CONCLUSIONES

Born in Massachusetts, Mary Reilly graduated from the Boston School of Occupational Therapy. Early in her career she entered military service as Chief Therapist at the Lovell General and Convalescent Hospital at Fort Devens, Massachusetts. Her later work at Fourth Service Command

included supervising occupational therapy programs in 11 general, 2 convales-cent, and 6 regional and station hospitals. Reilly retired from the army in 1951 with the rank of captain. She earned a doctorate in education in 1959 and later became Chief of the Rehabilitation Department at the Neuropsychiatric Institute at UCLA. She served as a professor at the University of Southern California until retiring in 1977.

As early as 1958, Reilly began to advocate for a change in occupational therapy education and knowledge to incorporate a broader focus on the meaning of produc-tivity and engagement in society and in individual lives. She argued that the human need for engagement in play and work was the foundation and raison d’être of the profession. In her 1962 Eleanor Clarke Slagle lecture, Reilly proclaimed occupational therapy to be “one of the greatest ideas of 20th century medicine.” She stated that the field’s bold hypothesis was that “man, through the use of his hands as they are en-ergized by mind and will, can influence the state of his own health” (Reilly, 1962, p. 2).

In this paper, Reilly challenged the field to move beyond its mechanistic focus and recommit to the focus on occupation.

Although Reilly’s writings are not extensive, her work was critical in shaping the movement from the paradigm of inner mechanisms to the contemporary paradigm.

This was accomplished largely through her work in directing graduate students at the University of Southern California. She led them to develop a body of knowledge that she termed “occupational behavior” to emphasize that the field’s knowledge should focus on occupation. She envisioned occupational behavior as the therapeutic frame-work for practice and education. Reilly contributed to this body of knowledge with her book Play as Exploratory Learning (1974). This text was the first serious treatment of the topic of play in the field.

In sum, Reilly was a pivotal figure in shaping the contemporary directions of the field. Her call for a refocus on the theme of occupation came at the time when the field was steeped in the mechanistic paradigm and went unheeded for a period of time.

Through her own writings and those of her students, she was able to provide the field with a broad and scholarly understanding of the complex phenomena with which occu-pational therapists work. Her contribution in shaping the direction of the field places her as one of the most influential scholars in modern occupational therapy history.

Focal Viewpoint

The focal viewpoint of the new paradigm reflects not only a return to occupation, but also a particu-lar way of thinking about what factors influence occupational performance. This viewpoint is de-signed to correct the exclusive emphasis of the mechanistic paradigm on clients’ impairments as the primary or sole problems to be addressed in therapy. It also reflects two important influences from outside occupational therapy: disability scholarship and systems theory.

Disability scholars emphasized that disability is not simply a consequence of impairments. They argued that disability is caused by environments that pose physical, attitudinal, economic, and political barriers (Charlton, 1998; Hahn, 1985;

Oliver, 1996). Moreover, they pointed out that, if environments are adequately supportive, peo-ple with impairments can participate in life in the same ways as their peers who do not have impairments (Crow, 1996; Fine & Asch, 1988;

Longmore, 1995; Shapiro, 1993). Albeit from a different vantage point, systems theorists made a similar argument. They noted that human thought, feeling, and action were consequences not only of factors inside the person, but also of characteristics of the person’s context including the nature of any task in which the person was engaged (Capra, 1997; Kelso, 1995; Thelen &

Ulrich, 1991; Vallacher & Nowak, 1994).

Person, Environment, and Occupation The focal viewpoint of the current paradigm in-corporates elements of both previous paradigms as well as ideas from disability studies and sys-tems theory, as noted earlier. It is focused on the interaction of person, environment, and occupa-tion (Christiansen & Baum, 1997; Dunn, Brown,

& McGuigan, 1994). This focal viewpoint em-phasizes that all occupational performance is a consequence of the interaction of person, envi-ronment, and occupation factors (Fig. 5.1).

Person factors are generally understood to include such things as underlying sensorimotor and cognitive capacities, skills, values, interests, and life experiences, as well as any impairments (American Occupational Therapy Association, 2002). The environment consists of those phys-ical, cultural, social, economic, politphys-ical, and

temporal contexts that affect various oppor-tunities for and influences on occupation (Christiansen & Baum, 1997; Dunn, McClain, Brown, & Youngstrom, 2003). The occupation refers to the specific task or activity that the person is doing and/or the goal of that task (Christiansen & Baum, 1997; Nelson, 1988).

Occupational performance is understood to emerge out of the interaction of these person, en-vironment, and occupation factors (Christiansen

Box 5.2 Definitions of Occupation

As the field sought to return to a focus on occupa-tion, different definitions have arisen. For instance, Christiansen, Clark, Kielhofner, and Rogers (1995) defined occupation simply as the ordinary and famil-iar things the people do everyday. Yerxa and her colleagues (1990, p. 1) defined occupation as “spe-cific chunks of activity within the ongoing stream of human behavior which are named in the lexicon of culture.” Kielhofner (2008, p. 5) defined occupation as “the doing of work, play, or activities of daily living within a temporal, physical, and sociocultural context that characterizes much of human life.” A definition offered by Canadian occupational thera-pists echoes these themes; it refers to occupation as

“the tasks and activities of everyday life, named, organized, and given value and meaning by individu-als and a culture” (CAOT, 1997, p. 34). Their defini-tion goes on to note that occupadefini-tion is everything that people do to occupy themselves, including “looking after themselves (self-care), enjoying life (leisure), and contributing to the social and economic fabric of their communities (productivity) (CAOT, 1997, p. 34).

Most definitions, then, agree that occupation comprises play/leisure, activities of daily living, and productivity. Play/leisure refers to activities under-taken for their own sake; exploring, pretending, cel-ebrating, engaging in games or sports, and pursuing hobbies are all examples (DiBona, 2000; Lobo, 1999; Parham & Fazio, 1997; Passmore, 1998).

Activities of daily living are tasks that maintain one’s self and lifestyle. They compose much of the routine of everyday life and include self-care, order-ing one’s life space (e.g., cleanorder-ing and payorder-ing bills), and getting to resources (e.g., travel and shopping) (Christiansen, 1994). Work includes productive activity (both paid and unpaid) that contributes some service or commodity to others as well as participat-ing in education or trainparticipat-ing that improves one’s abil-ities to be productive (Kielhofner, 2008).

& Baum, 1997; Dunn et al., 2003; Trombly, 1993). Thus, person factors alone cannot account for a person’s occupational performance since performance also reflects what the person is attempting to do and the context in which it takes place. This viewpoint guides occupational thera-pists to look beyond impairment to other person factors and also outside the person to the occupa-tion and the context. It also directs therapists to look beyond reduction of impairment to consider how environmental barriers can be removed and/or how occupations can be modified to allow persons to more fully participate in necessary and desired occupations. This perspective repre-sents a return to a more holistic viewpoint.

Core Constructs

As noted earlier, the contemporary paradigm has returned to a focus on occupation. Its core constructs include three broad themes that re-flect this focus:

•The importance of occupation to health and well-being

•Recognition of occupational problems/

challenges

•Occupation-based practice

The following sections discuss these themes.

The Role of Occupation in Health and Well-Being

There has been a growing recognition that occu-pation plays a central role in health and well-being. Humans have a strong drive to do things and flourish by engaging in practical, productive, and playful pursuits (Christiansen, 1994; Clark et al., 1991; Parham & Fazio, 1997; Wilcock, 1993). Through occupation (play, activities of daily living, and work), individuals fill their time, create the circumstances of their everyday existence, and make their place in the world (Christiansen, 1996; Wood, 1995). These occupa-tions contribute to development, provide neces-sary opportunities for physical and mental en-gagement, and connect people to their social and cultural environment (Clark, 1993; Hasselkus, 2002; Johnsson, Borell, & Kielhofner, 1997).

Moreover, participating in occupation creates and affirms meaning in life (Christiansen, 1999;

Hasselkus, 2002).

Occupational Problems/Challenges The contemporary paradigm recognizes problems of participating in occupations as the focus for service (Rogers, 1982). Persons who are denied access to or have restrictions in their occupations

Person Factors

• Sensorimotor, cognitive, and emotional capacities and impairments

• Skills, values, interests, life experience

Occupation

• The nature/goals of the task or activity being performed

Environment

• Physical, social, economic, political, and temporal context

FIGURE 5.1 The focal viewpoint: interaction of person, environment and occupation factors.

Box 5.3 Contemporary Occupational Therapy Around the World

Image rights not available.

may suffer and/or experience a reduction in quality of life (Christiansen, 1994). A lack or dis-ruption of participation in occupation may also restrict development, resulting in reductions of capacity and leading to maladaptive reactions.

Because of the potential negative consequences of such occupational deprivation, it is the central problem to which the field addresses its efforts.

Occupation and the Dynamics of Therapy

The third thematic area of the core constructs addresses the means and the goals of therapy. In

the contemporary perspective, the use of occu-pation to improve health status is once again recognized as the core of occupational therapy (Fisher, 1998; Reilly, 1962; Wood, 1998). As shown in Figure 5.2, therapists employ the ther-apeutic agency of occupation through four pri-mary pathways:

•Providing opportunities for clients to engage directly in occupations

•Enabling clients to engage in occupations by modifying the task or the environment in which the person performs, including removing architectural and social barriers Box 5.3 Contemporary Occupational Therapy Around the World continued

These images of occupational therapy worldwide demonstrate the field’s return to occupation-based practice. In this collage, occupational therapy in Africa, Asia, the Americas, and Europe engages

clients in valued occupations. Contemporary pists view their clients holistically and seek thera-peutic gains through the use of activities that are important to their clients.

Provide Technical Devices

Participation in Occupation Modify

Environments

Counsel/

Problem–Solve

Health Status Provide

Opportunities to Engage in

Occupation

FIGURE 5.2 Pathways to employ occupation as therapy.

(e.g., attitudes, discrimination, unfair poli-cies) (Dunn et al., 1994; Kielhofner, 2002)

•Providing training of clients in the use of various technical devices that extend limited capacity or compensate for lost capacity (Hammel, 1996)

•Providing counseling and problem-solving to facilitate the client’s participation in occupa-tions outside of therapy

Underlying these efforts is the recognition that clients’ engagement in occupations is the core of therapy. Engagement in occupation involves not only what individuals do but also their subjec-tive experience (Hasselkus, 2002; Yerxa, 1980).

Therefore, the client must find meaning in the actions that constitute the therapy. This meaning ordinarily derives from the client’s experiential background, the current impact of any impair-ments on the client’s experience, and the signif-icance of the therapeutic

activ-ity negotiated between the therapist and the client.

In the end, the meaning