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The practice of occupational therapists working with adults with learning disabilities has evolved over time in the United Kingdom and was influenced by service philosophy and settings. In the past, occupational therapists worked in institutions such as large

hospitals or day centres for adults with learning disabilities. People with learning disabilities, by definition, have difficulties with social functioning, so occupational

therapists’ focus has always been ‘on the ability or competence of an individual and the skills needed to live as full a life as possible’ (Locke et al 2009, p248). This experience of practice evolving and developing is not unique to occupational therapists working with adults with learning disabilities. Occupational therapy practice has a history of constant change as it adapted to working within different settings and services resulting in a ‘developmental sequence in the acquisition of knowledge’ (Hagedorn 2001, p20). Creek (2003) suggests that from this process, occupational therapy constructs

developed which include a shared value, belief and knowledge base that includes the belief that there is a basic human need to act by performing tasks and activities which ‘places demands on the individual to learn, adapt and respond, therefore, action facilitates change and personal development’ (Creek 2003, p28). Yerxa (2014) suggested that occupational therapy ‘practice is …the implementation of our belief in the inherent wholesomeness of activity’ (Yerxa 2014, p12) and acknowledged that this has developed differently in various countries as people organise their activities into routines that relate to their culture. Occupational therapy practice is affected by ‘’the

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context of social, political, economic, ethnic and gender circumstances and

values…[and]… it is recognised that this reality will continue to evolve in relation to internal and external developments’ (Creek 2003, p10).Hagedorn (2001) suggests that it was not until the 1960s that occupational therapists started to develop their own professional theories and body of knowledge.

Schön (1991) suggested that a professional knowledge base was traditionally seen in terms of a model of technical rationality where problems were solved by using scientific knowledge. This led to occupational therapy applying similar principles to those that had been used in established professions such as medicine and so the occupational therapy professional started to identity with a reductionist philosophy based in

rationalism and logical positivism and focused on the biomedical model of disability in which a problem or condition was identified and treated.

Schön (1991) suggested that from the early 1960s there were concerns about the limitations of traditional professional practice and knowledge. The technical rationality perspective of problem solving ignored that, in the real-world, practice situations are unique, can be complex and do not have clear remits or predictable outcomes. Often non-technical processes are required to identify what the problem is that needs to be addressed in a specific context and so practitioners use ‘artistic ways of coping with these phenomena’. Schön (1991) used the metaphors of ‘high, hard ground where practitioners can make effective use of research-based theory and technique and… swampy lowland where situations are confusing “messes” incapable of technical solution’ (Schön 1991, p42). The practitioner in attempting to meet scientific rigour may be constrained by this process and so fail to address what was most relevant for the client.

In the United Kingdom, exposures in the British press in the 1960s highlighted the abuse and poor treatments that some people with learning disabilities were

experiencing in hospital settings. This led to the publication of the white paper Better Services for the Mentally Handicapped (DHSS 1971) that led to the policy of moving people with learning disabilities out of institutional, medically-led settings to be living ordinary lives in the community taking into account their wishes and rights. A social model of disability, rather than a medical model came to be adopted by practitioners as services changed to become more community focused and person-centred.

Wolfensberger (1972) built on theories from Scandinavia, where people with learning disabilities had been supported in community settings from the 1950s, to criticise the

17 existing institutional practices in North America. He proposed that services should be organised taking into account the ‘normalization’ principle which he described as the ‘utilization of means which are as culturally normative as possible in order to establish and /or maintain personal behaviours which are as culturally normative as possible’ (Wolfensberger 1972, p28). These principles continue to influence policies for services to support people with learning disabilities in this country.

Law et al (1995) re-emphasised the person centred approach to occupational therapy practice underpinned by the concepts of autonomy, choice and that each person has their own perspectives on what is important for them in their lives. They have the right to be provided with information about their occupational therapy so they can be enabled to make their own decisions. Person centred practice ‘involves therapeutic rapport and a collaborative relationship’ (Fisher 2009, p52) with the person and the occupational therapist working in an equal partnership and sharing the responsibility to meet goals that reflect his or values. The importance of person centred practice

continues to be a central focus of occupational therapy with the expectation that occupational therapists are committed to ‘person-centred practice and the involvement of the service user as a partner in all stages of the therapeutic process’ (COT 2015a, pv).

In the United Kingdom, Jones (1995) reported that there had been rapid changes in how services for adults with learning disabilities were being provided and advocated for occupational therapists to change from their traditional approaches that emphasised the developmental acquisition of skills in segregated settings to a competency based approach developing skills in the place where the person needs to use them. The previous emphasis on working directly with people with learning disabilities in an institutional setting was replaced with more ‘emphasis on consultation and teaching roles with carers and or others, whilst maintaining the occupational basis for

intervention’ (Locke et al 2009, p248).

The changes in services appeared to have resulted in a review of the role and remit of occupational therapy within this specialism which was explored in four studies.

Llewellyn (1991) and Tannous et al (1999) explored the perceptions of occupational therapists working with people with learning disabilities in Australia and Lillywhite and Atwell (2003) completed a similar study in the United Kingdom. Adams (2000) gathered the views of health and social care managers, members of the community learning disability team, house managers and support staff in England. The findings of these

18 small scale studies suggested that occupational therapists working with adults with learning disabilities were supporting people to enhance their independence and quality of life. Occupational therapists were perceived as complementary and enriching to the multidisciplinary team approach. However, there were some concerns regarding how the occupational therapy role was understood by others and the restrictions on the occupational therapists’ ability to work holistically due to the expectations of other professionals or service demands.

The Government White Paper, Valuing People (Department of Health 2001) addressed how people with learning disabilities should be supported in England and clarified that they should not be excluded from generic services. For example: some services had been developed to provide equipment to address the physical needs of a person with learning disability and this was provided to the exclusion of other interventions. This resulted in people with learning disabilities being excluded from receiving the expertise and up-to-date knowledge of the specialist occupational therapists in these specific conditions and also not receiving the specialist occupational therapy to address the occupational performance concerns that were directly related to having a learning disability. In the United Kingdom, the principles for practice were developed (COT 2003) (see Table 1.1) to clarify the role of occupational therapists working in this specialism. Valuing People Now: A new three year strategy for people with learning disabilities ‘making it happen for everyone’ (Department of Health 2009) emphasised the need for partnership structures to be in place so that agencies including health and social care could work closer together.

The context of services described in some of the international literature regarding occupational therapy practice working with people with learning disabilities would often not meet the expectations of the practice principles (COT 2003, Table 1.1) and so it can be a challenge to consider the findings as relevant and ethical evidence to apply to practice. The contexts are often institutionalised settings such as residential homes, day service provision or sheltered workshops. Mahoney et al (2016) completed a study to review how people with learning disabilities demonstrate occupational engagement in a day service in the United States of America. No occupational therapists worked in this facility and one to two day centre staff worked with groups of eight to twelve adults with learning disabilities in sessions lasting one to two hours. The authors

acknowledged that staff struggled to engage with more than one person at a time within these groups but did not recommend that a more person-centred service approach may be beneficial. Cullen and Warren (2013) reviewed an occupational

19 therapy service for adults with learning disabilities in Ireland and found that the

occupational therapy role in this speciality was poorly understood. However, the most common interventions were addressing the physical mobility needs of adults with learning disabilities.