists, noting that resourcefulness anda respect for the client’s capacities and interests contributed to the client’s sense ofachievement.The work of Meyer and Slagle influenced others to establish occupational therapydepartments and the first in the UK was at the Gartnavel Royal Hospital whichopened in Glasgow in 19

Client-centred practice underpins Occupational Therapy and is defined as a partnership between the client and therapist that empowers a client to fulfil his/her occupational roles in a variety of environments. Given the importance of this approach, there has been limited exploration of