History shapes our personal and professional identities. To recognize our core assumptions, beliefs, values, and practices as occupational therapists, it is imperative to understand our history and to acknowledge how we as individuals and the profession as a whole were and are informed. This article does not provide a detailed account of the history of occupational therapy in the United Kingdom (Wilcock, 2001); rather, it is a reflective account of the past, present, and future of the profession.
Reform as an Informant
The Age of Enlightenment (1715–1789) was stimulated by individualism, reason, skepticism, science, and faith in human reason. This period motivated the arts and crafts (1880–1920s) and moral treatment (1900s) movements, which remain as the foundation for the occupational therapy profession.
William Tuke (1732–1822) was a merchant and renowned philanthropist who responded to the neglect and extreme cruelty that he witnessed at the Quaker Retreat Asylum for the care of Quaker members in England in 1796. The asylum was described as a prison where patients would at times be shackled and chained. Tuke rejected medical theories and techniques and viewed mental illness as a disruption of the mind and spirit. His treatment practices were designed to cultivate rationality and moral strength, and patients engaged in a balance of work and leisure time. This treatment included rest, talk, chores, and manual occupations that provided a sense of contribution and purpose (Tuke, 1813).
Bing (1981) commented that the ethos of moral treatment sprang from “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” (p. 502). The principles of the moral movement suggested that (Stoffel, Reed, & Brown, 2019):
- The mind and the body should be treated together.
- An individual's history and capabilities should be assessed.
- The context of the environment can be adapted to promote mental health.
- Individuals may have special or unique needs to be included in their intervention programs.
- Healthy aspects of the individual can be used to treat less healthy aspects.
- Occupations can be used to occupy, distract, or amuse the individual to counter the effects of less productive thinking.
- New habits can be developed to replace less desirable habits.
- New learning can occur that may provide useful skills for dealing with everyday life.
As the enlightenment of society progressed, moral treatment shifted, theory evolved, and mental disease came to be seen as a legitimate concern for humanitarians and physicians (Reed, Hocking, & Smythe, 2013). The development of moral treatment created an opportunity to enable the reason and rationality of meaningful occupation to influence one's health.
Arts and Reform
Meanwhile, in England, social philanthropist, thinker, and art critic John Ruskin (1819–1900) considered that there were many forms of social reformation. Ruskin noted that the Industrial Era lacked morals, social freedom, and restoration, and he added that restoration of the human spirit through engagement in honest craftsmanship influences one's state of well-being (Ruskin, 1884). Ruskin believed that society was healthier when people were connected to their environment, their work, and religious values (Levine, 1987). He challenged the idea that all work was intrinsically good. For him, the only work that was valuable was work that was enjoyable to the person and was not degrading. He advocated for the use of the arts to release society from social restraint and enable expression through one's hands, and he proposed that schools teach artisan skills to stimulate the “art spirit” (Ruskin, 1884). As a result, Ruskin educated the working class for free. Through this movement, Ruskin met Octavia Hill (1838–1912). Wilcock (1999) described Hill as possessing a history of occupational reform from her upbringing. Her father believed in enabling social well-being through day-to-day occupations and influenced her views regarding the importance of a satisfying occupation. Upon his passing, she continued to position herself as a social housing reformer alongside Ruskin's vision to enable one to build purpose, which is understood today as a sense of “belonging . . . meaning, 'a life worth living'” (Hammell, 2004, p. 302).
Hill is acknowledged as having been instrumental in influencing housing for working people and social reform. She advocated for playgrounds, the Army Cadet Corps, access to common lands, and the need for public open space, which was evident in Hill's role as one of the founders of the U.K. National Trust (Smith, 2008).
Ruskin recognized Hill's abilities and employed her to copy art and teach at the men's college and later to manage houses for the poor. Hill did not believe in charity, but believed in enabling those who had lost hope to build self-respect. She was innovative in the breadth of her interventions, which began with addressing housing needs. She also considered employment, leisure, and education as well as socializing residents, refurbishing environments, and developing classes of projects with the vision to enable one to build purpose (Smith, 2008).
Occupation as a Freeing Principle
Through the moral and arts and crafts movements, Ruskin and Hill identified the influence of occupational choice on health and well-being, and this informed the foundations of occupational therapy. They identified the arts as the freeing principle that enabled one's hands to create meaning. Hill identified the environment as contributing to the meaning of a person's engagement in well-being. This concept later informed and influenced the work of Dr. Elizabeth Casson (1881–1954) in becoming a pioneer of occupational therapy (Wilcock, 1999).
Casson observed the link between residents' poverty and their ill health and decided to train as a doctor at the University of Bristol in the United Kingdom. She “had a moral and social conscience . . . she saw beyond the 'easy' to the 'difficult'. She looked for and saw what lay behind the poverty and disease” (Butler, 2004, p. 287).
Intersection of Occupation and Health Care
Facilitated by U.S. orthopedic surgeon Joel Goldthwaite and Sir Robert Jones, an orthopedic surgeon of Britain, occupational therapy has been recognized as being developed from the British model of rehabilitation, which included medical-mechanical treatment, physical therapy, massage therapy, vocational training, and engineering workshops (Pettigrew, Robinson, & Maloney, 2017). The surgeons claimed that their medical knowledge of injury made them the most suitable to manage all aspects of reconstruction, including physiotherapy, bedside occupations, curative workshops, and vocational reeducation (Gutman, 1995). Their treatment demonstrated the intersection of the moral and the arts and crafts movements that was being embraced by the medical model. Although opportunities to engage in occupation were made available, prescribed occupation lacked individual and meaningful purpose (Wilcock, 1993). The treatment did not appreciate the nature of the human person and the idea that the mind and the body should be treated together.
After World War II, the profession of occupational therapy continued to expand (Rosser, 1990), with an emphasis on enabling servicemen to return to vocational occupations. During the 1950s, the focus on occupation began to broaden the scope of practice. Domestic tasks and the independence of persons with long-term disabilities were recognized. Nevertheless, the occupational therapy profession began to experience pressure from the medical model to “establish a theoretical rationale and empirical evidence for practice” (Kielhofner, 2004, p. 44). The methods of the day did not provide an opportunity to measure restoration of the human through craftwork. As a result of the early medical influence and assumptions about occupational therapy (Reed et al., 2013; Wilcock, 2002), the profession began to describe practice from a biomedical perspective. This perspective included reductionist views of the body as a machine or a single system, causing a shift in perspective known as the mechanistic paradigm (Reed et al., 2013). This concept stood in contrast to the views of the founders of occupational therapy, who considered mind-body synthesis fundamental to the therapeutic use of occupation (Reed et al., 2013). Consequently, the view of occupation and its connection to health appeared to be slowly eroding as its focus narrowed (Engelhardt, 1977).
In the mid-1950s, Casson and Foulds (1955) outlined modern trends in occupational therapy. They acknowledged that although physical and mental diagnoses were treated in different locations, occupational therapy remained the same, with “two definite components; its mental motivation and its physical expression” (p. 113). They reported that “occupational therapy depends on the mental activity of the patient himself, stimulated by the therapist” (p. 113). They discussed the importance of individualized treatment and its application of occupation to disability, noting the essential components of the patient's interests, attention span, and capacity to engage. The modern trend described in the 1955 article concerned the need to combine an understanding of mental health, neurology, the elderly, surgery, psychology, and the development of social services and to recognize the variety of occupations “arbitrarily grouped” as creative, social and recreational, educational, and prevocational, all used to meet the needs of the patient.
Development of Professionalization in the United Kingdom
In the United Kingdom, occupational therapy was first developed in Scotland after World War I. David Henderson (1884–1965), a Scottish psychiatrist, was influenced by his colleague Adolf Meyer (1866–1950) while working in New York and Baltimore. When Henderson returned to Scotland, he employed Dorothea Robertson, a Cambridge graduate, as the first instructor of occupational therapy (Henderson, 1925a). Although she was not trained in occupational therapy, her approach was reported as having an effect on the patient's self-esteem and purpose. In 1924, Dr. Elizabeth Casson attended a conference at which Henderson (1925b) described occupational therapy at the Mental Health Hospital of Gartnavel in Glasgow. In a tribute to Casson's work, Peto (1955) stated that occupational therapy was initiated during World War I by Sir Robert Jones. The profession was then abandoned in the United Kingdom but developed in the United States and was brought back to the United Kingdom by Casson.
In 1929, Casson founded Dorset House in Clifton, Bristol, as a residential clinic for women with mental disorders. Here, she led occupational and artistic therapies to promote psychological well-being and health. Interventions included activities such as dance, drama, and countryside excursions. A year later, in 1930, in the same location, Casson launched the first school of occupational therapy in the United Kingdom. Because of the bombing of Bristol during World War II, the school moved to Bromsgrove and then to Oxford after the war, initially to the grounds of the Churchill Hospital (Peto, 1955). Influenced by Ruskin and Hill's beliefs about social reformation (Wilcock, 1999), Dorset House was known for its communal nature, and staff and students shared a range of daily occupations. Casson's instruction of occupational therapists continues to influence the education of practitioners. In the same period, the Scottish Association of Occupational Therapists was founded and the professionalization of occupational therapy was established within the United Kingdom (Table A, available in the online version of the article).
The History of the Associations of Occupational Therapy in the UK from https://www.rcot.co.uk/about-us/our-history(accessed 5th March 2019)
Education of Occupational Therapists
The United Kingdom currently has 53 registered occupational therapy programs (World Federation of Occupational Therapists [WFOT], 2016). The Royal College of Occupational Therapists (2019a) regulates standards for education. Professional registration is via the U.K. Health and Care Professionals Council. All of the programs in the United Kingdom are guided by the WFOT Revised Minimum Standards for the Education of Occupational Therapists (WFOT, 2016). The United Kingdom has 48,000 occupational therapists who are employed in the public and private sectors (Stewart, 2019). As of 2019, there were a number of pathways to obtain eligibility (a license) to practice as an occupational therapist in the United Kingdom. For preregistration occupational therapy programs, the options included: (1) a bachelor of science (BSc, Hons) degree program, which is 3 years (4 years in Scotland); (2) a postgraduate program (master's or postgraduate diploma), which is 2 years; and (3) as of 2018, degree-level apprenticeships, which are 4 years (England only). For postregistration occupational therapy programs in the United Kingdom, master's-level advanced occupational therapy programs, professional doctorate degrees, and doctor of philosophy routes are available.
Preregistration programs include academic study in biological sciences, ergonomics, behavioral sciences, management and leadership, therapeutic interventions, environmental adaptations, research, occupational therapy knowledge and skills, core skills, humanities, the public health agenda, occupational science, theory, and other relevant areas of study. In addition to academic study, practitioners are expected to complete a minimum of 1,000 hours in practical placements (Royal College of Occupational Therapists [RCOT], 2019a).
Practice and Guiding Beliefs of Occupational Therapists
One guiding belief of occupational therapy is that time, place, and circumstance open paths to occupation (Peloquin, 1994). The 1980s saw a paradigmatic shift in occupational therapy, from the mechanistic paradigm, which focused on inner systems, to the contemporary paradigm of understanding that occupation has a central role in human life (Duncan & Townsend, 2011). This shift in knowledge-developed theory and evidence for the study of occupation is known as “occupational science.” As appreciation for the study of occupation and its influence on well-being has developed, both the breadth and the scope of the profession have expanded.
Occupational therapy practice in the United Kingdom considers rehabilitation, health promotion, health education, and prevention. The profession can be found in multiple environments, including but not limited to mental health settings, acute care hospitals, social work, care homes, human resources, schools, and prisons. Currently, there are no defined physical parameters to the environments in which occupational therapists work, and there is no limit to the conditions and age span of clients. Yet, despite overwhelming evidence that social factors are related to function and engagement in occupation and that the mind and body should be treated together (Bing, 1981; Casson & Foulds, 1955), mental rehabilitation and physical rehabilitation continue to be divided, and rehabilitation is not fully appreciated.
In 1948, the National Health Service (NHS) was born out of a long-held ideal that health care should meet the needs of everyone and should be available to all, regardless of wealth, on the premise that it is free at the point of delivery. The NHS is funded through payroll taxes. The government determines how much money the NHS receives and sets its health care priorities. Funding decisions are referred to local commissioning groups that determine health priorities for the local population.
Despite the 2015–2016 NHS Forward View Into Action (NHS England, 2014) that supports preventive care (i.e., care that is given to prevent illness or disease) (Ham & Murray, 2015), the health care system continues to be underfunded compared with the needs of the population. Demand is higher than the ability to supply medical attention and rehabilitation. The population is aging rapidly, with complex health care needs, and the NHS budget is not meeting the cost (NHS England, 2016). In 2017, the British Red Cross speculated that the NHS was facing a humanitarian crisis as demand continued to increase (Campbell, Morris, & Marsh, 2017). As a result of emergent health care needs and despite the identification of rehabilitation as a priority (Ham & Murray, 2015), rehabilitation is not seen as an immediate financial priority for health care. Unfortunately, given the decision for Britain to exit the European Union, the future of the health care system is unclear.
From an occupational perspective, it is essential to understand the effect of the environment on occupational form, function, and meaning. For occupational therapists who work in a high-pressure environment, the scope of practice is determined by the service. Unfortunately, the priorities of the health care system overshadow the sense of what is defined as rehabilitation and what is defined as occupation. In acute settings (i.e., hospitals), focused occupation concerns mobility and the ability to perform self-care, bathing, and dressing, which may disregard the core value of the profession to enable clients to do what they want and need to do (Wilcock, 1993). Therefore, rehabilitation may involve temporary compensatory support, such as assistive devices that enable safe and effective discharge from the hospital to allow rehabilitation within the home. However, funding restricts access to therapists and social care within the community, and waiting lists are long (Kings Fund, 2018). These limitations have the potential to reduce occupational performance by relying on compensatory methods that affect daily roles and meaningful occupation.
It is increasingly acknowledged that effective rehabilitation delivers better outcomes, improved quality of life, potential reductions in health inequalities, and significant cost savings across the health system (NHS England, 2016). However, occupational therapists are under constant pressure and may not know how to challenge their environment, their position, and the expectations placed on the profession. Therefore, to remain commissioned, occupational therapists are under pressure to ensure that the demands and outcomes of the practice are justified. As a result, research and evidence remain priorities (RCOT, 2019b).
This brief overview provides only a snapshot of the challenges experienced by occupational therapists in the United Kingdom. In many settings, occupational therapists who carry out occupation-focused practices continue to advocate for validation and approval of occupation as a means to health and well-being. These include the 2016–2017 to 2020–2021 NHS Allied Health Professions Into Action (NHS England, 2017). However, the immediate effect on occupational therapists in these settings should be addressed.
Consequences, Creativity, Social Reform, and Opportunity
Recent changes to the health and social care climate have affected the daily practice of occupational therapists, and consequently, occupational therapy practitioners are facing diminishing resources, increasing demands of the role, and workplace pressures. As a result, practitioners have reported a sense of burnout and loss of understanding of their professional values within practice and research (Perryman, Morris, Cox, Stoffel, & Taylor, 2019).
As occupational therapists and human beings, we have the innate need to make and create. Thompson and Blair (1998) described how humans are continually divided by their inner world and their external reality and explained that this tension compels humans to engage in imaginative processes “that can for the brief moments give us a sense of balance and our deepest consolation of our greatest glories” (p. 54). Here we pose a question: If occupational therapists do not have the opportunity to create their occupation and interventions for practice, what are the consequences for the well-being of our clients and the profession?
The RCOT (2015) emphasized that occupational therapists
view people as occupational beings. People are intrinsically active and creative, needing to engage in a balanced range of activities in their daily lives in order to sustain health and wellbeing. People shape, and are shaped by, their experiences and interactions with their environments. They create identity, purpose and meaning through what they do and have the capacity to transform themselves through conscious and autonomous action. (p. 1)
However, the terms “art,” “creativity,” “crafting,” and “create” are not clearly defined as skills for the profession and do not appear in the guidelines for practice and education (RCOT, 2019b). Therefore, these skills can be identified as implicit as opposed to explicit. Allowing occupational therapists to extend their creative practice to use the language and actions that are embedded in our roots cultivates a sense of the profession that allows our communication and interactions to serve as a catalyst to enable sustainable practice in health and social care reform.
The use of crafts is stigmatized among other professionals (Williams, Harrison, Newell, Holt, & Rees, 1987), and occupational therapists have had difficulty justifying interventions that use physical crafts (Bissell & Mailloux, 1981). However, in this article, the term “craft” does not mean simply creating art alongside the client for therapeutic benefit; it relates to the craft of occupational therapy practice. Occupational therapy practice emphasizes the process of how and why the therapist facilitates the client in engaging in occupation, and this takes precedence over both the outcome and the product. Therefore, we must consider the strength of the craft of occupational therapy practice, although craft activities are not always included in the academic curriculum. Barris, Cordero, and Christiaansen (1986) and Creek (1996) noted that specifying the importance of the occupational therapist's understanding of how to modify occupations is to know it themselves, which provides an opportunity to see the therapeutic power in the findings.
Bathje (2012) and Fortuna (2018) identified the essentiality of the arts and crafts movement within current occupational therapy practice. These authors recognize the importance of clarity in our approach as creative beings and professionals as well as the use of open and explicit language to state our position. However, does the arts and crafts movement remain an underground practice of occupational therapy (Mattingly & Flemming, 1994)? Schmid (2004) found that occupational therapists understood creativity in their practice to include adaptation, innovation, change, first insight, going with the flow, and taking risks. This exploratory study also recognized that practitioners identified creativity as “part of everyday practice” (p. 83) and that the use of arts and crafts activities in treatment encouraged patients to think creatively (Schmid, 2004). So, what happens if we return to using this explicitly in our education and everyday practice? This practice will have added benefits not only to the profession but also, more importantly, to our clients (Hasselkus & Dickie, 1994). Consequently, we propose “a vision for crafting creative occupation.” The opportunity will allow our roots to inform our practice and promote social reform, expression, individuality, and the interconnected practice of the occupational therapist and the practice, philosophy, and intentions of occupational therapy.
Crafting is a skill, but we believe that creativity can be taught. This can be described as “to craft,” to develop the creativity of occupational therapists. We propose that this approach will enable us to understand the relationships between interconnected components, to see barriers in interventions within the occupational therapy process, and to manipulate environments to create opportunities for action. The ability to enable, to do, to be, and to become is found within the process of creating, and to practice occupational therapy is to craft the vision for crafting creative occupation.