Whakaora Ngangahau Aotearoa
ISSN 1171-0462
April 2013 • Vol 60 • Issue 1
E rua nga- ao, kotahi te taura tangata:
Two worlds and one profession
Fresh perspectives on occupation:
Creating health in everyday patterns of doing
Doing well-Doing right TOGETHER:
A practical wisdom approach to making occupational therapy matter
Occupation for public health
The meaning of occupation: Historic and contemporary
connections between health and occupation
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CONTENTS
Editorial E rua nga- ao, kotahi te taura tangata: Two worlds and one profession
3
Jane Huia Hopkirk
5
Fresh perspectives on occupation: Creating health in everyday patterns of doing
Lena-Karin Erlandsson
16
Doing well-Doing right TOGETHER:
A practical wisdom approach to making occupational therapy matter
Frank Kronenberg
24
Occupation for public health
Clare Hocking
33
The meaning of occupation:
Historical and contemporary connections between health and occupation
Kirk Reed, Clare Hocking & Liz Smythe
38
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Volume 60
No 1
New Zealand Journal of Occupational Therapy
1
New Zealand Journal of Occupational Therapy
Abstracting and indexing
Is an official publication of the New Zealand Association of Occupational
Therapists Inc. You may visit our web site at www.nzaot.com
The Journal is now indexed in the CINAHL, EBSCO, ProQuest, OT
SEARCH, OTDBASE and INFORMIT databases.
Aims and scope
Advertising enquiries
The New Zealand Journal of Occupational Therapy is dedicated to the
publication of high quality national and international articles that are
grounded in practice. We invite practitioners, researchers, teachers, students
and users of services to submit manuscripts that provide a forum to discuss
or debate issues relevant to occupational therapy. These will be reviewed
promptly and, if accepted, will be published in a timely manner.
All matters relating to advertisement bookings should be addressed to:
Pam Chin
Tasman Image / Adprint Ltd
60 Cambridge Terrace, Wellington 6011
Phone: +64 4 384 2844 Fax: +64 4 384 3265
Email: pam@adprint.co.nz
Editorial correspondence
Subscription enquiries
Papers and other material for publication should be sent to the
Editor: Grace O’Sullivan
New Zealand Journal of Occupational Therapy
PO Box 10493, The Terrace, Wellington 6143, New Zealand
Phone: +64 9 410 9541
Email: sullies@xtra.co.nz
For details related to the submission of manuscripts please refer to the
Guidelines for Authors, available in this publication or from the Association
web site.
Associate editors
Dr Mary Butler & Kathy Pauga
The Journal is published twice a year.
All subscription enquiries should be directed to:
Administration Officer
New Zealand Association of Occupational Therapy
PO Box 10493, The Terrace, Wellington 6143, New Zealand
Phone: +64 4 473 6510
Web: www.nzaot.com
Fax: +64 4 473 6513
Disclaimer
The Association or the Editor cannot be held responsible for errors or any
consequences arising from the use of information published in this Journal.
Opinions expressed in articles and letters do not necessarily represent those
of the Association or of the Editor. Publication of advertisements does not
constitute any endorsement by the Association or the Editor.
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2
New Zealand Journal of Occupational Therapy
Volume 60
No 1
EDITORIAL
Editorial
Interactive Drawing Therapy (IDT)
I
have the pleasure of presenting the keynote proceedings from
the 2012 New Zealand Association of Occupational Therapy
Conference titled ‘Märamatanga Hou—Fresh Perspectives’ in this
edition of the Journal. The topics were diverse yet the authors
pointed to a common theme in each address and that is – the
central role occupation plays in making life better for people who
are disadvantaged by social determinants of health. Each paper
provides a unique view of how the complexity of occupations and
health interact.
I don’t have to say anymore because the articles will speak for
themselves but, before moving on I do want to thank the authors
for taking the time and making the effort to develop their verbal
presentation into an article suitable for publication. This is no
small task and so their commitment is welcomed in its own right,
and because it augments the reputation of the New Zealand Journal
of Occupational Therapy. The presentations, which are reported
(more or less) verbatim include:
“Working with imagery and metaphor
to unlock inner resourcefulness”
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The Frances Rutherford Lecture: Jane Hopkirk
E rua ngä ao, kotahi te taura tangata: Two worlds and one
profession
Keynote session 1: Lena-Karin Erlandsson
Fresh perspectives on occupation: Creating health in everyday
patterns of doing.
Keynote session 2: Frank Kronenberg
Doing well—Doing right TOGETHER: A practical wisdom
approach to making occupational therapy matter.
STAIRLIFTS
The fourth article in this issue reinforces the stance taken by the
conference speakers. In her professorial address Clare Hocking
highlighted the fact that concepts of health are changing. Moreover,
Clare challenged occupational therapists to look beyond quality
interventions to the societal factors that create health, ill-health,
and discrepancies in access to health.
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Last but certainly not least, Reed, Hocking & Smythe report the
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which uncovered the significance of occupation. The authors note
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there was increasing recognition of the connection between
occupation and health.
I hope the wisdom and knowledge that has gone into writing the
articles in this issue of the Journal offer insights that will be useful
in your practice. Comments and feedback are always welcome.
Grace O’Sullivan (Editor).
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Volume 60
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New Zealand Journal of Occupational Therapy
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Frances Rutherford Lecture
E rua ngä ao, kotahi te taura tangata: Two worlds and one profession
Frances Rutherford Lecture
E rua nga- ao, kotahi te taura tangata:
Two worlds and one profession
Jane Huia Hopkirk, Dip OT, MPhil (Ma-ori studies)
Tenei au, tenei au ko te hokai nei i taku tapuwae,
Ko te hokai-nuku, ko te hokai-rangi, ko te hokai
A to tupuna a Tanenuiarangi i pikitia ai
Ki te rangi-tu-haha, ki Tihi-o-Manono,
I rokohina atu ra ko Io-tematua-kore anake
I riro iho ai nga Kete o te Wananga:
Ko te Kete Tu-a-uri
Ko te Kete Tua-tea
Ko te Kete Aronui,
Ka tiritiria ka poupoua ki Papa-tu-a-nuku
Ka puta te ira tangata ki te whaiao
Ki te Ao marama!
Tënä koe e te Whare, tënä tätou
Ka mihi atu ahau ki a koe e töku Arikinui i te Rangi. Nähau ngä
whakaaro, ngä kupu korero, ngä mahi, ngä taonga pënä i te Tika,
te Pono, te Aroha i tuku iho ai hei oranga, mä ngä mokopuna, nä
reira e Pä, kei te mihi, kei te mihi, kei te mihi.
E te Tini e te Mano, ahakoa kua wehe atu koutou ki tërä taha o
te ärai, ki te ara whänui te ara whäroa ä Tänenuiärangi, ka haere
tonu ngä mihi ngä tangi ki a koutou ngä tüpuna. Nä koutou anö
ngä tämanako ngä wawata ngä moemoeä nö runga i te marae i
waiho, hei tüäpapa, mä ngä mokopuna e whai ake nei i te ora.
Haere atu rä, hoki atu rä, oti atu.
Tëna koe e Waikato, nä-hau anö te Whäriki mä öku rekereke,
otirä tënä koe e Kïngi Tüheitia me te Kïngitanga, nähau hoki te
Korowai mä öku pokohiwi. Nä reira nä körua tahi te maru hei
ähuru mowai möku nei, mö tätou katoa e huihui mai ana. Tënä
koe, tënä körua, tënä koutou katoa.
Tënä rä koe e te Minita, e Whaea Tariana. Ngä mihi ki a koe me
täu kaha ki te whai tonu atu i te oranga pai mö te whänau, me
täu tautoko i ngä kaupapa, ngä whäinga, ngä mahi o tënä whare
hauora o tënä whare hauora o tënä whare hauora nö Aotearoa
whänui, kei te mihi, kei te mihi.
Tënä koutou katoa e huihui mai nei i runga i tënei tü kaupapa
hauora arä ko te whakaora ngangahau. He mihi ki a koutou me
tö tuku whai wähi mäku kia körerohia he korero mo tënei momo
rongoä kei roto i te ao hurihuri nei, kei roto i ngä ao e rua nei, te
ao Päkehä te ao Mäori. Ko te amorangi ki mua, ko häpaio muri.
Tënä koutou, tënä koutou, tënä tätou katoa
(K. Takarangi, personal communication, September 9, 2012).
Volume 60
No 1
Ko Täkitimu te waka
Ko Pukengaki te maunga
Ko Ruamahanga te awa
Ko Ngäti Kahungunu te iwi
Ko Ngäti Muretu me Ngäti Moe ngä hapü
Ko Päpäwai te marae
Ko Jury öku tïpuna
Ko Ray Watters töku papa
Ko Honi töku hoa tane
Ko Huia, ko Kiriana ko Muretu äku tamariki
He Whakaora Ngangahau taku mahi
Ko Jane Hopkirk ahau
He taura harakeke ka kukumea ka whatia. He taura
tangata ka kukumea pehea te roa e kore ngamotu. The
rope made of flax will break. The rope made of people will
never be broken.
I have introduced myself today as a Mäori to situate myself in the
environment we are part of, with the line of ancestors or family we
have come from and the connections we have with those we are
speaking to. I have acknowledged the Kingitanga the Mäori King
movement in my welcome and wish to draw your attention to this
seat of knowledge. An expression of Mäori self-determination
and Mäori development is standing in the Kingitanga movement
and has been here for over 150 years (Origins of the Maori King
movement, 2008).
It is a significant and enduring demonstration of Mäori unity
which still has an acknowledged place and voice for Mäori
in Aotearoa New Zealand society today, as heard last week on
recent rights to water (Introduction - Origins of the Mäori
King movement, 2012). I do have links to this land through
colonisation as a share holder in Pouakani a Mäori land trust
at Mangakino up the Waikato River. This land was “given” by
the crown to the Wairarapa Mäori for the loss of our lake in the
Wairarapa.
Corresponding author:
Jane Hopkirk Email: j.hopkirk@maxnet.co.nz
New Zealand Journal of Occupational Therapy
5
Frances Rutherford Lecture
Jane Huia Hopkirk, Dip OT, MPhil (Mäori studies)
This paper was presented as the Frances Rutherford Lecture at the New Zealand Association of Occupational Therapists
Conference, on September 2012 in Hamilton.
Key words
Mäori, whakaora ngangahau, culture, bi-cultural, responsiveness.
Reference
Hopkirk, J. (2013). E rua ngä ao, kotahi te taura tangata: Two worlds and one profession. New Zealand Journal of
Occupational Therapy, 60 (1), 5–15.
Abstract
He taura harakeke ka kukumea ka whatia. He taura tangata ka kukumea pehea te roa e kore ngamotu.
The rope made of flax will break. The rope made of people will never be broken.
Occupational therapy or whakaora ngangahau represents the idea of reawakening, or restoring to health one’s activeness,
spiritedness and zeal. Occupational therapists (kaiwhakaora ngangahau) are poised on the threshold of the future: we
have the tools to deliver much to the people and to the communities of Aotearoa.
In te ao Mäori, we often draw upon the wisdom of our ancestors to understand today’s context so I will use the metaphor
of the flax rope that is weak, when woven by only one of us, but strong when bound by many, and is inclusive of the
other. I will reflect on our ongoing journey as a bi-cultural nation and how, within whakaora ngangahau (occupational
therapy), we can together make a rope woven by many, - never to be broken.
Mechanisms to move into the future include Whänau Ora where services are joining together under a variety of
arrangements to provide a Mäori responsive service to build well whänau and Mäori communities, and are driven by
Mäori aspirations, values, cultural contexts and ways of doing.
Whakaora ngangahau (occupational therapy) and Mäori health values align well, giving us a common ground to
enable wellness and make a strong multi-fibre rope to build a strong people. The challenge to whakaora ngangahau
(occupational therapy) is to recognize and acknowledge our profession’s shared understandings with Mäori, strengthen
them and support whänau to use them with whänau.
Together we can weave a strong flax rope to create our future.
Many years ago at Pouakani marae at Mangakino there was
vigorous debate on the selling of properties in the township. My
mother was a committee member of Wairarapa Pouakani trust
and was fighting for the retention of the land. She asked to speak
against the sale which resulted in a discussion between Tainui and
Ngati Kahungunu tribal elders about their differing practices of
women speaking in the marae. On this occasion she was granted
permission to speak because of the association of the marae to
Ngati Kahunungu ki Wairarapa traditions.
I use this illustration to acknowledge the leadership my mother
had within her own tribe, and the place she has in my being here
today. She was not afraid to stand and fight for retention of
Mäori land and the associated life and occupations. However
this illustration also shows the different responses and practices
each tribe has in the way they conduct their business and debate
matters of significance.
Today I will follow a Mäori word with the English translation. I
also often use New Zealander to identify non-Mäori or Päkeha
this does not mean Mäori are not New Zealanders but identifies
people by the terms they often describe themselves. Occasionally
I use a Mäori word and may not translate it as it does not translate
6
well and remains better understood in a Mäori context. This is
not dissimilar to occasions where English also does not translate
well for Mäori and is not well understood thus adding to the
diversity of our bi-cultural context.
Mäori theme
Ehara taku toa, i te toa takitahi, engari he toa takitini
Today I have the privilege of speaking to you with knowledge
that others have also contributed to Mäori development for
Mäori whänau and whakaora ngangahau.
Those of special note are the steering group for the development
of Te Umanaga Whakaora the accelerated Mäori occupational
therapy workforce development strategy and action plan (Te
Rau Matatini, 2009). This was supported and funded by Te
Rau Matatini a Mäori workforce development agency who were
present and we thank them for believing in and committing
such resource to our profession. This strategy was forwarded
and launched by the Hon. Tariana Turia, who we were also so
privileged to have open the conference. This was the first Mäori
strategy that was profession specific.
New Zealand Journal of Occupational Therapy
Volume 60
No 1
Frances Rutherford Lecture
E rua ngä ao, kotahi te taura tangata: Two worlds and one profession
The steering group to the development were Mäori kaiwhakaora
ngangahau of:
made up of nine elements necessary to provide for the whänau
and therefore enabling a community.
Georgina Davis from Ngäi Tai, Ngäpuhi, Ngäti Porou;
Jo-Anne Gilsenan Ngäti Apa Ki Te Rä Tö, Ngäi Tahu;
Jake Tahitahi Ngäti Manuhiri;
Kevin Brown Ngäpuhi;
Kristi Carpenter Kai Tahu;
Riwai Wilson Ngäti Porou;
Isla Te Ara Whittington; Ngäti Kauwhata, Ngäti Maniapoto,
Ngäti Kahungunu ki Wairarapa;
Whänau or family needs definition, to place it in context in
Mäori life and well being, hence the often used extension of it to
whänau ora - well families and communities. Family in a Mäori
context called whakapapa or blood related family includes the
nuclear family, grandparents, extended family (direct and more
distantly related) and those who have gone before. There are also
family of connection that Mäori identify and these can include
sports groups or work peers. Mäori identify whänau (usually
whakapapa related) as potentially the most effective system for
providing support and socialisation, developing new growth and
for managing and achieving change (Metge, 1995).
The service user advisor was:
Tania Marino Ngäti Ruanui;
and two kaumätua our guides to the world of Mäori:
Matua Brian Emery; and
Matua William Tangohau.
Whänau Ora - well families and communities is placed at the
top of the net and thus the peak of aspirations for wellness for
Mäori. This term was identified by the Hon. Tariana Turia in He
Korowai Oranga the Mäori Health Strategy (Ministry of Health,
2002). Therefore the significance for health practitioners is the
need to work with the family for wellness. When one is sick it
affects the collective (Ministry of Health, 2002).
The three key areas to develop the Mäori occupational therapy
workforce were recruitment and retention, cultural competence
and best practice. These highlighted the relationship of tools to
each other so it is not just a matter of increasing or retaining the
Mäori occupational therapy workforce. There was an equal need
to support this workforce to be culturally competent in their
ability to provide services from a Mäori world view and thus add
to best practice models and tools.
We had the opportunity to explore practice and how we wove
Mäori customs into the work we did with service users. The
discussions often centred on if we had a Mäori model of practice
what would that be and if we had Mäori occupational therapy
competencies what would those look like. We explored how we
identified as Mäori, reclaimed lost practices, strengthen our own
cultural competencies, and how was occupation seen by Mäori.
I want to thank this group for the privilege of being with you on
this journey. Within the strategy is a model based on a fishing net
Te Umanga Whakaora was situated in the context of Mäori
health development and advancement. Leadership to support the
ongoing direction of the model from within Mäori kaiwhakaora
ngangahau and the profession was also seen as necessary. Pivotal
to holding all above was the engagement of service users to guide
models of development on one corner and Mäori kaiwhakaora
ngangahau themselves in the other. The linking element of
partnerships primarily referred to the whakaora ngangahau
profession itself including elements such as the regulatory
authority, training programmes and employment settings (Te
Rau Matatini, 2009).
New Zealander theme
My success should not be bestowed onto me alone, as it was
not individual success but success of a collective
I am humbled to be presented with this award today. I looked for
a connection with Miss Rutherford. She was born in Masterton
in 1912 and established the occupational therapy department
at Masterton hospital in 1953 so there was a place link to the
Wairarapa where my maternal ancestors were from. On seeking
further information about her and her family from the local
archivist I was excited to find an interview Miss Rutherford’s
brother completed that speaks of her. He reported:
(Te Rau Matatini, 2009, pp. 24-25)
Volume 60
No 1
She went home to England for quite a while trained in the
main (Occupational Therapy) school in Liverpool and then
New Zealand Journal of Occupational Therapy
7
Frances Rutherford Lecture
Jane Huia Hopkirk, Dip OT, MPhil (Mäori studies)
came back and opened the occupational
therapy ward in Masterton… Then she
went from there to Auckland to be the
director of occupational therapy for New
Zealand. She retired a few years ago, did a
very good job. (Rutherford, 1991)
Maui placed his fish-hook, made from the
jawbone of his grandmother, onto his line. He
cast his hook into the sea saying karakia-prayer
as it went down and didn’t have long to wait
before he had caught a fish. With tremendous
effort he pulled up Te-Ika-a-Maui, the fish of
Maui the North Island of New Zealand.
I hope my dissertation honours those who
have gone before and inspires those yet to
come. There are many in the profession
that have shown an increased commitment
to supporting effective whakaora ngangahau
services for Mäori families and I acknowledge
you for this.
The fish was like a giant sting ray with its head
at Wellington Wairarapa region, its two fins
one New Plymouth and the other Mahia and
East Coast, and the tail trailing all the way up
to Farwell spit at the top of the North Island.
The South Island is referred to as Te Waka a
Maui, the canoe of Maui (Maui-Tikitiki-aOver the next hour I want to take you on a
Taranga). Iwi or tribes all through the north
journey through the ancient past, to then visit
island identify parts of Te-ika-a-Maui in their
Maui - Tikitiki - a – Taranga
the Wairarapa of my ancestors and national
local traditions. In the Wairarapa we speak of
responses of Mäori to their changing world.
the Te-Karu-o-te-Ika, the eye of the fish, which
It is difficult to speak of the history of Mäori so I have chosen to
refers to Lake Wairarapa the very lake that was taken away from
speak of my own family as an example of Mäori views. I have
us (Maui-Tikitiki-a-Taranga).
then looked at our profession and how culture interfaces with
it, considering research I have competed on an Aotearoa view of
The tauparapara or chant that was sung at the start of this speech
culture and its place in practice. I will end with opportunities
is very old and speaks of Tane climbing the heavens to search
open to us as we move into the future. I have shared what
for knowledge to bring back three baskets of knowledge to earth
has inspired me. In accepting this award I also celebrate the
to help sustain life. I have not translated the chant as it holds
achievements of my ancestors, colleagues and service users.
sacred knowledge precious to Mäori and by sharing it; I in turn
would help to perpetuate the loss of self determination for things
I have had little hope of ever not being passionate about
significant to Mäori. This chant however situates us here today
development of a people group with my Mäori whakapapa in a Mäori world. Mäori came with very limited resources to
links but also being the daughter of a human geographer. He, at
this land but had knowledge of how to turn this land into home
the age of 80 years, was very disappointed not to get a research
(Nikora, 2012). This tauparapara is sung in many places in
grant to go and continue the research he began over 50 years ago
Aoteroa and I have links to it because my great great Uncle Te
in a little village in South America. This did not dissuade him
Whatahoro Jury recorded it.
and he and three research assistants (his children) completed the
data collection in 2010 of which the ‘book’ is currently in its final
He has been the inspiration for much of my journey to walk in
stages. The passion, dedication and commitment to improve the
two worlds that of te ao Mäori - the Mäori world and that of
plight of poor to further their aspirations through consideration
the settler New Zealander. Hoani Te Whatahoro Jury was the
of culture, social structures, political economy and social change
eldest son of Te Aitu-o-te-rangi and her husband, John Milsome
(Watters, 2008) has been the driver of my Father’s life and a high
Jury. He grew up with the whänau of his mothers people Ngati
bar for us as children to aspire too.
Moe watching over and guiding him. Part of his life included
Mäori theme
Mäori tend to look back so they can look forward. I wish to
share some of the stories of my ancestors and ask that you respect
these stories as you will see they came with a price in all domains
of life. Mäori with the loss of occupation of the land that they
were integrally linked to and loss of occupations associated to
the land also lost the ability to protect, remain well and sustain
themselves. To help understand this link Mäori had to land, we
start with the Wairarapa creation story of te ika a Maui, the fish
of Maui.
Maui belonged to a family with older brothers who were
considered great fishermen and one day Maui persuaded them to
let him go fishing with them too. However, he was not satisfied
with the usual fishing spot so he persuaded his brothers to go
further out to sea than they had ever gone before. Once there
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E rua ngä ao, kotahi te taura tangata: Two worlds and one profession
living and participating in the activities essential to the family on
the shores of Lake Wairarapa. He learnt to read and write and
put that to use to become a prolific recorder of Mäori knowledge
and traditions. In the late 1800’s Mäori in the Wairarapa saw the
integrity of their way of life slipping away. At a large gathering of
whänau it was decided to record the knowledge of the tribe held
by tohunga – leaders (Wairarapa Moana Inc.).
Mäori believed knowledge was sacred and need protecting at all
costs. In order to protect it only certain people in the tribe were
given specific knowledge. In Mäori tradition understanding is the
key element of knowledge (Mercier, 2007). This has implications
for research especially in interpretation of data. Mäori have
experience of research being done to them in the past and in fact
the writings of Te Whatahoro were interpreted incorrectly thus
setting a theory purported by Percy Smith of the giant fleet of
canoes that settled Aotearoa (Smith, 2002).
New Zealander theme
In the Wairarapa, development of land for farming and crops
was escalating in the 1800’s and Mäori happily leased land to help
sustain the budding Wellington settlement. The government
with push from some local farmers however overrode this option
so sale and confiscation of land commenced despite strong Mäori
opposition. The Crown threatened military action and then
proceeded to confiscate eighty thousand acres because as the
local chief reported: “I would not allow them to feed their sheep
upon my land and enrich themselves at my expense.” Te Wereta Te
Kawekairangi, 1845 (Rangitane, 2009).
(Wairarapa Moana Inc.).
After 40 years of disagreement and debate Lake Wairarapa in
1896, because of its living nature to Mäori, was gifted to the
government to avoid confiscation. When the land was gifted
Seddon promised ‘a piece of land set apart’ to continue customary
fishing practices in the Wairarapa (Rangitane, 2009). A picnic
was held to celebrate the handing over of the lake. Tamahau the
chief noted the gift was from everyone describing the handing
over of the lake as ‘a noble canoe that was being hauled to its final
mooring-place, there to be regretfully taken leave of by those who
had so long voyaged in it’ (Waitangi Tribunal, 2010a, p. 107).
Wairarapa Mäori traditionally cropped and traded eels from the
mouth of Lake Wairarapa.
(National Library of New Zealand, 1896).
Seddon replied by stating:
When I listened today to the incantation, to the song of
farewell, sung by the chief in bidding adieu to that lake
which they have loved so long, which is vested with so many
historical associations for them, and which has been to them a
living necessity, I realised that that song came from the heart,
and I could feel that my spirit joined with theirs. (Waitangi
Tribunal, 2010a, p. 108).
(Potangaroa, 2010, p. 11).
In order to have so many eels the river needed to flood which
caused problems for the farmers in the region. In 1888 the
Ruamahunga River Board declared the Wairarapa Moana lake
a public drain and therefore under their jurisdiction leading
ultimately to the opening of the lake. This resulted for Wairarapa
Mäori, in loss of significant occupation and ability to provide for
themselves.
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This brought hope from those at the celebration that Seddon
understood the nature of the gift both intellectually and
emotionally and the responsibility to fulfil his side of the bargain
stood in good hands (Waitangi Tribunal, 2010a). Unfortunately
even though this was his intent, it was another 25 years before this
occurred. Wairarapa Mäori fought to have the promise fulfilled
with several petitions and a threat to go to the Privy Council
New Zealand Journal of Occupational Therapy
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Frances Rutherford Lecture
Jane Huia Hopkirk, Dip OT, MPhil (Mäori studies)
in England. The Kotahitanga also called the Mäori parliament
centred for a period at Papawai in the Wairarapa, supported the
protests and finally the government was forced to agree about
the injustice of the inaction (Wairarapa Moana). This period of
time had terrible consequences and the loss of occupation and
associated poor health led to Wairarapa Mäori not being able
to provide for their whänau or hapü. A local governor reported
that:
the physical and moral condition of the Native race in
this district has, I believe, considerably deteriorated … the
energies of the people are ill directed – the young of the race
are growing up entirely uneducated and untrained, while
the vice of drunkenness is unfortunately prevalent among
old and young. Their social habits are, in my opinion, of a
lower character than when in a more savage state; they have
lost a great deal of the energy which they formerly displayed,
and have acquired little else than the vices of civilization
(Thornton, 2004, p 15-16).
The link of Mäori in the Wairarapa between landlessness, lost
occupations and poverty was indicated in multiple ways but also
what was apparent was the difficulty accessing health care to
compound it further. Mäori during the late 1800’s accessed
health services less and less and avoided hospitals in particular
as stated:
Mäori now seemed reluctant to use European hospitals,
which were based ‘upon the European system’ and completely
ignored cultural values and principles. A growing social
divide, the result of Mäori poverty as well as ongoing cultural
differences and prejudices, underscored that reluctance.
Mäori patients were unwelcome. (Waitangi Tribunal,
2010b, p. 342).
The Kotahitanga movement brought tribes from around
Aoteroa together as equals to decide on things of significance
to Mäori which included, ownership and management of land,
decision making of things Mäori, access to education and health
services and they supported each other to retain what was
significant in the colonisation process. Te Whatahoro Jury was
the scribe to this parliament and recorded many of its meetings
(Wairarapa Moana Inc.).
Finally in 1925, 10695 hectares of land near Mangakino in South
Waikato was gifted by the crown in acknowledgement of the loss
of Lake Wairarapa. This land had no roads to it and was covered
in bush and scrub. There were no resources provided to develop
the land and so it was not farmed until 1948 when Sir Apirana
Ngata, under a development scheme, used Mäori to convert the
land into forestry and farming blocks (Wairarapa Moana Inc.).
In today’s world Mäori still struggle to have an equal position in
society but hold fast to the Kotahitanga movement aspirations of
the past as cornerstones to their future. Wairarapa Mäori wanted
and still want to be:
Located securely upon their lands with their own resources;
Able to provide for their own livelihood, growth and
development;
Able to benefit from the opportunities provided by European
settlement;
Able to access all the rights, protections and opportunities
available to non-Maori. (Wairarapa Moana Inc.)
In having these key aspirations they would then have control
of their occupations and therefore their health. The Waitangi
tribunal report, on the Wairarapa released its findings in 2010.
It considered that local Mäori have been ‘sorely tested over a
long period’ (Waitangi Tribunal, 2010b, p. 1). In the agreement
found in the Treaty of Waitangi was the granting of tino
rangatiratanga: that is full authority of chiefs. This is difficult
to understand what this guarantee is when lands are gone,
and people of the tribes dispersed. The question posed in the
Wairarapa Waitangi report was: “Has the elapse of time and the
turning of the world relegated chiefs and their rangatiratanga to the
mists of the past?” (Waitangi Tribunal, 2010a, p. iv).
The report states ‘No’ and I would support this. We see some
of the aspirations of the kotahitanga movement described above
and still held important by Wairarapa Mäori today and similar
aspirations sitting within policies such as the Mäori health
strategy and the Mäori disability action plan for support service
2012 to 2017 (Ministry of Health, 2012).
The Waitanigi report for the Wairarapa states that:
Mäori communities need to be empowered to rebuild so that
they can exercise authority over their affairs in place of that
of the State. They must once again be in a position to exercise
their own social control, so that they can look after their own,
and save them from becoming criminals and drop-outs in an
uncaring world. (Waitangi Tribunal, 2010a, p. v).
(Wairarapa Moana Inc.).
10 These findings from the tribunal also suggest that we all can play
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E rua ngä ao, kotahi te taura tangata: Two worlds and one profession
a part: “It is not too late. The time to start is now, and if we do,
our uri (descendants) will thank us for it, for New Zealand will be
a better nation” (Waitangi Tribunal, 2010a, p. v). Today we see
that the land in Mangakino has changed and farming has come
into its own. The land gifted many years ago to 139 whänau has
now come to contribute to 3224 share holders, all be it minimally
(N. Webb, personal communication, July 2, 2012).
The Incorporation is a leader in innovation in the farming sector
(Wairarapa Moana Inc.). This has been demonstrated in many
ways one of which was the winning of the prestigious Ahuwhenua
Trophy for excellence in its sheep and beef farming and more
recently opening its own milk processing plant.
What the treaty of Waitangi does for us in today’s world is
bring the relationship defined 150 years ago into today’s world.
Dr E Durie (2007), Mäori land Court Judge, states the Treaty’s
significance is in its position of securing a home for all peoples.
It situates the relationships between two people bigger than the
rights of any one group. Along with the building of relationships
he suggests comes the endeavour to see the world from others
eyes. The treaty then places obligations on both Mäori and
Pakeha to form partnerships that benefit the whole community.
New Zealander theme
I am also a descendant of a whaling and farming family. My
great great Grandmother, who was also called Jane came to New
Zealand on a sailing ship with her six children to meet up with
her husband who had already settled in the Wairarapa.
She and her sister in England had years of letter writing between
them many of which have been published (Holmes & Farley,
2006). She found the transition to settler’s life heart breaking.
She longed to see her family again.
Two worlds collide
I have described two worlds
one losing land the other
gaining land, one losing the
power to decide their future
and the other gaining more
power to do so, one losing
occupations associated with
a way of life, one bringing
occupations with them and one people becoming stronger and
the other becoming more unwell. How does this influence
whakaora ngangahau practise today and into the future?
We have a profession that affirms occupational justice. Some
of us have challenged the rest of us - kaiwhakaora ngangahau
to consider the impact of people being prevented, limited,
segregated, prohibited, alienated or marginalised from
participating in occupations of meaning (Carlsson, 2009; Iwama,
2006; Kronenberg, Algado, & Pollard, 2004; Kronenberg, Pollard,
& Sakellariou, 2011; Townsend & Wilcock, 2004). Others assert
that ‘listening to peoples stories’ gives us clues to the meaning
found in the occupation (Reed, Hocking, & Smythe, 2010).
Despite these strong attributes in our profession Mäori still do
poorly when accessing health services. We do not know how well
they do from whakaora ngangahau services as data is not specific
enough. At a national level disparities in our current health
statistics show that Mäori compared to the general population
have poorer health outcomes, mortality and disability rates. In
2006 it was estimated that when populations are adjusted 13%
of the non-Mäori population live with disability compared with
19% of Mäori and of those disabled Mäori, a further 61% have a
second disability (Office for Dissability Issues and Stastistics New
Zealand, 2010).
Western paradigms globally are recognised to have shaped
occupational therapy theory and practice and challenge to
reframe this in practice in non-western worlds has been heard.
It is with great enthusiasm that some practitioners from a nonwestern paradigm have reconsidered their practice but with their
own world view.
A concept that sits within our profession from the Western view is
the individualistic nature of us all compared to the interdependent
reality stated by Iwama (2007), and others (Kronenberg et al.,
2004; Kronenberg et al., 2011). Also challenged is the place of
independence in the profession (Busaidy, Najat Saif Mohammed,
& Borthwick, 2012; Hocking, 2012; Iwama, 2006).
Her occupations were based on survival and caring for her
family as they converted the land to a farm (Holmes & Farley,
2006). Her husband Samuel Oates brought the first mail over the
Rumataka range in a large wheelbarrow. He stopped for a drink
at the local pub in Greytown and while he was there one of the
seedling Eucalyptus trees he had was pinched by the local verger
(a relation by marriage of my husband). This tree was planted in
the local church grounds, not a great place to plant it, and it still
stands today to remind us of a different time with vastly different
occupations.
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We need to recognise and embrace people in their innate
diversity even when their diversity causes us to feel personally
challenged (Kronenberg et al., 2011). If we fail to do this we fail
to remain relevant. Within the Mäori world we have a concept
that reinforces interdependence. Whänau ora is seen as a Mäori
paradigm that reinforces the collective and interdependency of
those seeking services. It encourages practitioners to centralise
their practice in the family and community of the individual
seeking services. Central to this is belonging and the way the
New Zealand Journal of Occupational Therapy
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Frances Rutherford Lecture
Jane Huia Hopkirk, Dip OT, MPhil (Mäori studies)
community support one another. It is the belonging that is
essential to Mäori well-being (Carpenter & Sutherland, 2011).
Research shows that Mäori outcomes are enhanced when Mäori
practitioners are able to be matched with Mäori service users
(Durie, 2001). However, in Aoteroa we are a long way away
from reflecting the Mäori population in our profession. The
number of occupational therapists who are Mäori are 3% of the
registered practitioners (A. Charnock, personal communication,
June 11, 2012) contrasting to Mäori who are 15% of the general
population (Stastistics New Zealand, 2012).
Added to this picture is of the cultural capability of the few
Mäori kaiwhakaora ngangahau we have in the profession. The
process of colonisation has resulted in many losing their ability
to understand or speak their own language, know their own tribal
practices and beliefs, and engage in traditional occupations. Mäori
kaiwhakaora ngangahau reflect the Mäori population in that they
vary in identifying as being Mäori and having connections to
their whänau, land or spiritual roots. So we do not have many in
the profession brought up strong in the traditions and practices
of their hapü or iwi (Hopkirk, 2010).
I hold the hope that one day any Mäori will be able to access
whakaora ngangahau services that will meet their needs in three
ways. They will have:
1. good outcomes where the community of meaning is enhanced
because the service user is participating and contributing;
2. the choice of a Mäori practitioner; and
3. assessments and interventions provided from their world
view.
Clinical competence cannot be separated from culture. Culture
influences how behaviours and symptoms are perceived
understood and responded to, by both whänau and health
workers. Mäori culture is important to Mäori well-being. A
secure identity is a pre-requisite to good health. “Cultural identity
depends not only on having access to that culture and heritage, but
also on being able to express one’s culture and have it endorsed
within social institutions such as health services” (Durie, cited in
Te Rau Matatini, 2006, p. 51).
Table 1: Interviewee experience in Mäori services,
identification as Mäori and longest number of years
experience in occupational therapy.
In order to bring the ideas of this research together a framework
was presented to show the common views and an area of
development between a whakaora ngangahau view and a Mäori
view for the profession. The framework is illustrated by the use
of the whare or the place of meeting where sacred knowledge is
shared, and the spiritual and Mäori world is paramount. The
whare is symbolic of a human form and this framework uses the
front of the house. Traditionally the top of the framework is
the head and a significant ancestor of the people. Falling down
either side like the arms are included more carvings depicting
more pictures of further ancestors and the stories that made them
significant. This framework has a centre pole that is not found
in many whare but symbolises the central crucial concept and the
significant difference in view for working effectively with Mäori.
Culture means many things to people and a Mäori view from
an kaiwhakaora ngangahau assistant expressed it as the way we
collect food, the activities that filled play time, celebration of
family occasions, farewelling others to the next world, cooking,
fetching water, breaking rules, passing and retaining knowledge,
and relating or respecting others which all impact on the
relationship we have with service users day to day (Wilson, 2010).
Two worlds enhance
It is obvious there is significant need for research in occupational
therapy to strengthen cultural understandings for service users
and therapists who are Mäori. The emphasis of my research
was how culture impacted on practice. I engaged an initial 18
participants, of whom seven were Mäori followed by interviews
with five people.
12 Figure 1: Model of key themes from the research with
minor wording clarification (Hopkirk, 2010, p. 153).
The key component at the head of the model was the importance
of culture in practice. The four key concepts draped down the
two arms were client centred practice, spirituality, holistic models
of intervention, and the relationship with the environment. The
one significant to Mäori in particular was whänau family and
well families and communities. This view was not shared by New
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Zealand practitioners. Occupation and independence were not
recognised as significant terms to Mäori practitioners. Given this
framework is a guide to support effective service provision for
Mäori the Mäori view is highlighted.
Culture was shown to be significant with statements such as:
“Cultural perspectives are often central, whether recognised or not,
to a person’s involvement in occupation and the world around
them” (Participant 18). Mäori reported that:
Culture is a living entity made up of all the experiences from
home … contact with my whänau, discussions on iwi politics,
hui, waiata are all a part of my life and keep me close to my
Mäori cultural roots (Participant 15).
In line with Ramsden (1991) the significance we place on cultural
safe practice here in New Zealand was reflected in the research by:
Cultural perspectives are the lens through which I view my
practice. I am aware that another perspective exists and I
look for differences to ensure I am not assuming things for
clients. My own cultural perspectives help me feel confident
in my personal commitment to my profession and to my
responsibilities to people in my community. (Participant 15).
New Zealanders have noted that spirituality was part of a raft of
tools used and this was stated:
Spirit is unique – the life force – I can’t describe it, but it
drives all people the way we ‘do’. It is the fire within – what
you feed it will depend on what you do with it and feed
it. It is a journey, spirit, activity, meanings all combine.
(Interviewee A).
Wellbeing for Mäori is grounded in spirituality. Described as:
“Western cognitive interventions do not necessarily heal Mäori
spiritual issues. We need to see more recovery through the use of
healing the spirit. Link back to the land, to the beach – where Mäori
go to restore, to heal” (Interviewee B).
Another common perspective of client centred practice was seen
as an essential enabling skill: “If we are providing client-centred
practice then the cultural perspective of the client is essential to
recognise. Engaging people in the therapeutic processes means
engaging them from their perspective or the intervention won’t
be successful” (Participant 15).
A Mäori view was: “Tangata whaiora are the expert and this links
into the nature of the reciprocal relationship with occupational
therapists” (Interviewee B). Holistic indigenous models were
expressed by its link to pre-European times of: “Health was
joined by occupation and function and a holistic perspective”
(Interviewee C).
A New Zealand kaiwhakaora ngangahau view was: “holistic
approach and looking at the context the person is living/working
/playing within and how this influences meaningful occupations
for each person considering physical, emotional, spiritual, psycho
aspects of each person I work with” (Participant 8).
It is clear this therapist shares Durie (2003) holistic view:
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Indigenous peoples’ concept of health and survival is
both a collective and an ... inter­generational continuum
encompassing a holistic perspective incorporating four distinct
shared dimensions of life. These dimensions are the spiritual,
the intellectual, physical, and emotional. Linking these four
fundamental dimensions, health and survival manifests itself
on multiple levels where the past, present, and future co­exist
simultaneously. (p. 510).
The environment is a domain occupational therapy has the
opportunity to develop further in a way that no other profession
in my opinion can. We modify environments whether that
is physical, community or occupational to enable clients to
participate in activities of meaning for them. In the context of
a Mäori view it is the particular relationships with the physical
environment that is of significance. As a profession we are expert
at: “enabling occupations via increase of a person’s capability and
environmental accommodations” (Participant 17). Indigenous
practitioners expressed this as being and belonging: “connected
to nature and environment and land to sustain, to meet basic needs
– in flow. Your being was taken from around you” (Interviewee B).
What might be more useful to Mäori is the process of negotiating
with the environment prior to modifying it.
Whänau are crucial to a Mäori view and identified strongly by
all Mäori participants. This is the biggest opportunity for the
profession to use the family more effectively to enable wellness.
The relationship of the client to the family was seen as: “Mäori
want to be productive, participate and contribute to whänau, hapü
and iwi” (Interviewee E). Those who have passed away are often
still significant in the current context of the whänau as described:
“daily I have communication with my tïpuna” (Participant 15).
I believe as occupational therapists we have a considerable
resource to offer Mäori when they are on a journey to wellbeing.
If we can enable the whänau to support the recovery process using
our mutual skills together: them as the whänau specialists, and
us with our whakaora ngangahau skills then the outcomes for
Mäori are far more likely to be successful. This will not only lead
to a change for the individual but also a change for the family and
the community and therefore a very powerful enabler for all in
Aoteroa. A “Community which is participating and contributing
to community is
where whänau give
back to whänau
and
participate
in relationships.
It includes the
upholding
and
building of mana”
(Interviewee B).
In this speech today I have taken you on a journey in looking
back to look forward.
I have used some of the tools of my ancestors to highlight the
world view of Mäori. I have connected you to this place and some
of the struggle Mäori have engaged in over the years to retain
New Zealand Journal of Occupational Therapy
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Frances Rutherford Lecture
Jane Huia Hopkirk, Dip OT, MPhil (Mäori studies)
what is significant for them that of: land, occupations and health.
Durie (2005) stated that the rope that binds indigenous
peoples across the world is their common experiences of
having similar socio-economic positions, their fight to resist
assimilation, their aspirations for greater autonomy and their
often common experience of disease. This does not define them
nor does colonisation, socio-economic position or political
determination. The core factor that binds indigenous peoples is
a sense of belonging to the environment as stated by Mäori of the
Whanganui river: “People are the land and the land is the people.”
“We are the river, the river is us.” (p. 3).
The connection is further described by the intrinsic bond
between a people and their land and the opportunity this
profession has to use this to support adaptations that enable
participation in occupations that promote interdependent
relationships of significance to Mäori. We have seen occupation
in the link to land and health then becoming a determinant of
health (Carlsson, 2009). Woven through this discourse has been
the New Zealander view. As a profession we understand how loss
of occupations affects the health and well-being of the culture as
a whole and people within it and we know how restoration of
health and occupation go together.
Interviewee A stated that Mäori aspire to be:
able to live as Mäori, live - not die early, to be able to be full
citizens of the world with choice to choose a profession. Mäori
should be no more bounded or restricted than anyone else.
the land and the pain it caused him to be separated from it. This
amazing Mäori man with an awesome wairua has experience of
chronic homelessness and unmet health needs. He is currently
housed, connects to his environment through fishing and is well
on the way to having most of his health needs met. He said he
needs to go back to his land but that he will wait till he thinks his
life is nearly ended.
What will our descendants in the profession tell of our stories?
Will they depict us paddling to the deep as Maui did to pull a
new land into being with all the associated occupations it gives
opportunity too? Or will they show us travelling to the heavens
as Tane seeking knowledge to use in day to day life that has
meaning and value for those receiving it? Will you be in that
story? What will we as a profession do to empower Mäori to
live well participating in their families and communities in
meaningful ways to them?
Papakupu - Glossary:
Whakaora ngangahau – occupational therapy
Kaiwhakaora ngangahau – occupational therapist
Hapü – sub-tribe
Iwi – tribe
Karakia – prayer
Kaumätua – guides, to things Mäori
Mana – a supernatural force in a person, place or object, status
Tangata Whaiora – consumer advisors
Te Ao Mäori – the Mäori world view
Te Ao Päkehä – the settler world view
Tïpuna – ancestor
Waiata – song or singing
Whänau – extended family
Whänau ora – well families and communities
References
Mäori wish to be part of the flax rope; we don’t want two
ropes, but want to be visible and not excluded in the rope that
is Aoteroa New Zealand. Without a doubt whakaora ngangahau
in Aotearoa has a rope twisted together that includes Mäori and
New Zealand practitioners. Some of our understandings are
shared and could be further built on to strengthen the rope that
informs our practice, especially when working with Mäori and
supporting Mäori to work with Mäori, ideally.
Mäori theme
Recently I had a conversation with a man about where he was
from. We spoke of our connections to people and land. We
explored what being connected to the land meant and the work
that he had done in his early life to plant his land with trees. He
expressed being part of that place and being inextricably linked to
it. He spoke of his loss at not having being back there for many
years and his fear of the change that would have occurred in his
absence. He identified the link between his wairua or spirit to
14 Busaidy, Najat saif Mohammed A., & Borthwick, A. (2012). Occupational Therapy in
Oman: The Impact of Cultural Dissonance. Occupational Therapy International.
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Carlsson, C. S. (2009). The 2008 Frances Rutherford Lecture. Taking a stand for
inclusion: Seeing beyond impairment! New Zealand Journal of Occupational
Therapy, 56(1), 4-11.
Carpenter, K., & Sutherland, J. (2011). Weaving an understanding: Using the
experience of Harakeke Workshop to illustrate and find fit between occupational
therapy’s underlying philosophies and Mäori worldviews. Scope: Contemporary
Research Topics (Art & Design), Kaupapa Kai Tahu 1(November 2011), 44-49.
Durie, E. (2007). The Treaty Debate Series. Wellington: Radio New Zealand.
Durie, M. (2001). Whaiora (Second ed.). Melbourne: Oxford University Press.
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E rua ngä ao, kotahi te taura tangata: Two worlds and one profession
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OT Insight, 31, 15.
Volume 60
No 1
Postgraduate Study
We aim to meet all your postgraduate needs
wherever you are in the world!
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Select the courses that are relevant to you to create
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Clinical Reasoning
This course will provide students with new ways of understanding
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This course aims to provide both evidence based theory for effective
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foundation practical skills that therapists use to assist employees to
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Occupational Therapy in Primary and Population Health
There are significant opportunities for occupational therapists to
work within primary health. This course will help therapists position
themselves to provide such services.
Supervision for the Helping Professions
This course is designed to enable students to explore and critique
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to their own supervisory practice. Students will have an opportunity
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Specialty Practice
The aim of this course is to facilitate occupational therapists with
specialist experience to examine the diverse roles and responsibilities
of the specialist practitioner. Using examples from their practice and
exploring the relevant literature the course will enable therapists to
articulate and be more explicit about their specialist knowledge and skills.
Risk: An Occupational Perspective
Engagement in life has risks. This course will help occupational
therapists look at issues, legislation and processes associated with the
management of risk within a range of practice areas.
Negotiated Study
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New Zealand Journal of Occupational Therapy
15
Lena-Karin Erlandsson (PhD, O.T. Reg.)
VIEWPOINT ARTICLE
Fresh perspectives on occupation: Creating
health in everyday patterns of doing
Lena-Karin Erlandsson (PhD, O.T. Reg.)
I would like to thank the New Zealand Association of Occupational Therapists and the Scientific Programme Committee
for inviting me to present at this conference. It is an honour.
The theme of this conference is Fresh Perspectives and I will present three perspectives on maybe the most central
phenomenon for occupational therapists; namely daily occupations. My point of departure is my part of the world, a
Scandinavian and Swedish approach to occupational therapy practice, occupational therapy research, and education. I
present a view of the complexity of human occupation, from a time and doing perspective. The focus is how understandings
of the organisation and structure of occupations can be used to enhance health. I will address an occupation focused
intervention for women with stress-related illness, and where the knowledge can be used to enable participants to make
self-directed changes in their daily occupations.
Key words
Occupational balance, occupational therapy, life course, time use, intervention.
References
Erlandsson, L-K. (2013). Fresh perspectives on occupation: Creating health in everyday patterns of doing. New Zealand
Journal of Occupational Therapy, 60(1), 16–23.
The everyday is taken for granted
T
he starting point for this presentation is that if we understand
the complexity of everyday occupations and their various
relationships to health, we also know how to alter aspects of our
daily occupations in order to maintain and enhance health. The
everyday is made up of occupations, the things we do. In Sweden
we talk about the ordinary and grey everyday. The everyday is
like a road we travel, on our way to what is regarded as more
important or exciting, like the weekends or a holiday. The
everyday is often taken for granted but, with its predictability, it
constitutes a security and a structure that we can trust and rely
on.
We expect the everyday to float on in a steady pace, like the traffic,
when everything is working as it should. Much of the ill health
that currently exists in our societies is however, a consequence of
people’s lifestyles in their everyday not providing the balanced and
meaningful occupations they need; situations that may constitute
risks for illness and disease. For some individuals the everyday
can be too full of chores. Occupational imbalance might also
be due to lack of ability to organise the daily occupations or that
certain occupations take too much time. For others the opposite
might be true; that every day is like an empty road, with only a few
tasks and oceans of free time. For these people, the experience of
occasionally having a lot to do may be something that gives great
satisfaction. As well, there are groups in the society that have an
imbalance in their everyday lives caused by a shortage of things to
16 do, and people are denied a healthy variety of tasks because of, for
example, unemployment or functional limitations.
Usually, we do not think so much on how we are doing, when
and where, and why - our daily lives are in balance. In a way
we can be quite disrespectful towards everyday life and see it
as something that is always there. It is therefore not surprising
that the profession of occupational therapy (at least in Sweden)
often is regarded as common sense. We work with the ordinary
that everyone knows and takes for granted. The everyday life
is however, a phenomenon that many people think they know
everything about but few really understand the depth and
importance of it. It is in everyday life that the consequences of
sickness and injury become most obvious. An injury or illness
often means that the ability to manage everyday chores is lost or
reduced. The importance of being able to do what we usually do,
and want to do becomes so much more evident when the doing
Corresponding author:
Lena-Karin Erlandsson Associate Professor
Department of Health Sciences,
Lund University
Sweden
Email: lena-karin.erlandsson@med.lu.se
New Zealand Journal of Occupational Therapy
Volume 60
No 1
Fresh perspectives on occupation: Creating health in everyday patterns of doing
VIEWPOINT ARTICLE
Similar patterns
is no longer as doable as it was before.
This is why occupational therapists should be considered and
respected as a necessary profession in all health care areas. To
regain balance and routine in daily life, people need professional
support and guidance from expertise in people’s everyday
occupations.
But how do we investigate, define and handle balance among
the daily occupations in the everyday? As an occupational
therapist I see it as logical to call for occupational analyses and
more specifically it seems urgent to explore the organisation of
occupations in time.
Patterns of occupations in
three time perspectives
The occupations we do throughout life make up certain
individual patterns of occupations, the everydays are organised
in patterns of daily occupations, and in fact there is a specific
pattern or structure of actions building up each single occupation.
These three time perspectives are presented in the Value and
Meaning in Occupations Model (Persson, Erlandsson, Eklund, &
Iwarsson, 2001). The model is developed in our research group
with the purpose of describing and illustrating the complexity of
individuals’ occupational patterns and the values they hold. It
has turned out to be a useful model for analysing people’s doing,
in time.
A life course perspective
To explain the perspectives in the ValMO model I need a
new metaphor and I choose trees and forests. The first time
perspective in the ValMO model, the
Macro perspective, refers to a life course
perspective illustrating the changes in
the pattern of daily occupations over a
life span. If the daily occupations are
viewed as the creation of a tree (Figure
1), a child’s life perspective is like a
small plant. It has few branches and it is
formable. The tree grows with age and
the everyday becomes more complex; new
and different branches are added and the
tree becomes taller. The old tree gradually
loses branches and thereby complexity
and it also becomes more fragile.
If you look at a forest all trees may look the same. Likewise,
from a life course perspective, you can get the impression that
everyone does the same things, at the same time. For example:
at a certain time, around 12 o’clock most Swedes do exactly the
same occupation. The children at day care, at school and adults
at workplaces are all having lunch. This is true also for elderly
people since for example after retirement the pattern of daily
occupations is imprinted by the years in paid work and so the
rhythm is maintained (Björklund, Gard, Lilja, & Erlandsson,
2013) and of course lunch is served at 12 in elderly people’s
homes.
Aside from this detail we can conclude that changes in time use
over the life course are universal and that the main differences
in time use are instead between individuals in different ages,
life stages or family situations. This knowledge is based on time
use research from a number of countries (e.g. Zerubavel, 1981;
Singleton & Harvey 1995; Statistics Sweden, 2010). For this
presentation I thought it would be interesting to exemplify this
by looking a bit closer at time use in New Zealand and Sweden.
From the time use survey 2009/10 in New Zealand it was found
that women of working age spend an average of 4 hours and
20 minutes a day in unpaid work while men in the same age
group spend 2 hours and 32 minutes in these occupations. The
difference in time spent by males and females doing unpaid work
had narrowed slightly compared to the same measure 10 years
earlier; mainly because women in New Zealand have decreased
their time in indoor cleaning by 11 minutes (Statistics New
Zealand, 2011). In a corresponding time use survey in Sweden
2009/10 it was concluded that women
of working age spent 14 minutes less on
unpaid housework per day compared to
ten years earlier. (We Swedish women
have decreased our cleaning with 3 more
minutes than New Zealand women). It
was also concluded that Swedish men
spent slightly more, 11 minutes, than
before in the same group of occupations.
Altogether, Swedish women today spend
an average of 4 hours on unpaid household
tasks and the men do on average 45
minutes less (Statistics Sweden, 2010).
From this comparison we can conclude
that something is happening in both
The occupations dominating everyday
changes with ageing are different in
countries in mutual time use among men
and women of working age and who are
different life stages. Most children’s
daily patterns are dominated by play and
living with a partner. It seems that there
school occupations. In contrast, adults’
is a move towards more equally divided
The daily occupations through life can be
time in unpaid household work. Or,
of working-age have other and usually
viewed as the creation of a tree.
more occupations, often including paid
there seems to be another but similar
move: The same type of occupations, namely household
work occupations. With age, a decline in ability to perform
daily routine occupations may develop and self-care and rest
chores, seem to occupy less of the daily time among both men
occupations may take up a considerable part of the daily pattern
and women in working age, in the far north as well as in the far
the south of the globe!
of occupations among very old adults.
Volume 60
No 1
New Zealand Journal of Occupational Therapy
17
Lena-Karin Erlandsson (PhD, O.T. Reg.)
VIEWPOINT ARTICLE
The life stage perspective and health
The macro, life stage, perspective in the ValMO model relates to
the individual in relation to populations and different groups in
the society (like the trees in a forest) and it highlights similarities
between people, for example, in the same age groups. This
perspective on occupations in everyday at different life stages
helps us to reflect on an individual’s daily occupations in relation
to other people in the same life situation. This perspective for
occupational analysis can be connected to health issues: Our
repertoire of daily occupations is to a large extent imprinted
by social norms and phases in the society (Larson & Zemke,
2003). Thus, it might be of vital importance for a person to be
able to do what other people in the same life stage do. A person
may, however, be hindered from accessing a certain repertoire
of occupations because of ill-health and functional limitations,
or structural hinders such as for example unemployment or
language difficulties. Nevertheless, to be unable to have a daily
occupational repertoire that is similar to others with whom an
individual associates, is an example of occupational injustice
(Wilcock, 2006) and such a situation constitutes a considerable
risk for developing ill-health. Likewise to recognize the individual
stage in an occupational life-perspective, may guide occupational
therapists regarding what steps to take in the rehabilitation
process.
The everyday patterns of
occupations perspective
The second time-perspective in the ValMO-model is the mesoperspective. Going back to the tree metaphor it can be illustrated
by the branches on the tree. This perspective regards the daily
patterns of occupations. Each branch represents a day that in
turn and over time builds up larger branches. The day-branch
is filled with leaves; occupations that are placed in a certain
order. Here the complexity increases and even if there still are
similarities between our everydays this perspective contains a lot
of exciting dimensions!
The meso-perspective reflects the individual everyday doing
(Persson et al., 2001). Irrespective of where the individual is in his
or her life course, you can dive in to his or her everyday and you
will see a unique pattern of occupations. The time geographer
Professor Kajsa Ellegård (1999), stated that time is the most equal
resource we have; everyone has exactly the same 24 hours every
day, and the next day everyone gets 24 new hours.
Here it is important to recognise that not all people around the
world refer to clock time, hours and minutes. Some live in other
time contexts. There are people who regard the sun as a time
regulator, or who wait until it is the “right” time, whose doing
is regulated by the time of the year. In interviews with people
from Somalia living in Sweden we have for example learned that
scheduling appointments and phone calls referring to “tomorrow”
can mean approximately three days later, sometimes even longer,
but never exactly specified. It is important to consider that time
is not always the 24 hours that come every new day; measurable,
ordered and divisible into 60 minute intervals. Time can be
subjective but also shared within groups. However, clock time
18 is still the dominating perspective in existing research rooted in
industrialised societies. Accordingly, the everyday is measurable
and possible to record and there are several examples through
history of how people have documented and followed the flow
of every day.
The diary
The most common method for documentation of the daily
occupations is the diary. People have been writing diaries ever
since writing on paper was invented. The history of the diary
starts with handwriting and from the 13th century onwards.
The wealthiest men in Italy recorded everything from money
transactions to the military life (Johnson, 2011). In Sweden, the
earliest kept diaries are connected to agriculture and farmers who
in the 18th century began to keep records of their working days
to keep track of their harvests. Like many other things in history,
men are the dominating public diary writers. However, there is a
niche in the historical diaries describing the everyday life among
women living in the upper classes having very little to do and
thereby choosing to document their everyday life. I would like
to introduce lady Märta Helena Reenstierna whose diaries are
considered to be an important documentation of a duchess’s life
at a Swedish manor in the late 18th early 19th-century. She lived
with her husband at a relatively large estate with, among other
things, a tobacco farm (a climate that is unfortunately lost in
Sweden today). She had eight children and was writing personal
diaries from 1793 until she became blind in 1839. She herself
described her diaries as “… covering events in my little Sphere,
changes in weather, daily chores, visitors, trips, health and
indispositions, ... [translated from Swedish]” (Eriksson, 2010).
On the 20th of September 1818, almost exactly 200 hundred
years ago, she wrote:
Clear and lovely day – just a little wind. My work –
weekends as working days – is to write, read a bit and then in
the afternoon occasionally travel in to the town and do some
errands, those I cannot send someone else to do [translated
from Swedish] (www.facebook.com/pages/ÅrstafrunMärta-Helena-Reenstierna/118455131535351).
This glimpse of Märta’s everyday is an interesting comparison to
present day timelines that were recently introduced on Facebook.
This and additional new tools like the Twitter and Instagram
makes it possible for people to document their doing in time,
more frequently than ever and for everyone to share.
So what do diaries tell us? Around 300 years ago James Boswell,
a Scottish writer, stated that “I shall live no more than I can
record. I do not live more than I can register …” (Johnson,
2011). To me this is a very optimistic statement and I would
argue that documentation through diaries does not at all cover
the entire doing of human’s daily life. Ever since I started to
work as an occupational therapist in primary health care I have
been interested in the diary as a tool for investigating what
people do and to identify any problems or hindrances in the
areas of occupational therapy concern. To better understand
the connection between what people do on a daily basis and
New Zealand Journal of Occupational Therapy
Volume 60
No 1
Fresh perspectives on occupation: Creating health in everyday patterns of doing
relationships to their health we need to understand what people
actually do. Therefore, I used to encourage my clients to write
diaries. However, in reflecting upon my own doing I noted a
discrepancy between what my clients had recorded and what I
assumed they had actually been doing. What is missing and how
is this related to the client’s health issues?
The complexity in the everyday
In a case study (Erlandsson & Eklund, 2001), on one woman
working full-time, married and a mother of three children we
explored in detail her every day through self-reporting diary,
direct observation, video and experience sampling. The results
revealed a complexity of the everyday that I think is important for
occupational therapists to reflect upon. I will use the results from
this study and from the subsequent ones including 100 additional
Swedish women in the same life stage, to further explain the meso
and later the micro perspective on occupation as presented in the
ValMO model.
What we do forms patterns of occupations that, on a daily basis,
can be described as building blocks in the shape of all occupations
and sleep performed by one individual during one day and one
night, in 24-hour cycles (Erlandsson, 2003). The blocks of time
used for different purposes are related and more or less organized
in a certain order. Some occupations are located in time and
have to be performed before (or after) others. For example,
before you take the train you have to transport yourself to the
train station. When the train arrives at your final destination it is
a good idea to get off the train and then you can do the things you
planned to do there. What makes it more complicated is that we
do occupations in segments integrated with other occupations
such as calling home while on the train (to remind a son that it is
time to go to school). Thus, daily occupations are integrated and
the pattern is more or less complex and also to a varying extent
flexible and unpredictable.
Components of patterns of daily occupations
From the studies of the one woman’s doing it was concluded
that a pattern of daily occupations is dominated, in time and
awareness, by a few Main occupations (Erlandsson & Eklund,
2001). These are the occupations that we most often refer to if we
are asked what we did the day before. The main occupations are
the ones that from a population and life course perspective vary
with age, interests and context. From an individual perspective
I guess about 1-3 main occupations may dominate the day. The
occupations mentioned in the diaries by the Årsta lady; read,
write and do errands may be considered as her main occupations
that day.
Intertwined with the main occupations are the so-called Hidden
occupations (Erlandsson & Eklund, 2001). Hidden occupations
are important as they belong to, and are necessary for, the rhythm
of the daily pattern, but are performed in between the dominating
main occupations and with less attention from the performer. The
hidden occupations are what people do to be able to perform our
main occupations. Hidden occupations are the occupations that
are more or less forgotten or neglected when we reflect upon our
Volume 60
No 1
VIEWPOINT ARTICLE
daily life. We do grooming, get dressed, have breakfast and maybe
read the morning paper before going to work. We do some quick
errands during lunch, or read through the paper to be discussed
at a meeting in the afternoon, eat, drink coffee or tea and visit
the bathroom. In the evening, examples of hidden occupations
may be bringing in the mail, putting petrol in the car, buying
milk, or making a cup of tea. Hidden or forgotten occupations
are seldom, if ever, mentioned in the historical diaries. Similarly
and what is more important, the hidden occupations (since they
are performed with less attention and on a routine basis) are
often forgotten or missed in the diaries written by clients or not
detected through interviews.
Patterns of daily occupations also include a third category, the
unexpected occupations (Erlandsson & Eklund, 2001). Such
occupations occur unexpectedly in one’s regular pattern of daily
occupations and may interrupt the on-going rhythm of main and
hidden occupations. The unexpected occupations are sometimes
generated from positive events and can bring joy and happiness.
For example if you and some colleagues at work suddenly and
unplanned decide to go and visit a local fair during the lunch hour.
However, there are a significant number of unexpected events
that may interrupt and disturb a daily pattern and thereby may be
experienced as negative, such as a flat tire on the car or a missed
bus in the morning when you are on the way to work. Unexpected
situations like these force you to change the anticipated, or
expected plan for the day and to engage in occupations that are
suddenly necessary to cope with the situation at hand.
Finally, there is a fourth building block in the patterns of daily
occupations namely sleep. Sleep is a prerequisite for the ability
to participate in occupations during the waking hours but may
also be interrupted by hidden or unexpected occupations that,
in the long-term, can constitute a risk for ill health. The mesoperspective focuses on the 24 hour patterns of daily occupations
that are dominated by main occupations, accompanied with
hidden occupations and sometimes interrupted by unexpected
occupations. In order to be able to perform these occupations,
the patterns also include a significant number of hours of sleep.
The patterns of daily occupations and health
What about relationships between these patterns and health?
First, I would like to highlight the importance of the interplay
between the building blocks of occupations in the patterns. The
relationship between main and hidden occupations may change
and thereby have a considerable impact on subjective health and
wellbeing. Remember, the main occupations were identified as
dominating in time and awareness. However, when a person
experiences functional limitations in any way, things he or
she used to do on a routine basis, and perhaps automatically,
suddenly demand more attention and time. For example, it
takes longer and is harder to get up in the morning, get dressed
and have breakfast. Thus, what used to be hidden occupations
now demands both time and attention and most likely becomes
the new main occupations. In turn, there is less time left for the
occupations that used to dominate; the occupations we want and
need to do at home, at work and during our free (spare) time.
New Zealand Journal of Occupational Therapy
19
Lena-Karin Erlandsson (PhD, O.T. Reg.)
VIEWPOINT ARTICLE
The interplay between main
and hidden occupations
As a young woman, Sarah was traumatically injured and now
lives with a remaining tetraplegia. After months of rehabilitation,
she was once again living on her own and considered to be
independent with personal assistants, in no need of more
rehabilitation. However, despite the successful rehabilitation she
lacked wellbeing. Research has established that an impaired body
as a result of a spinal cord injury impacts greatly on the ability to
engage in desired daily occupations (Whalley Hammell, 2007).
Thus, what used to be routine occupations in daily life now takes
both more time and more energy. In talking to Sarah, it seemed
that using the terminology of building blocks in patterns of daily
occupations made her aware of the change between main and
hidden occupations in her every day. She realised that one of the
key consequences of the accident was that she had lost several
of her previous main occupations; the occupations that used to
affirm her as a creative person, a woman and a friend. She now
strived to handle the maintenance of herself and her home and
had very little time for almost anything else. The terminology of
main and hidden occupations and reasoning about their internal
relations helped Sarah to make changes in her pattern to limit
the time for some of the previously hidden occupations in favour
of important occupations to be reintroduced and given time as
main occupations.
Thus, the change in time use in different types of occupations;
to change the relationships between the building blocks of
occupations may impact on health and wellbeing. The power
of occupations lies in its impact on health – disorganisation of
occupations can lead to ill-health but the same occupations can
be re-organised and thereby promote wellbeing. To me this is
a central issue of great concern for occupational therapists. It
is important to reflect on the pattern of daily occupations that
develop in a rehabilitation process, discussion might reveal a
new perspective. What are the new main occupations? What
used to be this individual’s main occupations? Can a new main
occupation in the daily pattern be taken out, replaced, or maybe
altered to become hidden, in favour of full or segments of a
previously valued main occupation?
The impact of unexpected occupations
We also know from the subsequent empirical studies on
working, cohabitating mothers with children in pre-school
age that the unexpected occupations impact on well-being
(Erlandsson & Eklund, 2003). My co-researcher and I compared
patterns of daily occupations, i.e. diaries transferred to time and
occupation graphs, for 100 women, according to their complexity
(Erlandsson, Rögnvaldsson & Eklund, 2004). The occupations
reported in the diaries were coded into the categories of main,
hidden and unexpected occupations. The results of the analysis
showed that women who were more often interrupted in their
main and hidden occupations by unexpected events and hassles
reported lower subjective health than women experiencing fewer
unexpected interruptions (Erlandsson & Eklund, 2006).
risk factor for ill-health. In parallel, opportunities to perform full
occupations in an order that is, to some extent, predictable seem
to be of importance for health. Interruptions in occupations at
workplaces may impact on subjective health and even lead to
illness. For example, an administrative assistant who was the
closest co-worker to the manager for a company reported that she
could almost never do what she had planned to do when at work.
She was constantly interrupted and directed towards new and
unpredictable tasks. As a result she had developed a routine of
staying late, and working on weekends, in order to maintain her
ordinary work-tasks. I met her when she had developed a stress
related illness. When the woman understood what impact the
interruptions and unexpected occupations had on her health and
why, she secured an agreement at her workplace that when her
office door was closed others should not disturb her. As a result,
she could regulate her work day so that she had some designated
time to complete her ordinary tasks during work hours.
The single occupation perspective
To further understand why and how the unexpected
interruptions have such a negative impact on health, we need
to explore the third time perspective in the ValMO model; the
micro-perspective, regarding the pattern that develops within
each single occupation. Referring to the metaphor we now focus
on individual leaves.
The micro perspective in the ValMO model describes the
sequence of actions building up to a single occupation. An
occupation is the outcome of a person performing a task in a
context (Persson et al., 2001). The individual takes on a task
and, when doing it, it becomes an occupation. Each unique
performance of an occupation means a unique set of actions
(Erlandsson & Eklund, 2001). Thus, each performance of an
occupation is unique depending on the mood and capacity of the
individual; the way the task is performed; and where and when
it is carried out. To cook dinner in the evening may be stressful
due to limited time, you may be tired and hungry, there may
be lack of groceries and family members may be irritated and
not participating. Another day the same occupation may give
a completely different experience and outcome. You may have
everything you need, know what to do and have enough time.
The family may take the opportunity to spend time together.
The same occupation in the same environment and engaging the
same individuals may give very diverse experiences.
Furthermore, the sequences of actions in the specific performance
of an occupation may be more or less interrupted and the way
an occupation is performed, the sequence of actions, impacts
on the experience making it unique to each single performance.
This explains why it is hard to argue that some occupations may
be more health promoting than others. There are occupations
that are assumed to be fun or relaxing, like going fishing on a
weekend. This may very well be as expected but if your phone
rings frequently when you are out fishing you may end up talking
in the phone instead of fishing. The interruptions to the action
sequence impact on the experience of the occupation and if
Thus, interrupting occupations in the daily pattern seem to be a
20 New Zealand Journal of Occupational Therapy
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Fresh perspectives on occupation: Creating health in everyday patterns of doing
the occupation is frequently interrupted, chopped into small
sequences of actions, there is a risk that the pleasure of doing
may be lost. From empirical studies we know that it is important
for subjective health not to have too many interruptions in
everyday occupations and to be able to do what we intend to do
(Erlandsson, Björkelund, Lissner & Håkansson, 2010).
Occupational perspective in intervention
So far I have concluded parts of my research on patterns of
daily occupations, its inner complexity and given examples
of how circumstances and handling of aspects of the everyday
may constitute risk factors for ill-health. My wish is that
the perspectives in the ValMO model and the complexity in
theses perspectives will give you some ideas of how to analyse
clients’ everydays. But, what then? Occupational therapists are
becoming more and more skilled when it comes to assessment
and analyses but I would like to take the opportunity to highlight
the importance of keeping the occupational perspective following
interventions and coaching of clients.
If the issues a client is dealing with are grounded in a need for
re-organisation of daily occupations the effort required can be
summarized in various forms of lifestyle, or rather, everyday
changes. An occupational therapist is a central resource in
such a process of change initiating, supporting, and guiding the
individual in his or her own everyday change. The goal is to
create or retrieve a repertoire of occupations that enhance the
experience of health. Additionally, an important part of our
efforts is to prevent individuals’ patterns of daily occupations
from being characterized by alienation, deprivation or overload.
The Redesigning Daily Occupations
(ReDO) programme
I have developed an occupational therapy program aimed at
providing knowledge about daily occupations and their impact
on health (Erlandsson, in press). I introduce it here as an
example of an educative approach for occupational therapists.
In the ReDO programme, occupational therapists act as coaches
to support learning about occupation. The group leaders use the
perspectives in the ValMO model and research on patterns of
daily occupations to facilitate occupational self-analysis among
the group participants. Understanding the complexity in and the
influence of occupation may enable sustainable changes in the
everyday and patterns of daily occupations that promote health.
The ReDO-program has been evaluated for the rehabilitation
of women with stress-related ill-health and it has for example
been shown to improve return to work rates when compared
to a control group (Eklund & Erlandsson, in press). We also
know from interviews of participating women that accomplished
the ReDO-program that it was found meaningful and useful
(Wästberg, Erlandsson & Eklund, in press). The program is
manual directed and currently we are trying to establish evidence
for the method through various projects. It is being evaluated in
primary health care in Sweden, foremost for women with high
complex patterns of daily occupations. We are evaluating it in
a health preventive program among employees in elderly home
health care and it is being tested in a work rehabilitation project
for immigrants on long term unemployment. In some years
from now, I also hope to have results from health care sectors in
New Zealand.
To implement changes in everyday life may be a long, and often
We are social
hard, process. It can also be about change in very different
proportions. For some it is sufficient
for a limited period of time, to do a little
different, or do less. For others, it is about
changing the entire daily life and adapting
oneself to the new conditions, to learn
new tasks, to perform old occupational
patterns in a new way, or to be separated
from important occupations. Based on
my experience of meeting students at
the university, colleagues in different
settings and foremost from meeting
people in different life situations I have
concluded that the intricacies of daily
occupations; their temporal order and
structure, how they are experienced and
why, are complex and not at all common
knowledge. Therefore it is useful in process
of changing the everyday, to depart from
a knowledge base that is communicative,
between colleagues, other professions
but foremost that enables the client to Humans are social beings that live and act
understand his or her everyday and what together, like trees in a forest.
needs to be changed.
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New Zealand Journal of Occupational Therapy
beings
Being almost at the end of this
presentation I have to admit that so far
I have focused on the individual’s daily
patterns. However, humans are social
beings and therefore I have to alert
a last specific challenge with change
and reorganisation of pattern of daily
occupations related to that fact that
humans live and act together, like trees in
a forest (Figure 2). The occupations one
person chooses to perform often affect
others. For example, workplaces often
require coordination and teamwork,
and these requirements influence the
occupational patterns of everyone in
a workgroup.
Similarly, members
of the same family will influence the
occupational patterns of each other.
Because their actions and routines are
linked together, their different schedules
must be taken into account, and
competing time requirements must be
coordinated or synchronized.
21
Lena-Karin Erlandsson (PhD, O.T. Reg.)
VIEWPOINT ARTICLE
Thus, family members may share time together as well as divide
available time between each other (Orban, et al., 2012). The
social coordination of daily occupations has been defined by
Larson and Zemke (2003) as complex, concerning individuals’
routines and competing desires and needs. It is unusual that a
change in one individual’s pattern can occur without affecting
others’ patterns and this may, in turn, mean a barrier for change.
Even if we want and need to change our daily lives it may be
difficult because others do not want to or can see what they, in
turn, need to change. This is an important aspect of complexity
that is not always addressed. Understanding and recognising the
social coordination of patterns of daily occupations is however
important in planning intervention since the progress and
outcome of a process of change is highly dependent on the social
context in which individuals participate. It is important for
occupational therapists to also include related persons, friends
and colleagues in the change process; to enable others to help,
rather than hinder. In the ReDO programme we have included
a session where the participants invite people close to them to
a seminar presenting the complexity in daily occupations and
relationships to health with a focus on how the social context can
support desired and needed changes in an individual’s pattern of
daily occupations.
Conclusion
In this presentation I have presented my view on daily
occupations. They are the building blocks that make up complex
patterns in the everyday that in turn constitute our occupational
life history. I have
given examples of
how situations or
characteristics
of
this complexity may
constitute risk factors
for ill health but also
how alterations may
enhance recovery and
wellbeing. Patterns of
daily occupations are
something to recognise
and respect.
For
some individuals the
absence of needed and
desired occupations
(main, hidden as well
as unexpected) in the
everyday is evidently
causing ill-health.
Some individuals may experience absence of
needed and desired occupations, like a tree
Individuals that are
with no leaves.
denied access to what
they want and need
to do may as a consequence gradually develop a situation that
implies an even greater challenge in their strive towards regaining
22 a meaningful and health bringing repertoire of daily occupations.
Furthermore, there is a risk that the few occupations that are
accessible are risk occupations such as smoking or exaggerated
alcohol consumption. Referring to the tree metaphor; to ensure
occupational justice means enabling healthy leafs to once more
grow on the branches (Figure 3).
We also have a responsibility to ensure that individuals that
experience his or her tree as taken over by the jungle, i.e. having
a too complex and chaotic everyday, get support to weed and
maybe even re-plant in a new context, in a new way. This is true
for individuals as well as for groups in the society. Just as there
are individuals with unhealthy patterns of daily occupations
there are groups that are having similar problems.
The occupational therapists’ tool in this challenge is the very
same daily occupations. In this presentation I have tried to
emphasize the power that lies in the understanding of how daily
occupations are organised, how they impact on our wellbeing
and, if they are brought to light, how they can be handled and
organised.
Key points
n
n
n
n
n
n
The same occupations may generate very different experiences
which could be healthy or unhealthy;
When working with health issues related to everyday
occupations it is important to carefully explore the pattern and
content of the daily occupations since there are both hidden
and unexpected occupations that are likely to be overlooked
or missed in diaries written by clients or detected through
interviews. That is, occupations that might have significant
impact on the experience of health and wellbeing;
Re-organisation of daily occupations can enhance health.
Enabling self-directed change in patterns of daily occupations
is effective.
A desire to change aspects of daily life may be hindered by
individuals or groups who do not want, or do not understand
the need for change.
Involving people close to the person in need of change to daily
life process is encouraged.
I hope that my contribution to knowledge in New Zealand
will empower existing practice and support you in claiming
professional power. There are clear relationships between daily
occupations, health and people; groups, and individuals benefit
from understanding the complexity, and power, of the everyday.
Acknowledgement
The presentation is a conclusion of some of my current and
previous research and I therefore want to especially acknowledge
colleagues who have contributed to the research, Professor Mona
Eklund and Assistant professor Dennis Persson.
New Zealand Journal of Occupational Therapy
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Fresh perspectives on occupation: Creating health in everyday patterns of doing
References
Björklund, C., Gard, G., Lilja, M., & Erlandsson, L-K. (in press). Exploring and
visualizing patterns of daily occupations among elderly people living in the
north of Sweden. Journal of Occupational Science.
Eklund, M. E., & Erlandsson, L-K. (in press). Quality of life and client satisfaction
as outcomes of the Redesigning Daily Occupations (ReDO) programme for
women with stress-related disorders: A comparative study. Work.
Ellegård, K. (1999). A time-geographical approach to the study of everyday life
of individuals: A challenge of complexity. Geographic Journal, (48), 167-175.
Eriksson, K. (2010). Inblick i en dold värld: Årstafruns dagböcker [The diaries
of the Årsta Lady]. Populär Historia, (7), 48-52.
Erlandsson, L-K. (2003). 101 Women’s pattern of daily occupations. Characteristics
and relationships to health and well-being. PhD Dissertation, Lund University,
Lund, Sweden.
Erlandsson, L-K. (2013). The Redesigning Daily Occupations (ReDO)Programme: Supporting women with stress-related disorders to return to
work: Knowledge base, structure, and content. Occupational Therapy in
Mental Health, 29:1, 85-101.
Erlandsson, L-K., & Eklund, M. (2003). The relationships of hassles and uplifts
to experience of health in working women. Women & Health, 38(4), 19-37.
Erlandsson, L-K., & Eklund, M. (2001). Describing patterns of daily occupations:
A methodological study comparing data from four different methods.
Scandinavian Journal of Occupational Therapy, 8(1), 31-39.
Erlandsson, L-K., Eklund, M. (2006). Levels of complexity in patterns of daily
occupations in relation to women’s well-being. Journal of Occupational
Science, 13(1), 27-36.
Erlandsson, L-K., Rögnvaldsson, T., & Eklund, M. (2004). Recognition
of similarities (ROS): A methodological approach to analysing and
characterising patterns of daily occupations. Journal of Occupational Science,
11(1), 3-13.
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Erlandsson, L-K, Björkelund, C., Lissner, L., & Håkansson, C. (2010). Women’s
perceived frequency of disturbing interruptions and its relationship to selfrated health and satisfaction with life as a whole. Stress & Health: Journal of
the International Society for the Investigation of Stress, 26(3), 225-232.
Johnson, A. (2011). A brief history of diaries. London: Hesperus Press.
Larson, E. A., & Zemke, R. (2003). Shaping the temporal patterns of our lives:
The social coordination of occupation. Journal of Occupational Science,
10(2), 80-89.
Orban, K., Ellegård, K., Thorngren-Jerneck, K., &, Erlandsson, L-K. (2012).
Shared patterns of daily occupations among parents of children aged 4-6
years old with obesity. Journal of Occupational Science, 19(3), 241-257.
Persson, D., Erlandsson, L.-K., Eklund, M., & Iwarsson, S. (2001). Value
dimensions, meaning, and complexity in human occupation: A tentative
structure for analysis. Scandinavian Journal of Occupational Therapy, 8(1),
7-18.
Singleton, J., & Harvey, A. (1995). Stage of life cycle and time spent in activities. Journal of Occupational Science, (20), 522-672.
Statistics Sweden (2010). Swedish time use survey 2010. In S. Sweden (Ed.).
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Whalley Hammell, K. (2007). Quality of life after spinal cord injury: A metasynthesis of qualitative findings. Spinal Cord, 45(2), 124-139.
Wilcock, A. (2006). An occupational perspective of health (2nd ed.). Thorofare:
Slack Incorporated.
Wästberg, B., Erlandsson, L.-K., & Eklund, M. (in press). Client perceptions
of a work rehabilitation programme for women: The Redesigning Daily
Occupations (ReDO) project. Scandinavian Journal of Occupational Therapy.
Statistics New Zealand. (2011). Time Use Survey: 2009/10. Wellington: Author.
Zerubavel, E. (1981). Hidden rythms; Schedules and calendars in social life.
Chicago: The University of Chicago Press.
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New Zealand Journal of Occupational Therapy
23
Frank Kronenberg
VIEWPOINT ARTICLE
Doing well-Doing right TOGETHER:
A practical wisdom approach to making
occupational therapy matter
Frank Kronenberg
Abstract
The readers are invited on a full circle journey of what I hope to be ‘Märamatanga Hou—Fresh Perspectives’ of occupational
therapy…looking anew at, or valuing, and appreciating our profession differently. I will start by situating myself, offering
an account of a diversity of experiences that shaped this paper’s views, arguments and proposals. Next, an ‘occupational
diagnosis’ of our world and the profession will be conducted, addressing the questions: ‘how are we (as a world) doing?’
and ‘how are occupational therapists doing in response?’ which points to the need to find innovative ways to raise our
and society’s occupational consciousness (Ramugondo, 2012). A practical wisdom approach to making occupational
therapy matter is then explored. This involves a critical reflexive analysis of values and power, aimed at increasing our
capacity and that of individuals, organizations and society to foreground thinking and acting in value-rational vis-à-vis
instrumental-rational (theoretical and technical knowledge) terms. Dominant, traditional perspectives of occupational
therapy will be juxtaposed against emergent, alternative views of how, as health agents, occupational therapists can
contribute to society’s responses to global-local socio-sphere and eco-sphere challenges. Possible applications of a
practical wisdom approach will be illustrated through three examples of collective occupations-based practices from
Europe and Africa. I close with some reflections on the paper’s title ‘Doing Well-Doing Right TOGETHER’ and offer a
21st Century interpretation of the late Dr. Mary Reilly’s oft-quoted hypothesis upon which our profession was founded.
Key words
Phronesis, humanity, occupational consciousness, collective occupations, occupational justice.
References
Kronenberg, F. (2013). Doing well-Doing right TOGETHER: A practical wisdom approach to making occupational
therapy matter. New Zealand Journal of Occupational Therapy, 60(1), 24–32.
W
hen invited via SurveyMonkey to share how we had
experienced the conference, without intending to
romanticize the event, what stood out for me was the gathering’s
embeddedness in the context of Mäori culture and tradition.
It opened with the Pöwhiri—the ritual ceremony of welcome/
encounter involving speeches, dancing, singing and hongi, a
traditional Mäori greeting, which is done by pressing one’s
nose and forehead at the same time to another person at an
encounter, during which the ‘ha’ (or breath of life) is exchanged
or intermingled (Himona, 2006); the conference featured the
first ever Mäori Frances Rutherford Lecturer—Jane Hopkirk;
its AGM members voted that the association would also have a
Mäori name—Whakaora Ngangahau Aotearoa, which translates
as ‘Occupational Therapy New Zealand’; it bestowed special
honors, manaaki (support) and taonga (treasure), pounamu
(greenstone) toki pendants for all the keynote speakers; and it
closed with the Poroporoaki—the farewells/goodbyes which
incorporated reflections of the event, the good and the bad
(Maori Dictionary, 2013). The sense I got from the honouring
moments and the presence of the Mäori elders who led these
cultural rituals/ceremonies throughout, is that they allowed
24 the gathering to transcend beyond being a mere professional
conference centered on furthering professionals’ interests. It
became a space for Mäori, Päkehä (New Zealanders of European
descent) and international delegates to connect with what might
be considered occupational therapists’ ultimate purpose, i.e.
understanding and practicing ‘doing well—doing right together’.
Introduction
In line with Mäori tradition, and appreciative of the
anthropologist Lila Abu-Lughod’s (1991) stance “that every
view is a view from somewhere and every act of speaking, a
speaking from somewhere” (p. 141), the ‘Märamatanga Hou—
Fresh Perspectives’ that I am sharing in this paper are informed
significantly by a diversity of ‘somewheres’, as the following
account of my personal history will illustrate. These will be
Corresponding author:
Frank Kronenberg
Email: frank.kronenberg@gmail.com
New Zealand Journal of Occupational Therapy
Volume 60
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Doing well-Doing right TOGETHER: A practical wisdom approach to making occupational therapy matter
presented in three ‘stages’, each highlighting discoveries or
lessons learnt, not those taught at school or gleaned through
books but through living in and engaging with the world.
Personal history in three ‘stages’
1964 – 1985: I was born in 1964 in the Netherlands’ catholic
south as the oldest of four siblings of World War II survivors
Theo and Nelly Kronenberg. Both hailed from baker families and
had continued the tradition of putting food on our family’s table
by providing others with ‘daily bread’. Our customers included
people who lived and worked in my hometown’s large mental
health institutions which back then were largely run by catholic
orders, such as the Sisters of Saint Joseph, the Ursuline Sisters
and the Franciscans (OFM). Every now and then missionaries
visited my primary school to present their ‘development projects’,
through which I gained my first significant exposure to peoples
in other parts of the world who appeared, spoke, ate, lived
differently from us and who seemingly where in need of some
help with ‘getting their lives on track’. After graduating at age
19 from teacher’s training college, I considered myself to be too
young and inexperienced to be entrusted with the responsibility
to prepare ‘little human beings’ for life and living in the big
world. I felt that I needed to find out about this ‘bigger world’ up
close and personal, travel and work abroad a bit, immerse myself
in what I would today call an ‘experiential diagnosis of how our
world is doing’. For example, I felt a kind of push to explore the
origins and meanings of what was commonly referred to as ‘first,
second, third and even fourth world’, whilst it appeared to me
that as people we seem to be inextricably bound together by the
habitat we occupy. Mainly instilled by my parents’ upbringing,
one of the lasting discoveries during my first 20 years of life is that
humans cannot do without each other.
1986 – 1995: Although I didn’t mean for this journey to last
almost a decade, that is how it unfolded. I lived, worked, and
travelled in different regions of the world, engaging in so called
‘developed’ and ‘developing’ contexts. In very broad strokes, these
experiences included a kibbutz in Israel; healthcare, education
and community development initiatives in Nepal, Pakistan and
India; attending to the needs of children and adults with physical
disabilities and youth-at risk in New Jersey and New York; and
engagements with so called ‘street children’ in Mexico City.
VIEWPOINT ARTICLE
therapy in the Netherlands but was unhappy with what might
be considered as the (then) depoliticized condition of our
profession’s original activist-social vision (Frank & Zemke,
2008), which attracted me to it in the first place. With Salvador
Simó Algado, a like-minded colleague from Spain, I founded
what is today called a movement: ‘occupational therapists
without borders’. It produced a number of international ground
breaking publications (Kronenberg, Pollard, & Sakellariou, 2011;
Kronenberg, Simo Algado, & Pollard, 2007; Pollard, Sakellariou,
& Kronenberg, 2008), through which, perhaps not surprisingly,
I also met my wife and mother of our two daughters. Together
we are committed to making South Africa home. Besides being
involved with Shades of Black Works, Grandmothers Against
Poverty and Aids, and Isango Ensemble (see websites), I have
embarked on a PhD in occupational therapy/occupational
science at the University of Cape Town.
I now wish to return to the aforementioned notion of ‘home’,
given that it required to be given new meaning. A large portion
of the Netherlands is located below sea level, and the fight with
water and reclaiming land from the sea (first documented in 1533)
has dominated its history (Kazmierczak & Carter, 2010). The
Netherlands is often popularly referred to as Holland, ‘the land
of tulips, wooden shoes, cheese and windmills’. But, it is also the
birthplace of Jan van Riebeeck, who was appointed by the Dutch
East India Company (VOC) to establish a refreshment station
at the Cape. His landing in April 1652 marked the irreversible
beginning of the end of indigenous cultures, of their ways of
organizing society and of knowing. It has even been claimed that
Van Riebeeck may have opened up the floodgates for the total
colonization of independent political entities and free people
(South African History Online [SAHO], 2013a). Another native
of the Netherlands was Henrik Verwoerd, who later became the
Prime Minister of South Africa, but who in world history will
most likely be remembered for being the creator of apartheid
(SAHO, 2013b).
The overall sense I got from ‘how we are doing as a world’ was
that ‘whilst seemingly waging war against itself and the planet,
humanity is struggling on to keep alive what makes us human’.
I then wanted to better understand this ‘human condition’ and
learn what it may take to bring out ‘the best’ and ‘prevent the
worst’ that humans are capable of. This need basically ‘pulled’
me back to the university.
Frankly speaking, I never imagined that one day, I would have
my own family and commit to making home, the same land
that the Dutch natives Van Riebeeck and Verwoerd (among
others) had left with intended and unintended consequences of
almost four centuries of colonization and 46 years of apartheid
law (1948 – 1994). However, helped by the words of the South
African based Trinidadian author Ronald Suresh Roberts,
today home has to do with “where you feel that what you do
matters, and I think that to be part of what South Africa [must
do] matters for everyone in the world” (Matabane, 2005). In
other words, I believe that if all who live in South Africa were to
commit to learning to live ‘Doing Well—Doing Right Together’,
then everyone in the world can.
1995 – 2012: The aforementioned intense and rich years
prompted me to seek further formal training and to ‘put into
some kind of order’ all that I had experienced. That is when I
found my ‘conceptual home’ - ‘human occupation for health’,
which appreciates the complex relationship between doing and
wellbeing. I graduated with a bachelor’s degree in occupational
During the keynote I attempted to invite the audience to this
particular interpretation of ‘home’ by showing them a family
picture, featuring makhulu, our live-in aunt-grandmother, our
daughters Masana Nelly and Isha Tshiala, my spouse Elelwani
and myself. The delegates may as well have been looking at their
own and each others’ families, also identifying three generations.
Volume 60
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New Zealand Journal of Occupational Therapy
25
Frank Kronenberg
VIEWPOINT ARTICLE
However, the ‘somewhere’ where this family picture was taken
tells a particularly different story than if let’s say it would have been
taken in the Netherlands, my place of origin. Less than 20 years
ago, the apartheid law Prohibition of Mixed Marriages Act No
55 of 1949, prohibited marriages between Whites and members
of other racial groups (SAHO, 2013c). Therefore, back then that
picture was impossible. And although today it is possible, that
does not automatically mean that all those who live in South
Africa are equally comfortable with this reality. For example,
early on in our marriage (2006-2007), we had experienced direct
contrary responses to our ‘mixed race family’. In public spaces,
the Sea Point Promenade and the Century City mall, local South
Africans ‘who looked like Elelwani’ approached us expressing
approval of what they saw, commenting that ‘it gave them hope’
and that ‘things can change’. At another moment, local South
Africans who ‘looked like me’ confessed after a few bottles of
red, that they struggled to come to terms with what they saw, not
because they were not happy for us, but because of the strong
emotions (guilt, shame, rage) triggered by childhood memories
of daily reminders by parents, church, school, etc. that a mixing
of the races would not be good. Elelwani and I met and married
out of love and discovering a ‘goodness of fit’ of shared personal,
professional and political values. It was a deliberate choice to
raise our family and to commit to making occupational therapy
matter in post-apartheid Cape Town, South Africa. This requires
us to remain conscious of and to learn how to best respond to the
still divided, wounded, violent, dehumanized and dehumanizing
condition of post-apartheid South Africa (Adu-Pipim Boaduo,
2010; Ramphele, 2012; Tutu, 2011), being sensitive to the reality
that our mere presence may evoke different reactions from
possibly differently wounded people.
Occupational diagnosis: ‘How are we
doing: World & occupational therapy?’
I acknowledge that the following reference may only work in
English, the international lingua franca. If we stop and think
about it, does the mundane question that is asked every day all
over the world–‘how are we doing? - not embody the premise
of an occupational perspective of health in the broadest sense of
the word? After all, it does not straightforwardly enquire about
what people are doing, but it is based on the seemingly taken for
granted interrelationship between what we do and our wellbeing.
If we were to then project this question on our world or humanity
as a whole and then hold it against the light of how occupational
therapy is doing in response to an occupational diagnosis of our
world/humanity, what might we then find?
The ‘diagnostic instrument’ we employed to answer the first
question ‘How is our world doing?’ was a video-clip of a unique
‘glocal’ interpretation of the classic Bob Marley songs ‘War/
No More Trouble’. It was conceived, put together and posted
as ‘Song Around the World’ on YouTube in 2009 by the NGO
Playing for Change (see Websites). To date it hosted more than
10 million visitors and received over 8,000 comments! A review
of a couple of hundred of the comments posted by people from
different walks of life from all over the world yielded the following
26 ‘occupational diagnosis’… our contemporary world seems to be
‘hungry’, ‘thirsty’ for opportunities that allow: A) experiencing
a deeper sense of belonging; and B) contributing meaningfully
to the well-being of others. Interestingly, these findings resonate
with the first two discoveries that I highlighted in my personal
history. Might this be an indicator that the individualistic
tendencies that characterize our contemporary world seem to
be spiraling out of control? One could almost regard these as
embodying another strand of ‘apartheid’, dividing and pitching
each and every human being against each other and making them
compete for supposedly limited resources, pushing everybody to
be better and stay ahead of the next person, be they individuals,
families, organizations, communities, countries, and/or regions.
Among other social ills, ‘individualism in overdrive’ seems to be
failing us, it is failing humanity and its habitat!
Let us now occupationally diagnose ‘How is occupational
therapy doing in response to how our world is doing?’ For this
we employ Cohen’s anecdote, which Sandra Galheigo used to
start off her closing keynote at the 2010 WFOT world congress in
Santiago de Chile (Galheigo, 2011):
A man is walking by the riverside when he notices a body
floating down stream. A fisherman leaps into the river, pulls
the body ashore, gives mouth to mouth resuscitation, saving
the man’s life. A few minutes later, the same thing happens,
then again and again. Eventually yet another body floats
by. This time the fisherman completely ignores the drowning
man and starts running upstream along the bank. The
observer asks the fisherman: ‘What on earth are you doing?
Why are you not trying to rescue this drowning body?’ ‘This
time’, replies the fisherman, ‘I’m going upstream to find out
who the hell is pushing these poor folks into the water’.
After citing this anecdote, Sandra meaningfully paused, and
she then pointed out to a worldwide audience: ‘Some of us find
themselves attempting to rescue drowning bodies from the river.
More of us should also be doing that. But this is no longer enough.
Occupational therapists have an ethical-political responsibility to
also commit to understanding ‘upstream’ structural conditions
that produce and perpetuate social ills that manifest downstream’
i.e. social determinants of health (World Health Organization
[WHO], 2008). I would like to extend this analogy by proposing
that it seems to be called for, to go even beyond ‘upstream’, to the
origins of the river, to the source of what in-deed [pun intended]
makes us human, to learn where, when, how we might be losing
(sight of) this as life flows (away) from the source.
Evidenced by a steady production of position papers (Diversity
and Culture, 2010; Environmental Sustainability: Sustainable
Practice within Occupational Therapy, 2012;
Human
Displacement, 2012; Human Rights, 2006) and a commitment
to translate these mandates in the minimum standards that are
currently undergoing revision (anticipated year of publication
2014), the World Federation of Occupational Therapists
(WFOT) seems to underscore Galheigo’s (2011) reminder of our
ethical-political responsibilities. Take for example the following
excerpt from the WFOT position paper on Human Rights, which
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identifies “six global conditions that create barriers to human
occupation: poverty; disease; social discrimination; armed
conflict; natural disasters; forced displacement” (WFOT, 2006,
p. 1). Informed by the bakery milieu in which I was raised, I
understand this mandate as valuing ‘human occupation for
health’ simply as ‘the other daily bread’, which is as fundamental
to people’s health and wellbeing as eating, drinking, belonging
and loving (Kronenberg, 2012a).
into knowing: when and how to make the exception to every
rule; when and how to improvise. Real world problems are
often ambiguous and ill-defined, and the context is always
changing. Practical wisdom is exercised as jazz musicians
play music, using the notes on the page, but dancing around
them, inventing combinations that are appropriate for the
situation and the people at hand. It is also about knowing
how to use the moral skills in pursuit of the right aims.
The argument presented here is, that central to the issue of access
to health-promoting occupations is the capability for individuals
and collectives to influence their own unfolding occupational
narratives (Ramugondo, 2012). Therefore, the process of making
occupational therapy really matter, that is for our profession
to become socially, culturally, economically, politically
relevant and accessible to people from all walks of life, seems
to require occupational consciousness: an ongoing awareness
of the dynamics of hegemony, an appreciation of the role of
personal and collective occupations of daily life in perpetuating
hegemonic practices, and an appraisal of resultant consequences
for individual and collective well-being (Ramugondo, 2012).
Occupational consciousness calls for tapping into sources of
knowing that move beyond the purely theoretical analytical and
technical. A practical wisdom approach to making occupational
therapy matter is proposed. This approach involves an in-depth,
reflexive analysis of how particular sets of values and power
interplay in what we are doing/not doing with and to ourselves
and others in our everyday lives and how this influences our
health and our responsiveness, or lack thereof, as occupational
therapists.
This kind of knowing what ought to be done, speaks to Galheigo’s
call for occupational therapists to be more (pre)occupied by our
ethical-political responsibility, that is, exercising a ‘concern with
what is good or bad for Man and Planet’ (Aristotle, 1976).
A practical wisdom approach to
making occupational therapy matter
Aristotle believed that everything had a telos, that is its aim,
purpose, or maximum potential (Aristotle, 1976). What if we
were to identify as the telos of occupational therapy, contributing
to advancing understandings and practices of ‘doing well-doing
right together’, attempting to overcome ‘so what’ perceptions of
occupational therapy’s traditional roles juxtaposed against how
our world and humanity is doing as a whole?
Drawing from the self-identified phronetic social scientist Bent
Flyvbjerg (2001), a practical or situated wisdom approach to
making what we do as occupational therapists matter would
aim to balance instrumental rationality [theoretical and applied
scientific knowledge] with value-rationality by increasing the
capacity of individuals, organizations and society to think and
act in value-rational terms (Flyvbjerg, 2001). By focusing on
values, Flyvbjerg pointed out, occupational therapists must
face the question of foundationalism versus relativism, that is,
the position that central values exist that can be rationally and
universally grounded versus the view that one set of values is just
as good as another. Instead, Flyvbjerg (2001) suggested:
This paper does not allow for a thorough exploration of practical
wisdom, but I intend to offer what may serve as an introduction,
to trigger or feed your imagination of such an approach to
making occupational therapy matter.
What is practical wisdom? According to Aristotle (1976),
practical wisdom is the most important of the three intellectual
virtues that he identified: episteme—scientific knowledge;
techne—applied knowledge or know-how; and phronesis—
practical knowledge or wisdom. Wisdom refers to knowledge
about things that matter (Glossop, 2003). John Bradshaw (2009)
described practical wisdom as the ability to do the right thing,
at the right time, for the right reason, which resonates with
Aristotle’s shorthand definition ‘the combination of moral will
and moral skill’.
In his TED talk (see websites) “The loss of wisdom” Barry
Schwartz (2009) shared:
A wise person is made, not born. Wisdom depends on
experience, and not just any experience. You need the time
to get to know the people that you are serving. Practical
[or applied or situational] wisdom feeds the moral will to
do right by other people, and beyond this, the moral skill to
figure out what doing right means. This translates practically
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we are to reject both and replace them by contextualism—
situational ethics: a practical wisdom approach holds that
the socially and historically conditioned context—and not
the rational and universal grounding—constitutes the most
effective bulwark against relativism and nihilism. We
must realize that our sociality and history is really the only
foundation that we have, the only solid ground under our
feet. (p. 130)
The following classical Aristotelian value-rational questions
(the ethical dimension) and the added inquiry about power and
outcomes (the political dimension) may help us with exercising
a practical knowledge approach (exercising our ethical-political
responsibility) to making occupational therapy matter, engaging
in a critical reflexive analysis of values and power (Flyvbjerg,
2001):
Where are we going?
Who gains and who loses and by what mechanisms of
power?
n Is it desirable?
n What should be done?
n
n
The first question resonates with our proposed core concern
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‘how are we doing?’. The second question interrogates the
inclusiveness (or lack thereof) of the ‘we’ and how this may be
structurally maintained. Held against a telos of ‘doing well-doing
right together’, the third and fourth questions push us to find out
and negotiate in the particular situated contexts in which we find
ourselves and what might be the right thing(s) to do in order to
bring about and sustain ‘doing well together’.
Inspired by Flyvbjerg’s (2001) contemporary reading of
Aristotle’s phronetic or practical wisdom approach relating
explicitly to a primary context of values and power, the
following table juxtaposes dominant traditional versus emergent
practice’ (Kronenberg, Pollard, & Ramugondo, 2011, p 11).
Occupational therapists ought not to allow themselves to be
too preoccupied with ‘what is not’ but instead get occupied
with ‘what is not yet’, seeing and helping others and society to
see possibilities beyond limitations, and contribute to (social)
change from there. This ‘seeing’ cannot be taught, it is a frame
of mind and a value that is to be derived largely from personal
experience in and with the world.
Next we will get a glimpse of three implementations of a
practical wisdom approach to making occupational therapy
matter, i.e. advancing ‘doing well-doing right together’. All three
can be appreciated as concrete examples
Table 1
of collective occupations-based practices,
that is: “Occupations that are engaged in
Juxtaposing dominant versus emergent
by individuals, groups, communities and/
occupational therapy perspectives
or societies in everyday contexts; these may
Dominant traditional perspectives
Märamatanga Hou - fresh perspectives
reflect an intention towards social cohesion
or dysfunction, and/or the advancement or
• Occupational therapy = Monoculture
• Occupational therapies = Ecology of
aversion to a common good” (Ramugondo
occupation-based practices
& Kronenberg, 2013, p. 17). Each example
• Human occupation as an object
• Human occupation as a subject
will offer some insights in why and how
“All the ordinary and extraordinary things that
“Humans are occupation” (Guajardo &
the initiatives came about, which allows
people do every day” (Hocking, 2003)
Kronenberg, 2013); “Embodied and/or enacted
for how inferences of value and power
humanity” (Kronenberg, 2012b)
rationalities informed and guided decisionHuman occupation manifests on a continuum of
‘benign’ and ‘malignant’, a transactional interplay
making on what needed to be done.
of factors pertaining to agency and structure
(Kronenberg, 2012b)
Examples of collective
• Western/Judeo-Christian ontologies/
epistemologies
• Ontologies/Epistemologies of the ‘South’
Privileging worldviews, knowledges, ways of
knowing from the European and North American
metropole (Connell, 2007, Kantartzis & Molineux,
2010)
• Inclusive of plurality and voices - arguing
for a more democratic global recognition of
worldviews and knowledges from the peripheries
of societies within and outside the European and
North American metropole (Connell, 2007)
• Apolitical
• Political
• Medical Model
• Social Determinants of Health
• Therapy—focus ‘treating patients’
• Therapy—focus ‘healing relationships’
• Evidence: Empirical (EBP)
• Evidence: Multiple methods
• Individualistic (‘doing well)
• Ubuntu (‘doing well together’)
• Institutional or private practices
• Health promotion, Community-Based
Rehabilitation
• Neoliberal healthcare market
• Alternative ‘sustainAbilities’
Public (government) and private health insurance
Social entrepreneurship
Invitation-based practices: working for and
through public, business or civic society sector
organizations, not (necessarily) as ‘occupational
therapists’, but carrying out occupation-based
practices in response to the needs at hand.
Märamatanga Hou—fresh perspectives of occupational therapy.
There also seems to be a goodness of fit between a practical
knowledge approach and the proposal that ‘Occupational therapy
is essentially a possibilities-based practice, which generates
practice-based evidence and complements evidence-based
28 occupations-based practices
from Europe and Africa
Project Miquel Martí i Pol,
University of Vic, Catalonia – Spain
Concerned about the social and
ecological challenges of contemporary
Europe, Salvador Simó, professor at
the occupational therapy department
of the University of Vic, in Catalonia,
Spain, (simply) brought a group of his
occupational therapy students out to a
fence on the sidewalk that overlooked an
abandoned space of the campus. He then
asked them to describe what they saw. A
bit puzzled by this unusual situation, they
looked at the vacant plot and summed up a
number of negatives: ‘weed’, ‘dead trees’,
‘trash’, ‘used needles’, ‘a dead cat’, ‘a useless
plot’. When one of his students returned
the same question to him, Salvador replied:
I see the unfolding story of transforming
the sad space that you described into a
place of beauty, a communal garden…involving not only
you and me but also inviting the people who are on our city’s
sidewalks but who we seem to habitually overlook or ignore,
survivors of mental health, poverty, immigration, (forced)
displacement. (personal communication, 27 May 2008)
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This is how the Project Miquel Martí i Pol originated. It
integrates health, education, research, and poverty alleviation
(Simo, 2011). It can also be regarded as a collective occupation
(Ramugondo & Kronenberg, 2013) that brings together and
meaningfully engages differently situated persons (people living
with mental health issues, people who are displaced, students)
and multiple stakeholders (university, city council, business
sector, civic society organizations, European Community).
The project makes effective use of a variety of (social) media
to communicate its achievements and challenges to the larger
society, part of their commitment to make visible and educate
society about the value and potential of excluded people: they
are citizens who are contributing to society (Simó, 2011). The
project also recreates the university as a school for democracy
and citizenship, generating knowledge that matters, i.e. how
meaningful engagement in collective occupations can foster
spiritual, social, mental and physical wellbeing, and contribute to
cultivating inclusive communities and citizenship, and alleviation
of poverty. The art of politics and partnerships is central to the
process, linking the social-health sectors with the economic and
educational sectors. The goal is to create a society based on the
values of justice, equality, freedom, active respect and solidarity
(Simó, 2011).
To illustrate how various participants’ experiences in the project
cultivated their practical wisdom, here are some testimonies:
A civic sector partner: “The university should help the society to
avoid dying (from indifference). If the term university only implies
knowledge, it wouldn’t serve anything” (Simó, 2011, p. 362). One of
the gardeners: “I am known by more people in Vic in two years than
in 15 years in Centellas [a municipality in Catalonia] …the garden
helped me to enter the community” (Simó, 2011, p. 362). A City
Council representative: “To maintain well-being, it’s important
to take account of the public and the Third Sector’s powers, as these
strategic alliances are indispensable” (Simó, 2011, p. 363). And
from a student who was enabled to look beyond the diagnoses
and to discover the person and his or her potential: “Each of them
has shown excellent potential for humanity, generosity, sympathy,
commitment, friendship” (Simó, 2011, p. 362). And the garden
has been a place to encounter the ‘Other’: “It made me see the
world from the other perspective; from the point of view of those
socially considered as the “others” (Simó, 2011, p. 362).
Grandmothers Against Poverty
and Aids (GAPA)
According to the 2012 UNAIDS World AIDS Day Report, an
estimated 5.6 million people were living with HIV and AIDS
in South Africa in 2011, the highest number of people in any
country (UNAIDS, 2012). In the same year, 270,190 South
Africans died of AIDS-related causes. Although this number
reflects the huge amount of lives that the country has lost to
AIDS over the past three decades, it is 100,000 fewer deaths than
in 2001, demonstrating the many lives that have been saved
through a massive scale-up of treatment in the last few years
(UNAIDS, 2012). The reality that oftentimes remains hidden
behind such statistics is that many thousands of gogos (isiXhosa
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for ‘grandmothers’) who have lost their children to AIDS are now
sole providers for their grandchildren. Although traditionally,
grandmothers in Africa have cared for grandchildren, it has
not been without financial and emotional support of their
children. Overwhelmed by their plight, in 2001 a few gogos and
an occupational therapist, Kathleen Brodrick, came together to
form a remarkable organization called Grandmothers Against
Poverty and Aids (GAPA).
In her own words, Kathleen Brodrick succinctly captures the
core philosophy of occupational therapy which also serves as the
ethos underlying GAPA’s programs:
Everybody is capable of healing themselves, and by healing I
mean getting on top of their problems, so it’s through activities,
such as: doing something concrete, or learning something, or
supporting someone or being supported, through these kind of
activities you can be healed and you can have a good quality
of life. (GAPA promotional video, 2005)
How did GAPA come about? Kathleen explained:
In 2001 I was contracted by the Institute of Aging in Africa,
which is a department at the University of Cape Town, to
run some workshops for grandmothers who were heads of
households where Aids was feature. And halfway through
the workshops, the grandmothers started to wonder what
would happen once the workshops had finished. And it was
very much a case of me saying to them “what do you want to
happen to you?” And they said it’s been so successful, that
they actually would like to teach other grandmothers. So I
said “Fine, how are we going to do that?” Ten grandmothers
and Kathleen worked out how to become a Non Profit
Organization and that was it. (GAPA promotional video,
2005)
The GAPA programs include: Educational Workshops—
focusing on practical topics such as nursing skills and HIV/
AIDS, tuberculosis, parenting skills, vegetable gardening, human
rights and abuse, bereavement, business skills, drawing up wills
and how to access government; Support groups—emotionally
vulnerable grandmothers are recruited by grandmothers who are
known as area representatives to join the support groups that they
run in their homes once a week; Income Generation—handicraft
items that are wanted by their communities are made and sold
within the township and to visitors; Pre-school bursaries—
allowing the grandmothers to send their young grandchildren to
a safe and stimulating environment whilst having some time to
themselves; Aftercare—an enrichment program for vulnerable
children who attend the local primary school. Here home work is
supervised, the children are fed and a choir has been formed. The
grandmothers also teach English literacy, tell traditional stories
and teach traditional songs.
In July 2009, GAPA hosted a group of local and international
delegates as part of the ‘Occupational Justice’ Symposium and
Think Tank at the University of Cape Town, an experience
to which we will return at the end of this paper. After having
been introduced to GAPA’s gogos and its programs, all of us
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collectively engaged in vivacious song and dance, during a brief
pause, Vivienne Budaza, GAPA’s executive director, proudly
affirmed: “This is life at GAPA…no time for self-pity…no time at
all for depression” (personal video-recording 10 July 2009), after
which she involved all of us in more song and dance.
When listening to the gogos’ life stories, one is struck by the
multiple-level challenges they had and have to overcome. The
South African photojournalist Eric Miller captured this in the
GAPA honouring exhibition ‘Amatsha Ntliziyo’, colloquially
translated ‘The Nevergiveups’, highlighting the pro-active
resilience that the grandmothers display in dealing with the
circumstances in which they find themselves (see websites). As
with Vivienne’s affirmation, what again shines through is how
GAPA effectively taps into the healing powers of collective
occupation, wherever and whenever the heavy burdens of
everyday life have simply become too much to be carried by
anybody alone.
Isango Ensemble, Cape Town – South Africa
As shared earlier in this paper, although post-apartheid
South Africa is approaching its 20th anniversary (2014), it
remains a deeply divided, wounded, violent and to some
extent dehumanized and dehumanizing society (Adu-Pipim
Boaduo, 2010; Ramphele, 2012; Tutu, 2011). It has crafted
what is widely regarded as one of the world’s most progressive
constitutions (Government Republic of South Africa, 1996), but
the realization of its principles into everyday life conditions that
allow South Africa to truly be called home by all people who live
in it, continues to present as a tremendously complex challenge.
Taking this on requires everybody’s concern and commitment
and contributions…from where each is best positioned and
enabled to contribute.
The Cape Town based South African (opera and) theatre
company Isango Ensemble is committed to creating theatre that
is accessible to all South Africans and to contributing to a more
united South African society. Although its stage productions and
films have played to sold-out audiences across the world, and
received widespread critical acclaim and international awards, it
continues to struggle to build a home, an audience and support
in South Africa. In November 2011, Isango Ensemble performed
‘Magic Flute’ in honour of Arch Emeritus Desmond Tutu’s
80th anniversary, after which he expressed his appreciation in
an email: “Thank you too for proving apartheid so abominably
wrong. You have helped restore our faith in ourselves. Fantastic.”
(personal communication, 3 October 2011)
Isango Ensemble draws its artists mainly from the townships
surrounding Cape Town. Isango’s productions re-imagine
classics from the Western theatre canon, finding a new context
for the stories within a South African or township setting
thereby creating inventive work relevant to the heritage of the
nation. The company’s structure embraces artists at all stages
of their creative development, allowing senior artists to lead and
contribute towards the growth of rising talents.
Isango Ensemble’s Actor Patron Sir Ian McKellen identified a
30 distinguishing feature of how this company impacts its audiences:
‘Isango Ensemble is different...linking high art to the humble
lives of its astonishing performers.’ (see websites)
Viewing Isango Ensemble’s opera and theatre work through
the transdisciplinary conceptual lenses of ‘occupational
consciousness’ (Ramugondo, 2012) and ‘collective occupations’
(Ramugondo & Kronenberg, 2013) allows one to discover their
potential as a vehicle or avenue for restoring, (re)building, (re)
humanizing a society that suffers from historically damaged
human relations. I have been privileged to work with them in
the capacity of development director, assisting with building and
maintaining a home, an audience and (other) support networks.
All that we learn from this ‘collective (occupation) arts-based
practice’ can then be shared with and beyond occupational
therapy and occupational science audiences at universities and
conferences worldwide.
‘Doing well—Doing right together’:
Contemporizing Mary Reilly’s 50 year old
adage
We are now close to coming full circle on the ‘Märamatanga
Hou—Fresh Perspectives’ of occupational therapy journey of this
paper. Before presenting some closing thoughts, I will share the
experience that resonated with the enacted values that made
the 2012 NZAOT conference stand out for me, that is, how
it honoured Maori cultural traditions and language and the
sustained presence and participation of Maori elders.
As mentioned earlier, in July 2009 in Cape Town, South Africa,
a symposium and think tank took place at the University of Cape
Town (UCT) which explored ‘The relevance of an occupational
justice perspective in Africa and beyond’ (Kronenberg &
Ramugondo, 2011, pp. 202/203). It was co-hosted by UCT’s
Occupational Science Research Group and the International
Society for Occupational Science (ISOS). Its participants,
besides local, continental and international occupational therapy
and occupational science educators, researchers and students
also included young adolescents from ‘Facing Up’ (Joubert,
Galvaan, Lorenzo & Ramugondo, 2006) and a few ‘gogos’ from
Grandmothers Against Poverty and Aids. Not only did they
actively engage in the discussions and host us to their programs,
respectively in the township communities of Lavender Hill
and Khayelitsha, their presence as ‘non occupational therapists’
enriched the gathering with two additional generational
perspectives and kept the professionals ‘in check’, and
accountable regarding what was discussed and how it was shared.
The proceedings needed to speak to them, to their everyday
lives and the realities of their communities. In other words, for
occupational therapy to matter, it needed to (also) capture their
imagination and support.
Perhaps the most significant outcome of this unique two day
gathering was the moment when one of the ‘gogos’ at the very
beginning of the symposium asked in her mother tongue isiXhosa,
“What does that big word on the screen, ‘occupational justice’
mean?” Although at that time we could have cited a number
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of working definitions (for example by Townsend & Wilcock),
given that these would have to be translated into isiXhosa and
seemed to be rather abstract and theoretical, the truth was that
none of the occupational therapy professionals present seemed
prepared to respond to the gogo’s sincere fundamental question.
So what happened? We basically ‘copped out’ and left it up to
Vivienne Budaza, GAPA’s executive director (who accompanied
the ‘gogos’ and assisted us with translations and interpretations)
to respond. You must know, she is not an occupational therapist,
but has over the years developed a special appreciation (practical
wisdom?) for the ways the occupational therapists at GAPA think
and work. Remember our earlier exploration of a ‘practical
wisdom approach to making occupational therapy matter’,
experience seemed to be the source that Vivienne drew from
when, after a brief pause of thinking on her feet, she offered the
following response to the gogo: “Mama, occupational justice
means all of us doing well with you…doing well together.” All
the gogos, sitting at the first row in the auditorium, nodded,
indicating: “That makes a lot of sense” …prompting us that we
ought to carry on with the symposium.
It can be argued that in his Foreword in ‘Occupational Therapies
without Borders: Towards an Ecology of Occupation-Based
Practices’ (Kronenberg, Pollard & Sakellariou, 2011), the
South African Nobel Price laureate, Arch Emeritus Desmond
Tutu also endorses a practical knowledge approach to making
occupational therapy matter: “As occupational therapists you
have a significant contribution to make [to the world]…be inspired
by Vivienne Budaza’s explanation of ‘occupational justice’ as ‘doing
well together’, allowing people from all walks of life to contribute
meaningfully to the wellbeing of others.”
Drawing to a close, a practical wisdom approach to making
occupational therapy matter may require us to become (more)
mindful of all that humans do and not do (!) with and to
themselves and each other on an everyday basis, as it manifests on
a continuum of affirmations and negations of our humanity, and
as such may have implications for our health. Therefore, some
50 years after her 1961 landmark Eleanor Clarke Slagle lecture
(Reilly, 1962), remembering and standing on the shoulders of a
giant who passed away on 28 February 2012 at the impressive age
of 95, I wish to offer a 21th-Century interpretation of the late Dr.
Mary Reilly’s oft-quoted hypothesis upon which our profession
was founded—“Man, through the use of his hands as they are
energized by mind and will, can influence the state of his own
health” (Reilly, 1992): “Women, men, and children, through
joining hands, as they are energized by mindfulness and political
will, can influence the journey of their spiritual, social, mental
and physical wellbeing.”
Kia ora!
Acknowledgement
This paper is a modified version of the keynote presented at the
26th NZAOT Biennial Conference ‘Märamatanga Hou—Fresh
Perspectives’ on 20 September, 2012 in Hamilton, Aotearoa/
New Zealand. This privilege happened to coincide with the 6th
birthday of our oldest daughter Masana Nelly.
Volume 60
No 1
VIEWPOINT ARTICLE
Special note: After honoring Mount Fuji at WFOT 2014, please
allow me to extent a warm welcome to you to join the world at
the foot of Table Mountain at WFOT 2018 in Cape Town, South
Africa.
Websites
Social Determinants of Health (WHO) – www.who.int/social_
determinants/en/
Shades of Black Work – www.shades-of-black.co.za/
University of Cape Town – www.health.uct.ac.za/
Project Miquel Martí i Pol – jardimiquelmartipol.blogspot.
com/
Grandmothers Against Poverty and Aids – www.gapa.org.za/
Isango Ensemble – www.isangoensemble.org.za/
Playing for Change – http://playingforchange.com/
War/No More Trouble/Song Around the World –
www.youtube.com/watch?v=fgWFxFg7-GU
Barry Schwartz: Our loss of wisdom – www.ted.com/talks/
barry_schwartz_on_our_loss_of_wisdom.html
GAPA ‘The Nevergiveups’ (Eric Miller) – www.youtube.com/
watch?v=qUOUjmw3hgc & http://thenevergiveups.wordpress.
com/
Links to Radio New Zealand interviews
www.radionz.co.nz/national/programmes/oneinfive/
audio/2544535/one-in-five-for-27-january-2013
www.radionz.co.nz/national/programmes/artsonsunday/
audio/2538129/south-african-theatre-company-isango
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The AEC changing table is a
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Fax: 06 326 9383
Email: changetable@aec1989.co.nz
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New Zealand Journal of Occupational Therapy
Volume 60
No 1
Occupation for public health
FEATURE ARTICLE
Occupation for public health
Clare Hocking, PhD, Professor of Occupational Science and Therapy
Abstract
Occupational therapists are re-engaging with an occupational perspective of health. At the same time, outside
the profession, concepts of health are shifting, with three key ideas given increasing credence: that health is largely
determined by social factors, that health can be measured by what people do, and that health is a fundamental human
right. Occupational therapists are challenged to look beyond quality interventions to the societal factors that create
health and ill-health, and discrepancies in access to health. That agenda demands working with the poorest poor,
indigenous people and those subject to discrimination, to develop strategies that will change their health status and by
bringing knowledge of the health-giving power of occupation to the public health arena.
Key words
Occupation, health and well-being, human rights, social determinants of health, ICF.
Reference
Hocking, C. (2013). Occupation for public health. New Zealand Journal of Occupational Therapy, 60(1), 33–37.
Introduction
O
ccupational therapists’ passionate belief is that the things
people do in their everyday lives are the foundation of
health and well-being. Generations of occupational therapists
grounded that belief in humans’ biological capacities – the muscles
and neurones that give us movement; the mental functions that
empower the capacity to think, feel, and communicate. To
inform our work, we learned anatomy, physiology, the medical
sciences and psychology. Indeed, that knowledge base was
‘enshrined’ in the Minimum Standards for the Education of
Occupational Therapists, first adopted in 1952 (WFOT, 2002).
Alongside the ‘hard’ sciences, we acknowledged the spirituality
that enlivens humanity – each individual’s capacity for creativity
and transformation, the human potential to overcome adversity
and reach for our dreams. But knowledge moved on.
An occupational perspective of health
Over the last two decades, there has been much discussion
amongst occupational therapists of the paradigm shift in how we
understand, explain and practice occupational therapy. We look
back at the practice of the 1960s and 1970s, and perceive it to be
mechanistic; overly focused on the components of occupational
performance and the number and intensity of repetitions needed
to improve function. We now understand that we bought into
the reductionism that characterizes a biomedical view of health
(Kielhofner, 2004), neglecting the original insights of the founders
of the profession – that occupation, in itself, is transformative and
health-giving when people engage fully in what they are doing.
Spurred on by scholars such as Mary Reilly, who called on the
profession to refocus on occupation, the tide is slowly turning.
Reilly’s work at the University of Southern California inspired the
development of the profession’s first comprehensive explanation
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of people’s engagement in daily activities; Kielhofner’s Model
of Human Occupation (Kielhofner & Burke, 1980). Those
beginnings opened the door for occupational science, which
recognised the urgent need to establish a scholarly knowledge of
occupation to inform the profession. Betty Yerxa, Ruth Zemke
and Florence Clark were the primary architects of that programme
of scholarship, which was primarily aimed at occupational
therapists. In Australasia, the idea of occupational science took
a broader view of occupation for the health of the population at
large. Ann Wilcock, based at the University of South Australia,
and Liz Townsend, at Dalhousie University in Canada were
particularly influential in New Zealand. Their work, informed
by a social perspective of health, alerted us to the negative health
consequences of being deprived of access to a health giving range
of occupations and to the injustices experienced by marginalised
people in all societies.
Inspired by those ideas, an occupational perspective is now
embedded in the 2002 revision of the World Federation of
Occupational Therapists’ Minimum Standards for the Education
of Occupational Therapists. The impact of that paradigm shift
is still reverberating through the educational programmes,
practice and research of the profession. However, while we have
Corresponding author:
Clare Hocking
Department of Occupational Science and Therapy
Faculty of Health and Environmental Sciences
Auckland University of Technology
Auckland
Email: clare.hocking@aut.ac.nz
New Zealand Journal of Occupational Therapy
33
Clare Hocking
FEATURE ARTICLE
been engaged in a radical overhaul of the ‘occupational’ part
of occupational therapy, the ground on which ‘therapy’ stands
is also being challenged by new concepts about the nature and
causes of health. I will argue that there is a second paradigm
shift occurring outside of the profession that will challenge
occupational therapists to pay more heed to the contexts in
which health is created.
Shifting concept of health
I will outline three ‘seismic’ shifts. These are that:
n
Health is primarily determined by social factors
n
The measure of health is what people do and become, and
n
Health is a fundamental human right.
I will go on to consider what it might mean to have an
‘occupational perspective of health’ in a context where place,
politics, the economy, society and culture are recognised to be
the key drivers of the health people create in their everyday lives.
I will conclude with a vision of occupational therapists as leaders
in public health, people with something useful to say about
prolonging life and promoting health for all, not just those with
a health condition.
Viewing health from the perspective of its social determinants
‘shakes up’ established understandings of the cause and course
of illness. To understand just how radical that perspective is,
it is useful to set it against the prevailing biomedical view. The
medical model of health came to prominence at a time when the
prevalent health concern was deaths from infectious diseases
- scarlet fever, typhus, cholera, consumption (tuberculosis),
lockjaw (tetanus) (Carter, 1988), along with polio and flu
epidemics. Initial breakthroughs were in discovering vaccines
and antibiotics. Scientific methods, which involve “analysing
and describing a complex phenomenon in terms of its simple or
fundamental constituents” (Oxford, 2012), were pivotal in those
advances.
Limitation of the medical view
The First and Second World Wars gave impetus to further medical
breakthroughs, including enormous advances in rehabilitation
from illness and injury. Scientific evidence confirming the link
between cardiovascular disease and cancer and lifestyle factors
such as diet, exercise and smoking were also significant because
that knowledge points the way to managing and reducing the
incidence of the prevalent chronic illnesses of our time – cancer,
stroke and heart disease. That accumulated medical knowledge is
immensely important to preserving and restoring health.
But it is only part of the picture in relation to understanding
health. For example, even with all the knowledge gleaned from
decades of research, medicine cannot arrest the increase in
diseases attributable to unhealthy lifestyles (Katz, Hermalin, &
Hess, 1987). In addition, medical knowledge alone cannot predict
who will get sick and who will stay healthy. For instance, medical
indicators can only explain about 40% of cases of heart disease.
The other 60% of heart disease risk is unknown (Venkatapuram,
34 2011). That 60% is vitally important, because if societies cannot
explain who is at greatest risk, they cannot develop effective
health policies.
Social determinants of health
Internationally, and in New Zealand, we have all the facts we
need to convince us that people’s health status follows identifiable
trends. We know that as a group, pakeha people in New Zealand
enjoy good health and that the average life expectancy is steadily
increasing. Pacifica people don’t fare so well, lagging behind
pakeha in terms of life expectancy and not experiencing the same
steady increase in health outcomes that pakeha enjoy. Mäori,
the original inhabitants of this land, who might expect to be best
positioned to enjoy its benefits, fare worst. They have a full 10
years lower life expectancy than pakeha. So ethnicity is clearly an
important social determinant of health. We also know that if we
stratify the population according to income, each cohort from
rich to poor has decreasing health status. More poor people get
sick, more of their children get sick, and their survival rates after
stroke, cancer and other noncommunicable diseases are much
lower. Worse still, even if we correct for income, Mäori have
poorer health and health outcomes; just being Mäori confers a
health disadvantage. Housing, education, and quality of work are
other, highly influential social determinants of health (Ajwani,
Blakely, Robson, Tobias, & Bonne, 2003). I would also venture
that historical injustice is pivotal.
To drive the message home: people’s “social conditions
determine who is actually born and their genetic endowments,
how they behave, as well as the surrounding physical and social
conditions” (Venkatapuram, 2011, p. 11). Providing healthcare
services can go some way to addressing the health outcomes of
social conditions, but cannot level the playing field because health
and longevity are primarily caused by social determinants. The
most important determinants are access to income, education,
warm houses, nutritious food, and clean environments, as well
as inclusion and closing the gap between the richest people in
a society and the poorest. These are all things that societies
can change, and all of them affect the things people do and the
circumstances in which they do them. Starting to thinking about
health and longevity as the outcomes of socially determined
factors, rather than germs, injuries, and lifestyle “choices”, tells us
that occupational therapists need to look beyond providing good
quality intervention for individuals who have already acquired a
health condition. At least some of us need to look to the societal
factors that influence health and ill-health, so that disparities in
the incidence and prognosis of health conditions are addressed.
We need to bring our knowledge of occupation to solving the
problems of educational under-achievement, overcrowding,
damp houses, poor nutrition, decreasing levels of physical
activity across the whole population, binge drinking and illicit
drug use, domestic violence, homelessness, the isolation of many
older people, discrimination against immigrants, youth suicide,
insecure employment, and the degradation of the environments
where people live, work and play.
New Zealand Journal of Occupational Therapy
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Occupation for public health
FEATURE ARTICLE
Health as participation
Health as a human right
The second thing that is reorienting our understanding of
health is the International Classification of Functioning,
published by the World Health Organization in 2001 and
endorsed as the international standard to describe and measure
health and disability (WHO, 2012a). The ICF model separates
health conditions from the impairments attributable to health
conditions, limitations in people’s ability to engage in activities,
and barriers to participation – the things people actually do. It
is an interesting exercise to stand back from the model to ask:
Where is health?
Naming the groups most likely to experience poor health
and healthcare outcomes points to the third seismic shift in
conceptions of health: that is, framing health as a human
rights issue. Let me quote the first couple of sentences in the
WHO World Report on Disability (2011b). “Many people with
disabilities do not have equal access to health care, education,
and employment opportunities, do not receive the disabilityrelated services that they require, and experience exclusion from
everyday life activities. [Given that]…disability is increasingly
understood as a human rights concern” (p. xxi).
Illness is readily identifiable. It is there as a named disease or
disorder, with its severity measured in terms of impairments
to bodily structures and biological processes, and the activity
limitations and participation restrictions that are experienced
– noting that all of those elements are moderated by personal
factors and the physical, social and institutional environment. Is
health defined by NOT having a health condition, or not deviating
from normal body structure and function? Is health measured by
NOT experiencing limitations and restrictions associated with a
disease or disorder? Perhaps – but defining things by what they
are not risks becoming very convoluted.
To leave us in no doubt, a slew of recent United Nations and
World Health Organization documents assert the association
between human rights and health. Closing the Gap in a
Generation (2008) declares that “a society, rich or poor, can be
judged by … how fairly health is distributed across the social
spectrum” (p. i). Human Rights, Health and Poverty Reduction
Strategies (WHO, 2008) emphasises that “poverty and ill health
are deeply intertwined with disempowerment, marginalization
and exclusion” (p. 74). The starting point for the 2012 UNESCO
Advocacy Brief on Empowering Girls and Women through
Physical Education and Sport is the association between poverty
and gender inequality. The opening premise of WHO’s (2011a)
Human Rights and Gender Inequality in Health is that addressing
those issues “is not only the right thing to do, ethically and legally,
it also leads to better, more sustainable and equitable outcomes
in the health sector” (p. 9). In addition, starting this year,
WHO has a mandate to devote special attention to protecting
and promoting the right to health of the world’s indigenous
peoples (WHO, 2012b). The main thrust of the message is that
generalised health interventions are not sufficient. Changing
the health status of the poorest poor, indigenous people and
those subject to discrimination requires strategies specifically
developed with and for them.
One possible response would be to assert that health is equivalent
to participation, which implies that we can determine how
healthy people are by examining their pattern of occupation.
Reinforcing that perspective, occupational therapists might add
that health is both a resource that enables people to participate in
the necessary, valued and meaningful occupations of their culture
and conversely, participation is the means by which health and
well-being are created, experienced and restored. From this
perspective, one could conclude that ‘participation is the measure
of health’, whilst again acknowledging the influence of personal
and environmental factors in supporting or restricting the actual
achievement of health.
Cheering as that conclusion might feel to occupational therapists,
it is clearly too benign. Equating health with participation
does not explain the differential health status of people from
different sectors of society. Following Martha Nussbaum (2011),
occupational therapists might be wiser to assert that health is
the capability “to do and to be” (p. 18). Capabilities, Nussbaum
explained, are both internal and external. The talents and abilities
people develop by participating in play, sport, education, music
and the arts, work and so on are internal. External capabilities are
the freedom and opportunities to use those abilities in their social,
economic and political environment. That is, health depends on
having opportunities to develop capacities, such as the ability to
think critically and the skill to communicate one’s thoughts, the
confidence to use those capacities, and an enabling environment.
Even within relatively benevolent societies such as New Zealand,
it is easy to find information confirming that indigenous people,
poor people, women, people with a disability, immigrants without
legal rights and those whose qualifications are not recognised, do
not have the same freedoms and opportunities.
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Linkages between health and human rights
In teasing apart the relationship between human rights and
health, the WHO (2002) identified three ways in which health
and human rights are interlinked. The most obvious is the illhealth arising from human rights violations, such as slavery,
torture, or violence against women and children. Another link
is that the ways health policies or programmes are implemented
might violate human rights of some groups. Examples include
fees that make health care unaffordable, discriminatory practices,
health service delivery that breaches cultural conventions about
privacy, or health information that is withheld, inaccessible,
or inappropriately targeted. Conversely, implementation that
ensures health services and health information are accessible,
affordable, and culturally safe would promote human rights.
The third linkage is when a human rights approach is taken
to reducing people’s vulnerability to ill-health. That means
respecting, protecting and fulfilling each person’s right to health
by addressing the social determinants of poor health. The most
important rights in this regard are the right to education, to
nutritious food, and to freedom from discrimination that bars
New Zealand Journal of Occupational Therapy
35
Clare Hocking
FEATURE ARTICLE
access to a health-giving range of occupations. The WHO analysis
reveals that health justice is about righting the social conditions
that cause people to “suffer preventable impairments or to die
prematurely” (Venkatapuram, 2011, p. 5), such that individuals
are free to be and do what they want, in the context of social
arrangements that nurture, protect, promote and restore their
capability to be healthy.
would expose the array of social conditions that contribute to
obesity and how they interact. Such an occupational perspective
has the potential to generate new insights, because people’s
occupations integrate their internal capacities and what they have
the freedom to do in their social environment. Until we have that
knowledge, I don’t believe it will be possible to develop effective
public health policies to turn the tide.
To summarise: occupational therapy has recommitted to
occupation as the specialist knowledge it brings to health. And
while we weren’t watching, health was becoming much more than
healthcare services. Rather, it is the hallmark of a just society that
creates social conditions that enable people to do and to be “with
equal human dignity” (Venkatapuram, 2011, p. 8). So, how
can an occupational perspective nurture, protect, promote, and
restore the health of the most vulnerable people in New Zealand Mäori, women and children who live in poverty, and others who
are discriminated against. To explore that idea, let us consider
two frequently discussed health concerns: the obesity crisis and
population ageing.
Occupational perspective of
heath: Population ageing
Occupational perspective of health: Obesity
Obesity is a risk factor for all of the chronic non-communicable
diseases that threaten to overwhelm health services: cancer,
cardiovascular disease, stroke, and diabetes. The incidence
of obesity is rapidly increasing. It affects significantly more
women than men (Ministry of Social Development, 2010), and
is concentrated in the Mäori and Pacifica populations and in
the most deprived neighbourhoods (MoH, 2011). Obesity is
associated with food insecurity and obesogenic environments –
places with fewer fresh food outlets and recreational facilities,
and lower perceived or actual safety (Jones, Bentham, Foster,
Hillsdon, & Panter, 2007). A great number of researchers
are addressing the problem of obesity, from different angles:
nutritional, physical exercise, gender, age, how intention to be
more active translates into behaviour, what sustains people’s
engagement in physical activities, how neighbourhood design
influences activity levels.
What I haven’t seen is research conducted with populations that
are most at risk of obesity that puts together all the aspects of
their everyday lives that influence nutritional intake and energy
expenditure: their work, social, celebratory, leisure and spiritual
occupations; time use and sleep patterns; types of transport and
destinations; and the economic, cultural, geographic, climatic and
social influences on the occupational patterns that contribute to
obesity. We need to understand all of the antecedents to driving
into McDonalds, sending children to school without breakfast,
watching TV instead of more active pastimes, eating processed
food rather than fresh vegetables. And we need to understand
how people’s occupational patterns are influenced by things that
society can change – the location of supermarkets, urban design,
living in poverty, overcrowding.
Research of that kind, designed to identify the enablers, barriers
and mechanisms that underlie food choices and activity levels,
36 Population ageing is another demographic change with potential
to overstretch healthcare services (Statistics New Zealand, 2008),
as more and more people survive into old age. The magnitude
of the challenge is revealed in the figures for health expenditure,
which documents rapidly increasing costs of disability support
services for cohorts over 74 years of age (Bryant, Teasdale, Tobias,
Cheung, & McHugh, 2004). To remain healthy, older people
need to engage in occupations that are physically taxing, mentally
stimulating, and connect them to community. Dementia
threatens people’s capability to do that. Its prevalence in people
aged over 65 increases by 1-2% per year of age to approximately
34% of those aged 90 years and older (Alzheimers New Zealand,
2008).
Dementia is known to undermine people’s ability to participate
in everyday occupations. However, although their reduced
participation is generally attributed to cognitive decline, a recent
New Zealand study revealed that it is the stigma they encounter
that causes people with dementia to hide their condition and
withdraw from society (O’Sullivan, 2011). That response is hardly
surprising; media portrayals of dementia position it as a ‘living
death’, characterised by inappropriate behaviour and devoid
of meaningful engagement in occupation. Anticipating other
people’s lack of understanding and condescending attitudes,
people diagnosed with dementia hesitate to ask for assistance
with practical aspects of familiar tasks, such as selecting items in
a shop, withdrawing money from a bank, or keeping score at golf.
Informed by O’Sullivan (2011), two focuses for occupational
therapists’ knowledge of the health-giving power of occupation
become evident. One is that people diagnosed with dementia
need a hopeful message of living fully to preserve the highest
level of well-being. But justice is not served by telling people
subjected to stigmatising attitudes that it is up to them to get
on with their lives. Societal attitudes must be challenged and an
enabling environment created in order for people to use their
capabilities. Imagine a world where shoe shop assistants, bank
tellers, and gym coaches could unobtrusively greet, prompt,
and allow the time people with dementia need to participate in
familiar and unfamiliar tasks. Imagine a world where friends
and acquaintances would continue to feel confident with and
welcoming of them, even as memories fade, words prove elusive,
and decisions are not so quickly reached. What is needed is
more than a change of attitude; it is a level of skill in enabling
others’ occupations that would benefit everyone. Occupational
therapists have the knowledge to make that happen.
New Zealand Journal of Occupational Therapy
Volume 60
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Occupation for public health
FEATURE ARTICLE
Conclusion
I have painted a picture of an occupational perspective bringing
valuable new insights to two of the many public health issues
facing New Zealand: obesity and the well-being of people
diagnosed with dementia. Making a real contribution to public
health, the art and science of preventing disease and prolonging
life, is not just a new area of practice. It demands sharing
knowledge of occupation for health at a societal level, making it
as familiar as dietary advice – but better tailored to people from
the different cultures that make up New Zealand. In particular,
I have suggested that addressing the disparities between Mäori,
Pacifica people, and pakeha, and between rich and poor, is a
cornerstone of achieving health for all. It also means extending
our thinking from practice with individuals, to practice that
influences groups, organisations, communities – the whole of
society. Moving in that direction will require leadership, in large
and small ways; from influencing government policy to offering to
work with people to create an enabling environment. That might
be as simple as suggesting that the local play centre preserves
some open space for children to run around in or speaking to
a hair dresser or gym instructor about interacting with people
with cognitive challenges. It also demands research, conducted
with and for the groups most at risk from avoidable ill-health and
premature death, which brings to light the ways that their social
conditions work against health and well-being. Stepping up to
the challenge requires the courage born of recognising health
injustices and knowing that an occupational perspective is an
important part of the answer. It will be an exciting journey that
honours the profession’s commitment to biculturalism and its
early history of social activism. I invite you to join me.
Key points
1.Health is determined by things societies can change
2.The measure of health is what people do
3.Health is a fundamental human right
4.An occupational perspective is central to addressing health
injustices, using a public health approach.
Acknowledgement
This paper is Dr Hocking’s Inaugural Professorial Address,
presented at the Auckland University of Technology on 29
August 2012. To view the presentation, go to http://ondemand.
aut.ac.nz/Mediasite/Play/7b72f0cdff4a4a05a5bd8f3f7c1216401d
References
Ajwani, S., Blakely, T., Robson, B., Tobias, M., & Bonne, M. (2003). Decades of
disparity: Ethnic mortality trends in New Zealand 1980-1999. Wellington:
Ministry of Health and University of Otago.
Alzheimers New Zealand. (2008). Dementia economic impact report 2008. Wellington: Alzheimers New Zealand National Office.
Bryant, J., Teasdale, A., Tobias, M., Cheung, J., & McHugh, M. (2004). New
Zealand Treasury Working Paper 04/14: Population Ageing and Government
Health Expenditures in New Zealand, 1951-2051. Wellington: The Treasury.
Carter, J. B. (1988). Disease and death in the nineteenth century: A genealogical
perspective. The National Genealogical Society Quarterly, 76, 289-301.
Commission on Social Determinants of Health. (2007). Interim Statement on
Achieving health equity: From root causes to fair outcomes. Geneva: Author.
Volume 60
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Jones, A., Bentham, G., Foster, C., Hillsdon, M., & Panter, J. (2007). Foresight.
Tackling obesities: Future choices – Obesogenic environments. Evidence review. London: Government Office for Science. Retrieved from www.bis.gov.uk/
assets/foresight/docs/obesity/03.pdf
Katz, A. H., Hermalin, J. A., & Hess R. E. (Eds.). (1987). Prevention and health:
Direction for policy and practice. New York, NY: The Haworth Press.
Kielhofner, G. (2004). Conceptual foundation of occupational therapy (3rd ed.).
Philadelphia, PA: F. A. Davis.
Kielhofner, G., & Burke, J. (1980). A model of human occupation, Part one:
Conceptual framework and content. American Journal of Occupational
Therapy, 34, 572-581.
Ministry of Health. (2011). A portrait of health: Key results of the 2006/07 New
Zealand Health Survey. Retrieved from www.health.govt.nz/publication/
portrait-health-key-results-2006-07-new-zealand-health-survey
Ministry of Social Development. (2010). The social report 2010. Te pürongo
oranga tangata 2010. Retrieved from www.socialreport.msd.govt.nz/health/
obesity.html
Nussbaum, M. C. (2011). Creating capabilities: The human development
approach. Cambridge, MA: Harvard University Press.
Reductionism. (2012). Oxford dictionaries online. Oxford University Press.
Retrieved from http://oxforddictionaries.com/definition/reductionism
Statistics New Zealand. (2008). New Zealand age and-sex structures (1901, 2001,
2101). Retrieved from www.population.govt.nz
United Nations High Commissioner for Human Rights and World Health
Organization. (2008). Human rights, health and poverty reduction strategies.
Geneva: Author. Retrieved from http://www.who.int/hhr/activities/
publications/en/
United Nations Education, Scientific and Cultural Organization. (2012).
Advocacy brief: Empowering girls and women through physical education and
sport. Bangkok: UNESCO.
Venkatapuram, S. (2011). Health justice: An argument from the capabilities
approach. Cambridge, UK; Polity.
World Federation of Occupational Therapists. (2002). Minimum Standards for
the Education of Occupational Therapists. Perth, WA: Author.
World Health Organization. (2001). International Classification of Functioning,
Disability and Health. Geneva: Author.
World Health Organization. (2002). 25 questions and answers on health & human
rights. Health and Human Rights Publication Series Issue No. 1. Retrieved
from www.who.int/hhr/activities/publications/en/
World Health Organization. (2008). Closing the gap in a generation: Health
equity through action on the social determinants of health. Geneva: WHO.
World Health Organization. (2011a). Human rights and gender inequality in
health. Geneva: WHO.
World Health Organization. (2011b). World report on disability. Retrieved from
www.who.int/disabilities/world_report/2011/report/en/
World Health Organization. (2012a). Classifications: International classification
of functioning, disability and health (ICF). Retrieved from www.who.int/
classifications/icf/en/
World Health Organization. (2012b). Health and human rights: Indigenous
people’s right to health. Retrieved from www.who.int/hhr/activities/
indigenous_peoples/en/
IN-SERVICE TRAINING:
UPDATE YOUR KNOWLEDGE
ON STAIRLIFTS IN NZ
Two hour educational (not product)
n-service sessions including
morning or afternoon tea.
Please note: Any occupational therapist may set this
as an objective under their Continuing Competence
Framework for Recertification (CCFR).
To arrange, please contact
Neil at Acorn Stairlifts,
0800 782 475.
New Zealand Journal of Occupational Therapy
37
Kirk Reed, Clare Hocking & Liz Smythe
FEATURE ARTICLE
The meaning of occupation:
Historical and contemporary connections
between health and occupation
Kirk Reed, Clare Hocking & Liz Smythe
Abstract
The findings of an analysis of historical and contemporary literature to uncover the meaning of occupation are reported.
A hermeneutic method was employed to review Western sociology, history, philosophy and leisure texts along with a
search of professional literature ranging from 1997 to the current day. The findings of the review show that as occupation
became more recognised there was an increasing acknowledgment of the connection between occupation and health.
Historical developments lead eventually to the establishment of the profession of occupational therapy. In looking back,
the potential to conceptualise and refine current and future occupational therapy practice is opened up.
Key words
Occupational therapy, occupation, hermeneutics, Western society, health.
References
Reed, K., Hocking, C., & Smythe, L. (2013). The meaning of occupation: Historical and contemporary connections
between health and occupation. New Zealand Journal of Occupational Therapy, 60(1), 38–44.
Introduction
T
his article builds on an earlier discussion of the development
and use of the word occupation throughout Western
history. In the earlier discussion (Reed, Smythe, & Hocking,
2012) an overview of the word occupation was presented from
a hermeneutic and etymological perspective (etymology is the
study of the history of words, their origin and how their form
and meaning have changed over time). The aim was to show how
different meanings of occupation have built up over the centuries.
This article continues the analysis to show how in each new era,
circumstances change and shape what counts as occupation. As
the profession of occupational therapy developed, occupation
became a notion that was named, framed and conceptualised as
the domain of a professional group. Up until the establishment
of occupational therapy, occupation had not been recognised as
a notion that could form the basis of a profession. In this article
the history of how occupation became more recognised and
formalised will be outlined. The time frame spans the Age of
Enlightenment to the current day. A broad outline is presented
recognising there is obviously much more than can be recounted.
The aim is to bring to the fore how, in the context of occupational
therapy, understandings of the notion of occupation have
changed and evolved.
Method
As described in the previous article (Reed, Smythe, & Hocking,
2012) a hermeneutic approach based on the work of Gadamer
(1960/2004) was employed to explore the history of ideas related to
the notion of occupation. Hermeneutics creates the opportunity
38 to explore texts, and to show how ideas have been passed down
in language and words. In this review extensive reading through
Western sociology, history, philosophy and leisure texts was
undertaken along with a search of the professional literature
using the CINHAL, Proquest 5000 and Medline databases.
Literature published from 1997 to the present was the focus
of the database search, literature which described occupation,
the link between occupation and health, and contemporary
understandings of occupation from an occupational therapy
perspective were purposefully sought. A hermeneutic process of
analysing the text was undertaken by noticing the words used,
Corresponding authors:
Kirk Reed, DHSc, Head of Department
Department of Occupational Science and Therapy
AUT University
Private Bag 92006
Auckland
New Zealand
Email: kirk.reed@aut.ac.nz
Clare Hocking, PhD, Professor
Department of Occupational Science and Therapy
AUT University
Liz Smythe, PhD, Associate Professor
School of Health Care Practice
AUT University
New Zealand Journal of Occupational Therapy
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The meaning of occupation: Historical and contemporary connections between health and occupation
how they were brought into play, and the context in which
they were used, to highlight what was and what was not spoken
about. The questions that guided the analysis were as follows:
‘how did occupation show itself in relation to other people?’ and
‘what influenced the understanding and use of occupation by
occupational therapists?’
Analysis of the literature
Over the course of the profession’s development occupational
therapists have recognised that occupations either positively
or negatively influence health. Prior to the existence of
occupational therapy, scholars such as Galen (131-201 AD)
identified occupations for the maintenance of health. Conversely
during the Industrial Revolution those such as Fredrick Taylor
and the Scientific Management Movement (Applebaum,
1992) manipulated occupation in such a way that the focus
was on the production of items in large quantities, with little
or no consideration for those people that were involved in
the manufacturing process. This contributed to occupation
having a negative impact on workers’ health. To show how
understandings of occupation have changed and evolved the
analysis of the literature is separated into periods of development
throughout Western history from the Age of Enlightenment to
the current day.
The Moral Treatment Movement
The Moral Treatment Movement, which developed in Europe
during the Age of Enlightenment, laid the foundation for the
emergence of the profession by recognising the need to occupy
people confined to asylums. Brockoven, a psychiatrist, insisted
that “the history of moral treatment in America is not only
synonymous with, but is the history of occupational therapy
before it acquired its 20th century name occupational therapy”
(1971, p. 225). The Moral Treatment Movement was founded
on the work of Philippe Pinel (1745-1826), a French philosopher
and medical practitioner with an interest in mental health and
William Tuke (1732-1822) an English merchant-philanthropist
who developed principles of Moral Treatment and applied them
to the insane in institutions in France and England respectively
(Pinel 1806/1962, Tuke 1813/1964). Moral Treatment grew out
of the “fundamental attitudes of the day: a set of principles that
govern humanity and society; faith in the ability of the human to
reason; and the supreme belief in the individual” (Bing, 1981, p.
502). Moral Treatment saw a shift away from the notion that the
insane were possessed by the devil. A distinct method of therapy
evolved and mental disease came to be seen as the legitimate
concern of humanitarians and physicians.
At The York Retreat, an asylum for the insane, in Britain, Tuke
(as cited in Foucault 1961/2006) drew on his beliefs as a Quaker
and recognised that:
…in itself work possesses a constraining power superior
to all forms of physical coercion, in that the regularity of
the hours, the requirement of attention, the obligation
to provide a result detach the sufferer from a liberty of
mind that would be fatal and engage him in a system of
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FEATURE ARTICLE
responsibilities. (p. 247)
Tuke (as cited in Foucault 1961/2006) was influential in
establishing a philosophy of discipline and hard work rather
than external control of mental patients. At around the same
time as The York Retreat was using occupation to assist in the
recovery from mental illness, Pinel (1806/1962) also recognised
the value of occupation. He established an environment of work
programmes allowing those with a mental illness, previously
constrained in chains, to be liberated. Pinel noted that even “the
natural indolence and stupidity of ideots (sic), might in some
degree be obviated, by engaging them in manual occupations,
suitable to their respective capacities” (p. 203).
Across the Atlantic in the United States of America (USA),
Thomas Story Kirkebridge implemented a regime of Moral
Treatment in The Pennsylvania Hospital for the Insane in 1833.
Annual reports detailed that more than 50 occupations were
on offer including lectures, gymnastics and magic (Handbook
for attendants on the insane, 1896). At the same time scientific
trends were beginning to challenge the philosophy of Moral
Treatment and the way work was carried out. The decline of
Moral Treatment was identified by Peloquin (1998) as being
closely related to “a lack of inspired and committed leadership
willing to articulate and redefine the efficacy of occupation in the
face of medical and social changes” (p. 544).
Vernon Briggs (as cited in Woodside, 1971) described in 1911
how patients’ engagement in occupation had a positive effect on
their health, based on several occupational initiatives occurring
in various sites across the USA. Just prior to this in 1906, Susan
Tracy, a nurse and teacher, had developed a course on invalid
occupations for nurses (Woodside, 1971). Tracy is credited by
some to be the first occupational therapist of the 20th century and
a book of her work was published in 1912 (Tracy, 1912/1980).
Also occurring at about this time was the work of Adolph Meyer
(1866-1950) a psychiatrist, humanist and mental hygienist,
who immigrated to the USA from Switzerland. Meyer took on
board the educational philosophies of John Dewey and in 1892
professed, “doing, action and experience are being” (as cited in
Breines, 1986, p. 46). Meyer held that people could be understood
through consideration of the activities that they engage in during
their day to day life, for which Meyer demonstrated a mindbody synthesis and supported his view that individuals can only
be studied as whole people in action. In 1922, Meyer published
a paper entitled ‘The philosophy of occupational therapy’ and
because of this he is often heralded as the philosophical father
of occupational therapy. Meyers’ accounts showed a critical link
between an individual’s activities and activity patterns and his or
her physical and mental health. Even in the face of adversity such
as mental ill health, there was still the potential for people to be
engaged in occupation, and that occupation could provide some
benefit and relief from their health condition. Despite adversity,
the very nature of their Being called them to be connected to
others and the world. Wider society, the ‘They’, prescribed and
decided what was acceptable in terms of health, education and
income, and it is from this line in the sand that a person measures
New Zealand Journal of Occupational Therapy
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Kirk Reed, Clare Hocking & Liz Smythe
FEATURE ARTICLE
and compares themselves against what others have achieved or
failed to achieve. Thus a person understands himself or herself
in their difference from others (Christiansen, 2007; King, 2001).
Arts and crafts
Jane Addams’ work at Hull House, where Meyer also had
some involvement, led up to the establishment of occupational
therapy as a profession. Hull House was a settlement home for
new immigrants and was influential in establishing the Arts and
Crafts Movement in America. The Arts and Crafts Movement, of
which Ruskin and Morris (1883/1915) were leading proponents
in the United Kingdom, holds views about work and a simple
life, which includes restoration of the human spirit through
engagement in honest craftsmanship. Morris (1883/1915)
associated the experience of pleasure with skilfully creating an
object. He affirmed that:
…art is the expression by man of his pleasure in labour. I
do not believe that he can be happy in his labour without
expressing that happiness; and especially this is so when he
is at work at anything in which he especially excels. (pp.
41-42)
These beliefs informed the delivery of services in mental health,
tuberculosis sanatoria and physical health settings, and saw
manual training as a solution to the problems created during
the industrial era. In 1911 Eleanor Clarke Slagle, a social work
student, attended a course at Hull House on curative occupations
and recreation. She later became the Director of the Henry B.
Favill School of Occupations, which is thought to be the first
formal school of occupational therapy. Slagle’s work, which
incorporated ideas from Addams, focused on habit training
through meaningful use of time and purposeful activity. Slagle
(1922) actively promoted the use of occupation in relation to
health when she included the concept that:
…for the most part our lives are made up of habit reactions.
Occupation used remedially serves to overcome some
habits to modify others and construct new ones, to the end
that habit reaction will be favourable to the restoration and
maintenance of health. (p. 14)
World War One and the early 1900s
In Britain, occupation was increasingly recognised as important in
the treatment of people with mental disorders and was beginning
to be accepted as having value in the rehabilitation of people with
physical conditions (Amar, 1920). This was the case especially
across Europe, following World War One (1914-1918), where
occupation was seen as important to the curative process and the
economic future of returning servicemen. It was the British Red
Cross that “took a lead in establishing programmes of occupation
and entertainment for injured servicemen” (Wilcock, 2002, p. 62).
At about this time, occupation was also being used by Sir Pendrill
Varrier-Jones as the basis of treatment for people with tuberculosis.
Varrier-Jones held the view that the treatment of tuberculosis should
not be left to medicine alone and as a result created Papworth Village,
a combination of hospital, sanatorium and industries. For VarrierJones (as cited in Fraser 1943):
40 The true colony consists of a sanatorium, in which all that
is best in sanatorium treatment is carried out, but with
the addition of an industrial section where the treatments
may be prolonged and training in suitable occupation
begun. To my mind a man engaged in productive work,
keeping his wife and children, ceasing to be a danger to
the community, is a more economical proposition than a
similar person propped up by poor relief, a danger to his
family and to the community, as well as an unproductive
unit thereof. (p. 52)
During the 1920s there was growing acceptance of the specific use of
occupation as a treatment method, which was coined ‘occupational
therapy’. Wilcock (2002) points to the spread of occupational therapy
as a result of the medical profession endorsing this new profession,
which saw the increasing employment of occupational therapists by
local authorities as they gradually assumed responsibility for the care
of people with disabilities. An additional boost came during the Great
Depression of the 1930s, which was a period of high unemployment,
one result of which was the general recognition that engagement in
occupation was necessary for well-being (Rerek, 1971).
World War Two
Following the ravages of World War Two (1939-1945),
occupational therapy was again recognised as a key component in
the rehabilitation of injured service people. The view of the use of
occupation during this time was that it diverted attention away from
the pain and trauma of injury and was used to teach new skills to
allow the injured soldiers to have a vocation when they were able to
be discharged from hospital (Dudley Smith, 1945). The previous use
of craftwork as a therapeutic tool was restricted by both the British
Government and a lack of resources. It was during this period that
remedial approaches were introduced into the profession as a viable
tool in the rehabilitation process.
In the United Kingdom there was ongoing growth and development
of the profession following World War Two (Rosser, 1990). During
the 1950s the focus of rehabilitation broadened from getting
servicemen back to work, to recognising the importance of domestic
tasks and independence of those with long term disabilities.
Occupational therapy came under increasing pressure from the
medical profession to “establish a theoretical rationale and empirical
evidence for practice” (Kielhofner, 2004, p. 44). This is perhaps
not surprising given the strategic connection that early professional
leaders had developed with medicine, which had undoubtedly
influenced the assumptions and development of occupational
therapy (Hocking, 2007; Wilcock, 2002). At that time it was difficult
to measure restoration of the human spirit through craftwork, using
research methodologies of the day. As a result the profession began
to explain practice in terms of a biomedical perspective, which
included reductionist views of the body as a well-oiled machine.
This was in contrast to the views of the founders of occupational
therapy, such as Meyer, who considered mind-body synthesis to
be fundamental in the therapeutic use of occupation. The view of
occupation and the connection to health was slowly eroded as the
focus of occupation narrowed (Engelhardt, 1977) in response to
the challenge to provide evidence of the effectiveness of occupation
New Zealand Journal of Occupational Therapy
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The meaning of occupation: Historical and contemporary connections between health and occupation
from a bio-medical perspective. Understandings of occupation
appear to have changed during this era as the emerging dominance
of the scientific paradigm began to negate and bypass the complex
nature of a person who is always situated in context, shaped by place,
people, climate and all that is beyond knowing (Heidegger, 1993).
The entwined occupation, person and world dynamic was eroded in
favour of a rational explanation of occupation based on science. The
‘spirit’, the indefinable, was lost in theoretical models.
The 1960s and 1970s
As occupational therapy progressed into the 1960s, the focus
of practice continued to be based on concepts from medicine
which pervaded both physical and mental health. Psychodynamic
concepts used by psychiatrists were deemed to be more important
in occupational therapy mental health practice than concepts of
occupation (Fidler & Fidler, 1978), which led to an emergence of
therapeutic communities and group and industrial therapy. In
physical health the focus was on “understanding function and
dysfunction” in anatomical and neurological terms (Kielhofner,
2004, p. 46). From the bio-medical perspective, occupation was
viewed as something that calls on muscle strength, joint flexibility,
stamina and changes in behaviour. These were things that could be
observed and measured and could therefore provide the empirical
evidence that was required to demonstrate the effectiveness of
occupational therapy.
As the profession expanded and diversified, there was a call
to reinstate the aims and functions of occupational therapy.
Wilcock (2002) recalled that during this time “general treatment
responsibilities were to assist the recovery of patients from mental
or physical illness. Training patients to use returning function or
residual ability to gain social and vocational readjustment” (p. 289).
The focus on the use of occupation as therapy shifted to centre
on function rather than diversion, and fostering independence,
responsibility and resettlement in relation to the demands of home
or job.
During the 1970s there was a phase of professional self doubt as
the philosophical base of the profession was challenged (Kielhofner
& Burke, 1977). Shorter hospital stays meant limited opportunities
for patients to engage in occupations as they had done in the past
and less time for the occupational therapist to build a therapeutic
relationship. The influence of the medical profession also saw a move
towards increased specialisation by occupational therapists based on
their knowledge of medical conditions rather than knowledge of
occupation.
Renaissance in the commitment
to occupation
In the latter part of the 20th century there was a renaissance
in the commitment to occupation as a necessary component of
health. Within occupational therapy there was a growth in models
of practice such as the Model of Human Occupation developed
by Kielhofner (1985). This model was created to be used with
any person experiencing problems related to occupation and
was concerned with “the motivation for occupation, pattern
of occupation, subjective dimension of performance [and the]
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FEATURE ARTICLE
influence of environment on occupation” (Kielhofner, 2004, p. 148).
As the renaissance continued during the 1990s the word occupation
was being used more universally. Hagedorn (1995) identified that
occupation was the unique element forming the focus and vehicle
for occupational therapy. There was also an increase in occupational
therapy research as the profession responded to the call to focus on
specific occupational themes (Wilcock, 1991). The research themes
included studying human occupation, occupational function,
occupation for health and the subjective experience of participation
in occupation. One consideration highlighted by Hasselkus (2006)
that could potentially limit further understandings of occupation
by the profession of occupational therapy is its conceptualisation
“within a problem framework. We have linked our focus on
occupation to a context of disability – making everyday occupation
part of the problem” (p. 630). While there was a renewal of ideas
during this time about the importance of occupation connected with
enabling and empowering people within their own communities
and linking self health to occupation, Hasselkus (2006) signalled
that there was still the need to consider occupation in its broadest
context.
The interest in occupation linked to human life, health and wellbeing is evident in the maturity of occupational therapy. The
desire for further knowledge and understanding of occupation led
to the development of occupational science. Occupational science
distinguishes itself from occupational therapy by being concerned
with creating a basic understanding of occupation, without
immediate concern for the application of that knowledge. Early
advocates of occupational science, such as Zemke and Clark (1996),
suggested that the study of occupation would enhance occupational
therapists’ appreciation of the role of occupation in life and health.
Contemporary understandings of occupation
The notion of occupation in recent literature is presented in a
range of ways. This section of the review will focus on descriptions
and definitions of occupation and key terms associated with
occupation. Occupation has been described by Sundkvist and
Zingmark (2003) as a conceptual entity which “includes all things
that people do in their everyday life” (p. 40) and by Wilcock (1998)
as “all ‘doing’ that has intrinsic or extrinsic meaning” (p. 257).
This certainly gives the sense that occupation is something that
is all encompassing, without any bounds. These recent views of
occupation are complemented by components of definitions which
were brought together in the Journal of Occupational Science
Occupational Terminology Interactive Dialogue (2001). The
dialogue included a definition from Yerxa, Clark, Frank, Jackson,
Parham, and Pierce et al (1989) who considered occupation to be
chunks of activity within the ongoing stream of human behaviour,
self initiated, socially sanctioned and a complex phenomenon.
Similarly, McLaughlin Gray (1997) described occupation as units
of activity, classified and named by the culture. According to
Sabonis-Chafee (1989) occupation is seen as purposeful activities
that fill a person’s waking hours and something that is ‘more than
just doing’. Kielhofner (1995) considered occupation to include
action and doing in the physical and social world. This string of
perspectives was brought together by Crabtree (1998), who defined
New Zealand Journal of Occupational Therapy
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Kirk Reed, Clare Hocking & Liz Smythe
FEATURE ARTICLE
occupation as “intentional human performance organised in
number and kind to meet the demands of self maintenance and
identity in the family and community” (p. 40).
and to express personal and cultural ideas. More importantly she
agrees that occupations are named and valued differently in each
culture.
The extent of occupation is also denoted by the American
Occupational Therapy Association Commission on Practice
(2002), which used the term occupation to “capture the breadth
and meaning of everyday life activities” (p. 610); the members of
the Commission viewed occupation as the means and outcome
of occupational therapy intervention. Likewise, when Wilcock
(2003) interviewed occupational science and occupational therapy
students, the students simply described occupation as employment,
a career path, day-to-day tasks and something that takes up time.
In summary, current conceptions of occupation consider it to be
central to a person’s identity and competence, to influence how
a person spends time and makes decisions, to have an element of
needing to be endorsed by a person’s cultural or social group, and
having common components such as groupings of activity. In
addition, occupation implies a sense of intentional and purposeful
action. An important point made by Sundkvist and Zingmark
(2003) is that a consensus has not been reached on the complex
meaning of occupation and the discussion, indeed this debate,
still continues in the literature (Hammell, 2009; Reed, Hocking,
& Smythe, 2011). This supports the discussion by Christiansen
(1994) and Law, Steinwender, and Leclair (1998), who recognised
the complexity of attempting to understand occupation.
Discussion and implications
A key point that has been made is that occupation is often socially
and culturally sanctioned and defined (Yerxa, Clark, Frank,
Jackson, Parham, & Pierce et al, 1989; McLaughlin Gray, 1997),
which indicates that different cultural groups will have their own
unique understanding of occupation. Darnell (2002) pointed out
that occupation, as understood by occupational therapists, is from
a Western point of view, that social recognition is important to
the value placed on an occupation, and being occupied is socially
valued. When considering occupation from the viewpoint of other
cultures, it is important to acknowledge that the focus may not
necessarily be on productivity, as it is in Western culture. Further
the focus of occupation may be to support extended family or to
be in balance with nature. The complex nature of the meaning of
occupation, which is circumstantial and shaped by the dynamics
of the interaction between people, competing demands and
possibilities, where the meaning of occupation goes beyond the
individual was highlighted by Reed, Hocking, and Smythe (2010).
The transactional nature of occupation is also addressed by Dickie,
Cutchin and Humphry (2006) who proposed the Deweyan concept
of ‘transaction’ as an alternative perspective for viewing occupation.
This is where occupation is no longer seen as something arising
from the individual, but should be viewed in its complex totality
of the person in context, where the meaning of occupation goes
beyond the individual. This seems to suggest that understandings
of occupation are much broader than those that are created by the
individual, but extends to understandings generated by groups
of people. Similar points about the culturally specific nature of
occupation are acknowledged by Townsend (1997), in that she
agrees that occupations are named to represent purposes and goals,
42 Understanding is always shaped by our own historical
circumstances. We stand “within a tradition [that] does not
limit the freedom of knowledge but makes it possible” (Gadamer,
1960/2004, p. 354). Our taken for granted understandings that we
have been brought up with, that have become embodied in practice,
teaching and scholarship, are often difficult to challenge to see how
such understandings have been socially constructed. This paper is
an attempt to momentarily break free of the notion that occupation
and occupational therapy are generic entities in their own right,
determined by the profession itself. Looking back provides evidence
of the shaping of understandings of occupation and occupational
therapy which have themselves been shaped by the social milieu of
the times.
For example, with the Moral Treatment Movement, beliefs about
individuals’ ability to reason shaped an understanding that mental
illness was not the result of an external force. Thus the value of
occupation was recognised and initiated in the treatment of people
with mental illness. Those underlying beliefs contributed to the
establishment of occupational therapy in the early 1900s. This new
profession claimed occupation as its domain of concern and built
on the growing recognition of the connection between occupation
and health. In its formative years occupational therapy was also
strongly influenced by the Arts and Crafts Movement, Adolph
Meyer, a psychiatrist and mental hygienist, and Eleanor Clarke
Slagle who had an interest in habit training. All of those influences
came from outside the profession.
With the advent of World War One and Two the use of occupation
in the realm of healthcare shifted from being used solely in the
treatment of mental health conditions to deal with the alarming
rise of physical conditions. Occupation was seen as an important
part of treatment to allow injured servicemen to return to the
front, or in the case of people with tuberculosis, to regain a level
of economic independence. Again, society dictated the need
and the purpose. The professions of medicine and psychiatry
became highly influential in challenging occupational therapy to
provide evidence to show how and why occupation contributed
to health outcomes. As a result, the holistic perspective of using
occupation therapeutically changed from it being used for diversion
or resettlement to being used to increase function in the home or
workplace. Engagement in occupation became something that
could be manipulated and used for remediation as part of a person’s
overall rehabilitation programme, to the point where occupation or
parts of occupation were prescribed. This meant that much of the
value of the experience of participating in occupation was lost. The
practitioners themselves would have had little control over this reshaping of their practice, as this would have been determined by the
economic imperatives of society at the time.
The rise of professionalism amongst other health professions (Saks
as cited in Taylor & Field, 1998) meant occupational therapy had
New Zealand Journal of Occupational Therapy
Volume 60
No 1
The meaning of occupation: Historical and contemporary connections between health and occupation
no choice but to meet the challenge of becoming a profession;
the alternative was to perish. It followed the other professions
in the establishment of ‘Schools’ of Occupational Therapy and
professional bodies. During the 1960s, there was a call by members
of the profession to reclaim the aims and functions of occupational
therapy. Heidegger (1927/1995) talks of authentic resoluteness, or
the times when we see the possibilities of our own being and take
a stand. This came in response to the profession being in a phase
of uncertainty as a result of the dilution of the understanding of
occupation, which had been strongly influenced by biomechanical
and psychodynamic paradigms. Occupational therapy scholars
were attuned to what was determined to be worthy scholarship.
Much of the literature during this time focused on describing and
defending practice, and providing evidence for practice based on
these dominant paradigms, rather than focusing on understanding
occupation from the lived experience. It was not until the 1980s
that models of practice with a strong occupational element began
to emerge. The resurgence of interest in occupation led to the
call to focus research on occupation, particularly the link between
occupation and individual and community health. It is interesting
to note that in this same era nursing was very intent on articulating
the essence of nursing. Part of this move was to distinguish each
discipline as ‘distinct’ in an era of competition for territory in
the health domain (Saks, as cited in Taylor & Field 1998). The
establishment of occupational science, marking occupational
therapy as having a rightful place with the University, created
an avenue to lead and show the way for generating a greater
understanding of occupation.
Conclusion
Having reviewed the historical and contemporary literature, the
question that now arises is ‘how is society currently shaping our
understandings of occupation, and therefore the mode of practice
of occupational therapists?’ It is not possible for any discipline in
the current context to escape expectations such as using evidence
to underpin practice, cost effective service, or proof of useful
outcomes. Yet, it behoves the profession to explore who the voices
are behind such powerful shapers. The research by Reed et al.
(2010) moved beyond the broad societal shapers to hear the voices
of the individuals engaged in occupation. The findings of the study
revealed the limits of theoretical models of practice that did not
appreciate the dynamic, contextual, relational and ever changing
understanding of occupation. Our challenge is to once again
return to a moment of authentic questioning when, recognising the
inescapable shapers, occupational therapists resolutely decide how
their practice can most effectively serve society. Shaping itself is a
dynamic unfolding in which those being shaped can resist, explore
and propose. Let our shaping be in the image of what works for the
recipient of occupational therapy. Let us listen to them. Let us take
their voice to the table of shapers.
Key points
n
n
Different meanings of occupation have built up over time
Occupation became a notion that was named, framed and
conceptualised as the domain of occupational therapy
Volume 60
No 1
n
n
FEATURE ARTICLE
A connection between occupation and health was recognised
Knowledge of the historical context has the potential to assist
with the conceptualisation of current and future practice.
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Kirk Reed, Clare Hocking & Liz Smythe
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NZAOT are the proud hosts of the 6th Asia Pacific
Occupational Therapy Congress in 2015.
Held at the Rotorua Energy Events Centre, expect
a huge exhibition gallery displaying the best product
and services available in the Asia Pacific region.
Clear your diaries now!
REHABILITATION HEALTH PROFESSIONAL REQUIRED:
SOUTH CANTERBURY and SOUTHLAND
Advantage South has a vacancy for a skilled, enthusiastic
Occupational Therapist to join our community rehablitation service in
South Canterbury and in Southland districts.
Advantage South specialises in the delivery of community based
rehabilitation and vocational services for people with injury-related
needs. We have a particular focus on return to work services.
We are looking for a full time therapist with the following
qualifications and experience:
• Current NZ Occupational Therapy registered health professional
• 2 years or more clinical experience in rehabilitation services
• High level of organisational and self-management skills
• Excellent report writing skills
• Current driver’s license
This role is for a full time position, but there can be negotiable hours
and we will consider part time commitment, at a minimum of 0.6 FTE.
The salary and conditions are very competitive.
If you are looking for a challenging, interesting job where you are
working closely with other disciplines and providing client centered
care, then you need to contact us!
For further information or to submit a letter of application,
please contact:
Chris Nolan – Managing Director, PO Box 129, Cromwell
Phone: 03 445 0300
Email: referrals@advantagesouth.co.nz
Applications close Tuesday, 30 April 2013
44 6TH ASIA-PACIFIC OCCUPATIONAL THERAPY CONGRESS
DOING WELL TOGETHER
14 – 18 September 2015
Rotorua, New Zealand
NZAOT Clinical Workshops, 18-20 SEPT 2013
Registrations open – June 2013
Late registration applies – 16 August 2013
Last clinical workshops until 2016
Mark your diaries to attend this year NOW!
www.nzaotevents.com
Venue: Copthorne Hotel and Resort,
Solway Park, Masterton
New Zealand Journal of Occupational Therapy
WEBSITE: www.nzaotevents.com
EMAIL:
nzaot@cmsl.co.nz
Volume 60
No 1
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