Professional identity in occupational therapy

Dr Elizabeth Casson’s light bulb moment of understanding the positive impact that engagement in meaningful occupation has on health and wellbeing is probably well known to many reading this page. Her statement, when she saw the positive change in patients engaged in making Christmas decorations that “I knew from that moment that such occupation was an integral part on treatment and must be provided.” (Casson 1955) was an articulation of her conviction, the nub of her central idea about the relationship between health and occupation.

So when I was given the honour and somewhat scary opportunity to deliver the Elizabeth Casson lecture in 2011 I wanted to explore with the profession what had happened to this core concept. Was our professional identity intact? Was Elizabeth Casson’s idea still the central concept that drove our practice? What journey had it been on? And why, oh why, did so many occupational therapists seem to feel that people didn’t understand what they were all about?

To an extent I could identify with this feeling and for me the exploration involved in compiling the lecture was cathartic and affirming. I think by the end I could finally say that I’d ‘got it’, that I truly understood what occupational therapy was about, that I could debate and defend its kaleidoscope of practice scenarios. But I had by then been practising for more than four decades and my path to this understanding had been convoluted and complex. When I reflected on my own journey to ‘getting it’ I realised that, when I qualified with a diploma in the late 1960s, I didn’t really understand what occupational therapy was all about. I knew a lot of anatomy, a lot of craft activities and had some knowledge about mental ill health. I had an idea that putting these together as a form of rehabilitation was what constituted occupational therapy. But we were steeped in the medical model back then and that dominated our thinking and reasoning.

My reflection led me to realise that I’d had a number of light bulb moments in my career too that had led me to ‘getting it’. Amongst the most formative was my time spent working in Honduras, Central America (pictures in the header of this post), early in my career, as the only occupational therapist in the state psychiatric hospital. I had five assistants but we had no facilities, just a blanket request to ‘help all the patients’, so I had to go right back to basics – what was I actually trying to do? It really made me think. We set boundaries (no attendance at occupational therapy unless you had clothes on was our first) and respecting all patients came high on the list. We established a routine so that weekdays and weekends became distinguishable. What was my favourite time of the week? Friday afternoons when a local marimba band came and played and we encouraged everyone to dance “¡Vengan todos! Vamos a bailar!”

Being lead editor of five occupational therapy texts made Sybil, Marg and I debate late into the night about what concepts underpinned professional practice; my Masters course taught me how to think, analyse and debate. But two particularly pivotal experiences stood out. The first was reading Ann Wilcock’s brilliant article A theory of the human need for occupation (1993) which I’ve re-read many times and still love. The second was being involved in the first iteration of the QAA Benchmark Statements for Health Care programmes (2001) which demanded that we separated, for the first time, our profession specific knowledge and skills from those common to all the other health and care based professions. That REALLY got us thinking and having to articulate our uniqueness.

All these experiences, and more, underpinned my central theme of professional identity. I was able to explore what appeared to have happened that had led to a continued uncertainty around what we were about, our relationship with the medical model and our eventual conceptual separation from it with the realisation that we come from different philosophical bases which are complementary. I likened our profession’s development to the stage of adolescence, separating our identity from our parents but still unsure about quite who we were.

So is the need to explore, understand and articulate our core concept as strong today as it was 10 years ago? Absolutely it is! Following the Casson lecture I received many invitations to run workshops for groups of occupational therapists around the country. All wanted to explore their understanding of occupational therapy and talk through their confusion and lack of clarity about the core of our profession. It was fascinating ….. and enlightening. I started most workshops with an open question about what drove our profession and asked people what inhibited and facilitated their professional identity. This led to an initial negative catharsis of responses about not being valued by colleagues, not having an identity within a generic team, being embarrassed by what they felt they had to offer, being unable to explain their worth, and more. But it was important that these concerns were articulated, so that then we could address them. People agreed that a focus on and use of occupation based thinking, reasoning, evidence and language was a gateway to a specific identity and confidence in their professional uniqueness although many felt they had forgotten much of what they’d learned about the profession’s unique theory; that their knowledge base had been overwhelmed by a need to understand local priorities, fulfil local targets and work generically.

My reflection on this state of affairs led to two conclusions.

Firstly – wow! If we don’t understand and can’t articulate what we’re trying to achieve then of course other people won’t understand us, or give us credence. I realised that primarily, we are responsible for other people’s lack of understanding about our profession.

Secondly – well OK, let’s do something about it. Writing a pair of articles with two amazing colleagues led to a further exploration of the passage and position of our professional identity (Turner and Knight 2015) and an articulation of what we considered were our profession’s core skills (Turner and Alsop 2015 Figure 1). We concluded that there were several elements that can lead to an uncertain identity and proposed what could be done to address this (Turner 2018 Figure 2).

Articulating what we saw as the ‘issue’ with professional identity was cathartic – but I was at the end of my career and had recently retired. However wanting to understand the why further led me to undertake my PhD to explore in more depth our profession’s identity. Using the History of Ideas approach (Lovejoy 1940) I delved more deeply into how Elizabeth Casson’s core concept, the use of meaningful occupation to positively influence health and wellbeing, had been initially executed but then smothered when our need for status and access to people we could help led us to try and further our profession by medicalising our thinking and actions. I discovered that our professional tipping point came with degree level pre and post-registration education together with the development of occupational science and its evidenced articulation of our beliefs and values. I also found that we are in a process of recognising that our philosophy is different but complementary to the one that dominates healthcare systems in many countries, but that it’s perfectly OK to be different. We do, after all, live in a world that is beginning to celebrate difference.

We also inhabit a culture that is beginning to recognise that to maintain and recover our health the application of medicine is a vital stage in the process but other paradigms are often needed too. This current pandemic is a classic example. Our society has recognised, more than ever, how hugely grateful we are to the medical profession for its innovations and advances in treating COVID-19, but it has also recognised that there are wider concepts that have value and efficacy in the restoration and maintenance of health.

So where is our professional identity now? Reading about the many innovative developments initiated by occupational therapists, especially those beyond the realms of conventional health and social care settings, makes me believe that there is resurgence amongst occupational therapists of understanding of our core concept, coupled with the confidence and opportunity to develop practice initiatives based on this belief. However I also read in OT News in May 2020 an occupational therapist’s exasperation that “…it [occupational therapy] is so hard to define because we cover such a vast area as a profession…” (Fennelly page 37). Clearly our diversity is both our strength and an inhibition.

I wonder then where your professional identity sits on this continuum? Honestly the core concept isn’t rocket science is it? However negotiating the systems, expectations and values in which it is embedded can certainly be a huge challenge. But, as a very good occupational therapist friend said to me recently “We are no longer a young profession, no longer adolescent. We’ve got to grow up. It’s time to put on our big pants and just get on with it!”

I agree!

February 2021

References

Casson E (1955) Dr Casson tells: How the Dorset House School of Occupational Therapy came into being Occupational Therapy 18(3) 92-94

Fennelly S (2020) Occupation and isolation OTnews Royal College of Occupational Therapists, London

Quality Assurance Agency for Higher Education (2001) Benchmark statement: Health care programmes: Occupational Therapy Gloucester, Quality Assurance Agency. Available at: www.qaa.ac.uk

Turner (2018) Professional Identity in Occupational Therapy PhD by Published Work, Ulster University (unpublished)

Turner A and Alsop A (2015) Unique core skills: Exploring occupational therapists’ hidden assets British Journal of Occupational Therapy 78 (12) 739-749

Turner A and Knight J (2015) A debate n the professional identity of occupational therapists British Journal of Occupational Therapy 78(11) 664-673

Wilcock A (1993) A theory of the human need for occupation, Journal of Occupational Science 1(1) 17-24