Search

Have occupational therapists lost the art of using occupations as therapy? This article proposes that in moving away from its art and craft roots towards an increasingly scientific paradigm over the past 50 years or so, the profession has jettisoned one of its core values ± creativity. The loss of awareness of and appreciation for creativity in the therapeutic dynamic has radically altered and constrained the practice of many occupational therapists and engendered a shift away from using occupations in healing. An illustration drawn from continuing care for older people demonstrates how occupational therapy is failing the field of chronic disability. It suggests that the profession must urgently consider the establishment of a new kind of practitioner for chronic disability settings, allied to but independent from occupational therapists.

Owing to the cognitive disability of people with dementia, the direct observation of behaviour is often the only means of evaluating the impact of therapeutic interventions. A number of standardised instruments of direct observation have been developed in recent years, but none offering the occupational therapist the flexibility with which to evaluate the diversity of physical, emotional, cognitive and behavioural variables encountered in dementia care. Conventional group-comparison methodology is inadequate in the clinical setting. Single-system evaluation is able to address the highly individualised needs of people with dementia. This paper describes how an evaluation may be custom-built to identify the specific changes elicited in a specific individual by a specific intervention under specific conditions.

This project represents the first phase of a larger study, the whole of which is intended to demonstrate the occupational need of elderly persons, in hospital or residential settings, who have severe dementia and to identify those therapeutic approaches which serve to meet such need. One hundred and nine severely impaired persons in nine dementia care units were each observed over the course of a day, using the dementia care mapping instrument. Results indicate a severe dearth of occupational provision for this client group, most of whom spent the greater part of their day unoccupied. They also highlight the conditions of minimum well-being experienced by most residents for most of the time. The anomaly of those units whose dementia care mapping scores did not match the perceived quality of their social and physical environments is discussed. A hypothesis of an altered perception of environment in severely impaired persons is proposed.

The occupational therapy profession has a long-standing dilemma over how it is perceived and understood both by lay people and by health and social care disciplines. The roots of the dilemma appear to lie in the disparate nature of clinical practice among client groups; for example, to the uninitiated, occupational therapy with the person who has a dense hemiplegia looks very different from occupational therapy with a group of depressed young men in prison. The reason for the uniqueness of each individual's occupational therapy package is that, unlike some health care professions, occupational therapy does not usually work directly with ill-health or disability, but with the occupational need engendered by ill-health or disability – i.e. with occupational deprivation or disruption or imbalance. Primary signs and symptoms of ill-health and disability may have some similarity from person to person, but occupational need is always unique. Occupational therapists' tools are the ordinary, often mundane, occupations of daily living. Thus, what occupational therapists do can sometimes appear neither therapeutic nor health-driven, and herein is the profession's greatest difficulty – conveying to the professional person as well as to the lay person the potential of everyday activity to embrace the complexity of ill-health and disability and to restore and maintain health and well-being. Occupational therapists continue to make a unique and potent contribution to health care, but the dilemma of the profession's public persona continues.