15
Therapeutic Recreation
Jean Folkerth
Richard Paulsen
Robert Frost
Handicapper fishing site with “balconies” for wheelchairs, St. Clair County.
(Photo courtesy of
Theodore Haskell.)
Therapeutic Recreation is considered an emerging profession in health care settings. Because of the
Americans with Disabilities Act (ADA), the need for persons with degrees in therapeutic recreation to
provide recreation or recreation consultation for persons with disabilities is growing. The two national
professional membership organizations offer similar, but different definitions of therapeutic recreation (TR).
According to the National Therapeutic Recreation Society (NTRS) therapeutic recreation is:
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Practiced in clinical, residential, and community settings, the profession of therapeutic recreation uses treatment,
education, and recreation services to help people with illnesses, disabilities, and other conditions to develop and use
their leisure in ways that enhance their health, independence, and well-being (National Therapeutic Recreation Society,
1994).
The American Therapeutic Recreation Association (ATRA) offers the following definition of therapeutic recreation:
Therapeutic Recreation is the provision of Treatment Services and the provision of Recreation Services to persons with
illness or disabling conditions. The primary purpose of Treatment Services, which are often referred to as Recreation
Therapy, is to restore, remediate or rehabilitate to improve functioning and independence as well as reduce or eliminate
the effects of illness or disability. The primary purpose of Recreation Services is to provide recreation resources and
opportunities in order to improve health and well-being. Therapeutic Recreation is provided by professionals who are
trained and certified, registered or licensed to provide Therapeutic Recreation (American Therapeutic Recreation
Association, 1987).
Within the field, therapeutic recreation is practiced differently dependent on the population, setting, philosophy of the
agency and reimbursement. It is expected that therapeutic recreation services are delivered by persons whose minimal
qualifications are that the person has a degree in therapeutic recreation and/or is certified by the National Council for
Therapeutic Recreation Certification. The person so certified is a Certified Therapeutic Recreation Specialist
(CTRS).
How the Field Developed in Michigan
The history of therapeutic recreation in the State of Michigan does not reach as far back as most of the other areas of
recreation service, but in it’s comparatively short lifeline, therapeutic recreation has taken a “fast-track” in emerging as a
reputable health service provider.
Therapeutic recreation’s early roots can be traced to our state institutions for persons with emotional and mental
impairments. In the late 1940s, state facilities, like Traverse City, Oak-dale, and Kalamazoo Hospitals, began to shift services
from custodial to more active forms of care, including activity programs. After World War II, the Veterans Administration
Hospitals also introduced “medical recreation~~ services aimed at improving the social and emotional adjustment of their new
resident clients. In the 1950s, recreation services people appeared in large private psychiatric facilities, like University of
Michigan Hospital and Pine Rest Hospital in Grand Rapids. These early forerunners of therapeutic recreation were called
Activity Therapists. During this decade, the value of recreation services was also recognized in expanded programs within prison
settings and community centers. The growth of recreation for persons with special needs resulted in the first state conference in
1957, the Michigan Activity Therapy Conference.
The 1960s and 1970s were a boom era for therapeutic recreation. The creation of enabling legislation,
the “deinstitutionalization” of state facilities, the advent of professional curricula and the foundations of
professional organizations all paved the way for the profession of therapeutic recreation to blossom. In 1963,
federal legislation created Community Mental Health services. This led directly to the shifting of services
from Michigan’s state hospitals to the providing of community-based services for persons with emotional or
mental impairments. These outpatient or day treatment programs featured recreation as a key component of
their services. Programs and facilities emerged with recreation for special populations as their main focus,
including specialty camps like Indian Trails (physical impairments) and Teushmaheta (visual impairments)
in West Michigan, being prime examples. In 1968, the Michigan Special Olympics was inaugurated.
Accessibility and “least restrictive environment” were legislative concepts that pushed recreation into
community settings. In the mid-1970s, the Tri-City Therapeutic Recreation Program was launched. This
program focused on serving the special population community of Wayne, Westland, and Garden City. This
was the first of many Michigan communities to provide special recreation programs within the traditional
parks and recreation departments.
In 1974, under a federal grant from the Bureau of Education for the Handicapped, the first Michigan
professional therapeutic recreation curriculum was established at Michigan State University. It was around
this time that the body of knowledge in therapeutic recreation began to take form in textbooks and
professional journals, like the Therapeutic Recreation Journal. By the late 1970s, therapeutic recreation
had become an established branch of the main state recreation organization, Michigan Recreation and Park
Association (MRPA).
As much as the time frame of the 1960s through the 1970s was that of foundation building, the time
frame of the 1980s to the mid-1990s can be characterized as that of creating professional depth and
definition for therapeutic recreation. Early in the 1980s the National Council for Therapeutic Recreation
Certification (NCTRC) assumed responsibility for the certification and recertification of therapeutic
recreation professionals. The research and development of this organization led to the first national
certifying exam being administered in 1990. In 1984 numerous therapeutic recreation practitioners created a
second organization to service the profession, the American Therapeutic Recreation Association (ATRA). A
Michigan chapter of ATRA was created in the early 1990s. The professional organizations in this time frame
worked to legitimize the role of therapeutic recreation in health care services. They created standards of
practice, codes of ethics, and an enhanced body of knowledge via research and publications.
The practice of therapeutic recreation responded to shifts in health service delivery by programming
for shorter hospital stays in clinical settings. The shift away from hospitals also created the need for
therapeutic recreation services to assist in the transition back to life in the community for special
populations. Therapeutic recreation programs in the areas of return to work, community reintegration, and
partial hospitalization are examples of this trend.
The last decade (1980s) has seen the number of certified therapeutic recreation specialists double to
almost 700 in the mid-1990s in the State of Michigan. The expansion of the field in the 1980s is also seen by
the creation of seven colleges or universities providing academic preparation in therapeutic recreation. The
professional organizations representing therapeutic recreation in the State of Michigan now number seven
and annually offer over 70 different workshops or conferences.
The history of therapeutic recreation in the State of Michigan is really rather remarkable given its late
inception. Therapeutic recreation has emerged from a diversionary service within custodial care to a frontrunner in today’s changing health services. With a projected growth rate of 20% through the year 2000,
therapeutic recreation will need to continue its rapid development for years to come.
144 Recreation in Michigan: Great Professional Opportunities
Therapeutic Recreation in
Clinical Health Care
Due to the changing nature of the health care system in this country, the field of therapeutic recreation
also has been going through changes. Agency accrediting bodies, such as the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) and the Commission on Accreditation of Rehabilitation
Facilities (CARF), third party reimbursement companies and managed care providers, are demanding that the
profession become more accountable for their outcomes. This will change the way therapeutic recreation
professionals think about their responsibilities to their patients and how they perceive themselves.
The profession has long believed that there is a process in the delivery of therapeutic recreation
services. This process is what all recreation therapists do, regardless of the patient population. The process
consists of assessment, planning, implementation and evaluation.
Assessment is the first step in the process. It is, therefore a very crucial step. It is assessment that tells
the recreational therapist7 (RT) how and at what level the patient is functioning. To do this effectively, the
RT must assess the client in at least four behavioral domains:
physical, social, emotional and cognitive. Since an RT’s expertise is in the area of recreation and leisure, it is
generally accepted that the client also must be assessed in the areas of leisure attitudes, skills and knowledge.
In many clinical settings the recreational therapy program is not being reimbursed by third party payers, thus
some programs are not determining specific functional skills in relation to the four behavioral domains, but
are using recreation and leisure assessments only.
To assess a client, the RT may use a variety of assessment instruments or just one. Most agencies try to
use a “commercial” assessment instrument that has had validity and reliability tests completed on it. These
assessment instruments measure functional abilities, e.g., Leisure Competence Measure (LCM) or the
Comprehensive Evaluation in Recreation Therapy (CERT), or they measure leisure attitudes and knowledge,
e.g., Leisure Diagnostic Battery (LDB). To determine a person’s leisure interests and skill level, most
agencies design their own assessment tool. While using the assessment instruments, the RT must utilize
observation and communication skills to ensure that clients not only understand what is being asked of them
but also begin to form a trusting relationship with the RT. At the completion of the assessment, the RT
summarizes the assessment findings in relation to the client’s strengths, weaknesses and functional abilities.
Planning is the second step in the therapeutic recreation process. Following the completion of a
client’s assessment, the RT must write an individual treatment plan. According to ATRA’s Standards of
Practice (1994) and NTRS’s Administrative Guidelines (1990), the treatment plan must include long and
short term goals, behavioral objectives, intervention strategies, outcome evaluation procedures and discharge
or transition plans (Carter, Van Andel & Robb, 1995). Within the planning phase, the RT is also considering
all the information received from the treatment team and making treatment and program adjustments
accordingly. In addition to writing treatment plans, the RT is responsible to ensure that the resources are
available for the client’s treatment.
Implementation is the third step in the therapeutic recreation process. It is within this step that the RT
draws upon his/her leadership skills and any special knowledge that will enhance the client’s treatment. The
RT’s listening and understanding skills are brought once more into
7 Recreational Therapist (RT) will be used in this section only since most persons working in therapeutic recreation
in the clinical area are referred to as Recreational Therapists.
Therapeutic Recreation 145
action to form a clinical bond with the client and encourage recovery. It is within this step that a thorough
understanding of activity analysis and the adaptation of both activities and equipment is necessary. When
implementing the client’s individual treatment plan, the RT must be aware of the client’s goals, any
behavioral interventions required and the client’s actual behaviors during all the sessions. Depending on the
agency, the RT will document treatment sessions and client behavior within those treatment sessions on a
daily or weekly basis.
Evaluation is the last step in the therapeutic recreation process. It is at this step that the RT collects
data and develops a discharge plan for the client. It is now that the RT must report to the treatment team on
the effectiveness of the treatment and whether the client improved his/her functioning by achieving the
established outcome measures. The treatment team as a whole determines whether to revise, continue or
discontinue treatment.
Settings
Health Care Services
The therapeutic recreation process (see preceding section) is applied in a variety of health care settings,
such as Sinai Hospital (rehabilitation), Stepping Stones Pediatric Center (children, outpatient, TBI), St.
Joseph TBI Community Re-entry Program (adult, outpatient, TBI), and Chelsea Community Hospital (all
disabilities). An illustrative case study of Chelsea Community Hospital is presented.
Chelsea Community Hospital. Chelsea Community Hospital is a community owned, not-for-profit,
acute care hospital in the Village of Chelsea. It provides services for persons in the Washtenaw County area
and is a 113-bed facility. Chelsea Hospital offers recreational therapy services to patients in the psychiatric,
rehabilitation, older adult, chemically-dependent, and head pain inpatient units and brain injured day
treatment programs through both individual and group treatment. The RT (Recreation Therapy) department
consists of a director, three full-time and two part-time CTRSs. Each therapist is primarily responsible for a
specific unit but is able to work with patients from other units through programs that combine unit activities.
The Mission of the Recreation Therapy department is
to renew and discover one’s passion for life. Through education and experience we will provide an
environment where patients, families, and community members feel safe and respected as they take
risks to realize their talents, interests, and abilities. We believe that therapeutic leisure activities
empower people to enrich their quality of life, instill self-respect and discover their potential to
contribute to the well-being of themselves and others. We are committed to people living lives that
they love (Chelsea RT Departmental Mission, 1994).
...
Each year the department services over 11,000 persons through its inpatient and some specialized
outpatient programs. Each unit offers a variety of programs dependent upon the needs of the clients and the
skills of the therapists. There are a variety of interdisciplinary groups co-led by Recreational Therapists,
Occupational Therapists, Speech Therapists, Social Workers and Nurses. Functional Living Skills, Tuesday
Lunch Special, Assertiveness, Distress Tolerance, and Family Day are examples of these groups. The
department also provides
146 Recreation in Michigan: Great Professional Opportunities
therapy programs in the areas of sports/fitness, leisure education, and arts and expressive activities. To participate in RT, patients
on the medical units and adolescents from the head pain units must have a referral from their doctor. The RT department also
offers “combined” activities open to patients from all units in the evenings and weekends, rotating around activity themes based
on social games, leisure education, horticulture, entertainment, crafts and pet therapy.
Since Chelsea is a community hospital, some of its most innovative and exciting programs are the outreach programs that
are available for persons in the community who have special needs. “Partners in Golf” is a golf workshop for the physically
impaired which receives much attention every year. “Playing Through” is a drop-in golf league, which has the physically impaired and the able-bodied playing together. A different type of program is REConnection Day which offers a sampling of
leisure activities adapted to meet the needs of persons with physical, mental or social challenges. The Traumatic Brain Injured
Camp is an annual event and includes 15 campers who are survivors of traumatic head injuries. An interdisciplinary team, including physical, occupational, speech and recreational therapists, social workers and nurses, accompany the clients. It is a
week-long residential program which allows the participants to re-engage in leisure activities and be with others who have
sustained similar injuries.
Thus, it can be seen that the Recreational Therapy Department at Chelsea Community Hospital offers a comprehensive
program, which serves a variety of populations and provides a variety of inpatient and outpatient treatment and recreation
programs.
Special Recreation Services
Therapeutic recreation also provides programming through community recreation. It differs from the health care settings
by its application of the TR process.
According to the 1990 United States Census, approximately 485,000 Michigan citizens with disabilities live, work and,
recreate in their communities. Since the early 1970s, specialized units within local recreation and park departments have
provided services that specifically address the leisure needs of people with disabilities. Non-profit advocacy and support
organizations providing a variety of services to persons with specific disabilities and their families have included recreational
programming in their offerings, particularly at the local level, since their inception. Examples of such organizations include:
Association for Retarded Citizens, United Cerebral Palsy, and Little People of America. Special recreation services differ from
therapeutic recreation services in that the focus is not on medical treatment. Kennedy, Smith and Austin (1991) describe special
recreation as a leisure service that modifies equipment, environment, and access to enable persons with disabilities to participate
in community-based leisure experiences. The term “special recreation” often is used in reference to the specialized nature of the
assistance provided to enable participation.
Support and Advocacy Organizations. Michigan is unique because organizations that support the needs of persons
with disabilities do not typically provide services directly to their membership. Organizations, such as United Cerebral Palsy of
Michigan and the Association for Retarded Citizens, focus their resources on advocacy, education and referral. Services such as
day care, vocational training and recreation are accessed through existing community-based programs offered by churches,
schools, municipalities and human services organizations.
148 Recreation in Michigan: Great Professional Opportunities
Therapeutic Recreation 147
Community Services
In Michigan, special recreation services have been provided through municipal government, county
government, and non-profit support organizations. Examples of each class of special recreation service
highlight the role of recreation, program offerings, and management.
Sterling Heights. The City of Sterling Heights’ Special Recreation Program was the 1994 Special
Recreation Award winner for cities under 200,000 in population. During its award winning year, 650 persons
with special needs were provided opportunities to participate in 35 different activities. Professional
leadership was used to plan and implement 386 sessions which served 10,753 participants.
Programs were developed to provide the citizens of Sterling Heights a variety of leisure opportunities.
Programs included: Super Saturday for the Artistic, Sports Night, Early Childhood Learning Program, Day
Camp, Recreation Plus Club & POHI Teen Club, Wheelchair Tennis and Basketball, Dinners Club, Dance,
Choral Group/Music Lessons and Travel Club. As a result, persons with mental, physical, auditory, and
emotional impairments were provided with opportunities to actively participate in the life of the community
throughout the year.
The Sterling Heights Special Recreation Program is a unit within the Parks and Recreation Division of
the Department of Community Services. Staffing throughout the year varies from 13 to 30 part-time/seasonal
employees. Professional full-time staff includes the Program Coordinator and the program assistant. They
function as a team to plan, manage, and supervise staff and programs.
Oakland County Parks and Recreation. Oakland County employs a certified therapeutic
recreation specialist (CTRS) to serve primarily as a consultant to constituent communities and to coordinate
large events for persons with disabilities. Efforts by constituent communities to provide “inclusive” (the new
term under ADA) recreation services are supported by the county consultant educating recreation leaders in
appropriate modification techniques for persons with disabilities enrolled in their programs. During 1994 the
county directly served constituents through coordinated events, enabling nearly 9,000 recreation
participations by persons with disabilities. Programs include activities such as: cerebral palsy state games,
disabled aerobics, recreation and respite, and wheelchair basketball.
While one county therapeutic recreation specialist facilitates a variety of recreation services in the
county, as in other public agencies, it should be recognized that volunteers play a significant role in
providing leadership and assistance in the many programs offered throughout the year.
Professional Organizations
There are two national professional membership organizations with Michigan affiliates, as described in
“How the Field Developed in Michigan.” The National Therapeutic Recreation Society (NTRS), a branch of
the National Recreation and Park Association (NRPA), was founded in 1965. Its focus is on the provision of
services in both health care and community settings. The American Therapeutic Recreation Association
(ATRA) was founded in 1984. It is an independent organization with its primary focus being the delivery of
therapeutic recreation services in health care settings.
The profession also has an independent certifying agency, not a part of either professional organization.
The National Council for Therapeutic Recreation Certification (NCTRC) was
Therapeutic Recreation 147
formed in 1981 and is responsible for the management and administration of certification and recertification
standards for therapeutic recreation personnel. In the State of Michigan most therapeutic recreation positions
require that the person be certified by NCTRC. Most students who graduate from a therapeutic recreation
program at a Michigan college or university will be eligible to take the certification examination, given twice
a year. A person who has been awarded the credential is called a “Certified Therapeutic Recreation
Specialist” (CTRS).
Michigan, itself, has two statewide professional membership organizations and several regional
organizations. The statewide professional organizations parallel the national membership organizations. The
Therapeutic Recreation Committee is a committee of the Michigan Recreation and Park Association
(MRPA). It works within the state to ensure recreation services are available for persons with disabilities. It
also provides a TR Institute every June. The Michigan Therapeutic Recreation Association is a state affiliate
of the ATRA. Its focus is primarily on needs of persons who work in health care settings. It provides a oneday workshop in the fall. The Activity Therapy Conference is a group of professionals from a variety of
health care settings who sponsor a workshop every fall in therapeutic recreation. Its only purpose is the conference and, thus, is not considered a professional membership organization.
There are also a variety of active local and regional groups in Michigan, such as the Metro-Detroit TR
Association. These groups focus on local problems and needs and serve as an excellent networking
opportunity. It is desirable for professionals to participate in both a national organization and its Michigan
affiliate and a local or regional organization, if one is in the vicinity.
Career Opportunities
Therapeutic recreation has been described as one of the “hottest” professions of this decade (the
1990s). In fact, recreational therapy is identified as the 14th fastest growing profession requiring a bachelor’s
degree. Nearly 33,000 therapeutic recreation specialists were employed in 1990. There is an expected 39%
increase in employment opportunities through the year 2005 (Occupational Outlook Quarterly, Spring
1992).
Therapeutic recreation specialists are employed in a variety of health care settings, such as physical
rehabilitation hospitals, psychiatric treatment facilities, substance abuse treatment programs, and geriatric
care programs. These provide opportunities for the therapeutic recreation specialist to work as a member of a
medical treatment team. In many of these settings a therapeutic recreation specialist may work with inpatient
units or outpatient services. There also are some positions in the community services settings with local
government recreation departments, and limited positions with support and advocacy organizations. (See
comments in next section.)
Therapeutic recreation specialists working in entry level positions can expect to earn between
$18,000—$24,000 per year (1995). This range is affected by geographical location and by the type of
organization. Clinical rehabilitation services positions are at the high end of the salary range with geriatric
services (nursing homes) positions at the lower end of the range. Community setting positions usually are
mid-range.
Therapeutic Recreation 149
Future
Changes in the funding of health care and health care delivery will have a direct effect on the provision
of therapeutic recreation services. If the profession is able to demonstrate effectiveness of care through
patient outcomes and documentation of treatment practices, the resulting demonstration should legitimatize
including therapeutic recreation services in various health care delivery systems.
Community-based organizations, primarily local park and recreation departments, also hire therapeutic
recreation specialists to manage special recreation services for their constituents. As a result of expectations
placed on local park and recreation departments by the Americans with Disabilities Act (ADA), therapeutic
recreation specialists also may be sought to fill general recreation leadership positions.
The ADA with its philosophy of “inclusive services” is presenting new challenges to the provision of
recreation services in Michigan communities. Including persons with disabilities in the activities of the
community has always been part of therapeutic recreation. Renewed emphasis has been placed on the
increased participation of persons with disabilities in non-special recreation programs in the regular ongoing programs. As a result, general recreation leaders need to develop attitudes, knowledge, and skills that
will enable them adequately to serve any citizen who participates in an activity they offer. Notwithstanding,
it is expected that Special Recreation Services will continue to be provided to meet affiliation, social, and
skill development needs of persons with disabilities.
References
American Therapeutic Recreation Association (1987). Definition Statement. Hattiesburg, MS:
American Therapeutic Recreation Association.
American Therapeutic Recreation Association (1993). Standards for the Practice of Therapeutic
Recreation and Self Assessment Guide. Hattiesburg, MS: American Therapeutic Recreation
Association.
Carter, M.J., G. Van Andel, & G. Robb (1995). Therapeutic Recreation: a Practical Approach. (2nd
ed.) Prospect Heights, IL: Waveland Press.
National Therapeutic Recreation Society (1994). Definition of Therapeutic Recreation. Arlington, VA:
National Recreation and Park Association.
National Therapeutic Recreation Society (1990). Guidelines for the Administration of Therapeutic
Recreation Service. Alexandria, VA: National Recreation and Park Association.
Recreation Therapy (1992). Occupational Outlook Quarterly.
150 Recreation in Michigan: Great Professional Opportunities