The International Journal of Psychosocial Rehabilitation

Instrumentalism in occupational therapy:
 An Argument for a pragmatic conceptual model of practice


Moses N. Ikiugu, Ph.D., OTR/L

Assistant Professor,
Department of Occupational Therapy, University of Scranton
800 Linden Street, Scranton, Pennsylvania 18510-4501
Phone: (570) 941-4158
Fax: (570) 941-4380

 

 

   Citation:
Ikiugu, M.N.(2004)  Instrumentalism in occupational therapy:An Argument for a pragmatic
conceptual model of practice
.   International Journal of Psychosocial Rehabilitation. 8, 109-117

 

Acknowledgements:
I thank Dr. Jack R. Sibley of Texas Woman’s University for introducing me to American philosophy. I also thank Dr. Janette Schkade, professor emeritus, Texas Woman’s University and Dr. Sally Schultz, professor and dean, School of occupational therapy, Texas Woman’s University, for stimulating my interest in the philosophy of occupational therapy. Many thanks to my dear friends Frances Punch, John Kiweewa, Susanna Davila, and Dick Curtis for providing valuable feedback regarding this work.


 
Abstract
The purpose of this paper is to present an argument for a conceptual model that can be used by occupational therapists to apply the pragmatic construct of instrumentalism in their practice with clients. Instrumentalism refers to the view of the human mind as a tool for adaptation to the environment (Dewey, 1996a). The use of instrumentalism provides a way of accessing the client’s mind to facilitate adaptation through occupational performance. It is argued that this instrumental use of the mind in rehabilitation would help occupational therapists to develop holistic, occupation centered practice based on a sound philosophical framework. In the paper, it is asserted that viewing the mind as an instrument for adaptation to the environment and accessing it for occupational performance in therapy is in keeping with the historical origins of the profession and therefore enhances the profession’s unique identity.


Introduction
Wood, Nielson, Humphry, Coppola, Baranek, and Rourke (2000) state that there is a need to educate occupational therapists with skills that prepare them for practice that clearly demonstrate the uniqueness of occupational therapy. However, a literature review indicates that occupational therapy students graduate with a fragmented knowledge base and are not well prepared for practice that is based on a firm knowledge of the nature of occupation (Peirce, 2001). They spend more time acquiring component based physiological and medical facts instead of occupation-based knowledge (Peirce, 2001; Stern & D’Amico, 2001).

In a study to evaluate the congruity between the intended and actual outcomes of problem based learning, Stern and D’Amico (2001) found that students’ perceptions regarding their learning outcomes were consistent with the faculty’s objectives. However, further examination of the case based learning objectives that were set for the students by faculty indicates that many of them were geared towards medical understanding of the conditions rather than application of occupation as intervention. Out of the 20 objectives for the three case studies, 9 (45%) were oriented towards the medical aspects of the cases. They included objectives such as, “Medical complications associated with cerebral palsy”, “Medical options for managing spasticity”, “Orthopedic management of secondary conditions related to cerebral palsy”, and so on (p. 458). The remaining 11(55%) objectives which might be seen as pertaining to the application of occupation were not explicit regarding what the students were required to learn about application of occupation as intervention. They included objectives such as, “The impact of impairments on functional performance associated with spinal cord injury” (without specifying what ‘functional performance’ meant), “The occupational therapist’s role”, and “The concept of role change”, (The last two more explicitly addressing the application of occupation as intervention) (Stern & D’Amico, 2001, p. 458). While it is desirable that students understand the medical aspects of conditions that therapists address in practice, it seems that according to the objectives set in this study, emphasis was placed on discussing those medical aspects, deemphasizing a thorough study of application of occupation as intervention. Furthermore, students indicated that objectives directed towards understanding of the medical conditions were met more frequently than those directed towards understanding occupational functioning of clients.

In addition, Doyle, Madigan, Cash, and Simons (1998) indicated that since the 1970s, there has been a trend for increasingly fewer therapists choosing to practice in the area of mental health. Penny, Kasar and Sinay (2001) concurred that occupational therapy is becoming less involved in mental health practice. Considering that the practice of occupational therapy historically originated from mental health (Bing, 1981; Peloquin, 1991), the departure from this area of practice indicates the profession’s loss of identity. In order to regain that identity, it is necessary, as Wood, et al. (2000, p. 591) contend, for occupational therapists to engage in an “… in-depth study of the social movements and philosophies that gave rise to the idea of occupation as therapy….in addition to modern approaches to studying occupation…”. Such movements and philosophies include the moral treatment, pragmatism, and the mental hygiene movement (Barton, 1980; Bing, 1981; Bockoven, 1971; Breines, 1986; Dunton, 1957a; Peloquin, 1991; Pinel, 1962; Woodside, 1971). All those movements and philosophies emphasized the role of the mind in enabling human engagement in occupation so as to interact with the environment adaptively.

The purpose of this paper is to present an argument for a proposed conceptual model of practice that is based on the philosophy of pragmatism, which has been suggested to be the philosophy that guided the maturing of the idea of occupation as therapy (Breines, 1986; Hooper & Wood, 2002). Practice based on such a philosophy would be consistent with the occupational therapy roots in mental health because it would provide interventions that are primarily based on the concept of the mind as a means of activating mind-body action through occupation. In the proposed model, the pragmatic construct of instrumentalism (Dewey, 1957; 1996a; 1996b) will be operationalized for application in practice which centers on the notion of the mind as an instrument which can be accessed to facilitate occupational functioning thus promoting the client’s adaptive interaction with his/her environment. The model comprises three phases: The belief establishment, Action, and Consequence Appraisal phases (see figure 1).

           Figure 1
 

The belief establishment phase consists of clarification of beliefs that guide a person’s actions in occupational functioning, in an attempt to enhance instrumental use of the mind in occupational performance. Beliefs that hinder effective occupational performance are identified and occupational activities are presented to assist the client to challenge them. New beliefs that support desired occupational functioning and subsequent consequences (outcomes) are developed when necessary. In the action phase, the client makes a commitment to act in accordance with the newly established, more adaptive beliefs, until such beliefs become ingrained in his/her mind as a guide to the person’s occupational activities. In the third and final phase, the consequences of actions resulting from the newly established beliefs are examined. If such consequences are what the client desired, therapy is considered to have been successful and is terminated. If such consequences are not what the client desired, the therapist guides him/her back to the belief establishment phase. Beliefs are re-examined to determine if they support action that is in accordance with the desired occupational performance, and the therapeutic process begins all over again.

The Construct of Instrumentalism defined
Since the proposed conceptual model is based on the pragmatic notion of instrumentalism, it is necessary at this point to define the construct. According to Dewey (1996a), pursuit of knowledge by human beings is for the purpose of controlling nature, by correlating objects of experience and using the correlations to make desirable changes in the environment. As such, “… the goal of knowledge, the fulfillment of its aim in discovery of these correlations, is equivalent to placing in our hands an instrument of control” (p. 349). Since knowledge is acquired through operations of the mind (for instance correlation of the objects of experience is achieved by thinking, which is a function of the mind), it follows that Dewey views the mind as an instrument that a human being uses for the purpose of controlling his/her environment, or as Darwin (1985) proposes, adapting to the environment. Dewey’s instrumental view of the mind is even clearer in his statement that: “When it is apprehended as a tool and only as a tool, an instrumentality of direction, the same scrupulous attention will go to its formation as now goes into the making of instruments of precision in technical fields” (Dewey, 1996a, p. 375). The proposed conceptual model of practice is designed to provide guidelines that occupational therapists can use to access the mind as an instrument for facilitation of human adaptation to the environment.
Development of the Conceptual Model 

Mosey (1996) provides a five step format for the development of sets of guidelines for practice. These steps are: analysis of an enigmatic problem, identification of theoretical information to form a theoretical core, selecting and synthesizing postulates to form a theoretical core, deducing guidelines for problem identification and intervention, and assessment of the completeness of content and internal consistency. The proposed conceptual model was developed in three parts following Mosey’s (1996) guidelines as explained above. This paper consists of part one, in which the problem is stated, the proposed conceptual model of practice outlined, and a rationale for choosing sources of theoretical constructs/concepts for the model stated. In part two, a theoretical core will be articulated. Guidelines for problem identification and intervention will be outlined in part three. Parts two and three will be presented in two other papers.

Definition of the problem
Various frames of reference have been developed which offer guidelines for patient assessment, treatment planning, and intervention (Bruce & Borg, 2002; Christiensen & Baum, 1997; Creek, 2002; Kilehofner, 1997; Neistadt & Crepeau, 1997; Schultz & Schkade, 1992; Schkade & Schultz, 1992; Stein & Culter, 2002). Each of the frames of reference approaches human occupational problems in a unique way. For example, the Occupational Adaptation frame of reference conceptualizes the human being as a system consisting of the sensorimotor, psychosocial, and cognitive subsystems. Humans are conceptualized as interacting with and adapting to their environment through occupation using the three subsystems (McRae, Falk-Kessler, Julin, Padila, & Schultz, 1998; Schkade & Schultz, 1992; Schultz & Schkade, 1992).

The Model of Human Occupation (MOHO) also views the human being as a system in interaction with the environment (Kielhofner & Burke, 1980; Kielhofner, 1985; 1997). The Cognitive Disability frame of reference is concerned with the cognitive dysfunction, which is seen as originating from the brain structural/biological pathology (Allen, 1982; 1985; 1996; Earhart, Allen, & Blue, 1993). The life-style Performance Model focuses on the occupational lifestyle that is understood to sustain health and to enable life satisfaction (Fidler, 1996). The Canadian Model of Occupational Performance emphasizes interaction between the person, environment, and occupation (Law, Baptiste, Carswell, McColl, Polatajko, & Pollock, 1998). The Cognitive-Behavioral Frame of Reference is closest to the conceptual model proposed in this paper in that it is based on the assumption that thinking (cognition) affects behavior. The thrust of the frame of reference is to change thoughts that are believed to cause specific behaviors while assisting the client to develop a knowledge base for problem solving (Bruce & Borg, 2002). Therefore, its goal is to help the client regulate him/herself through change of thoughts, behavior, and environment (Stein & Cutler, 2002). 
In all the above models, and many others, the theme of a person who is in interaction with the environment through occupational performance is apparent. There is general recognition that motivation for action is for individuals to meet their internal needs and environmental challenges (Kielhofner, 1997; Mcrae, et al., 1998; Schultz & Schkade, 1992; Schkade & Schultz, 1992) and that cognition is the determinant for human behavior in his/her environment (Bruce & Borg, 2002; Stein & Cutler, 2002). However, the exact nature of human occupational needs, how they arise, and their purpose, is not clear. Also, the philosophical orientation or system on which these frames of reference are based is not apparent. Perhaps this is why it is so difficult to follow their guidelines to establish occupationally based practice (Blanche & Henny-Kohler, 2000; Wilcock, 2000).

This difficulty was particularly emphasized by informal feedback from students in one occupational therapy program in which this author taught. Many students in this program reported, during one of the informal debriefing sessions after their level I fieldwork affiliation in physical disabilities, that their clinical supervisors emphasized upper extremity exercises, ambulation, manual muscle testing, splinting, assistive devices, and techniques such as NDT (Neurodevelopmental techniques) in their interventions. One student stated that she observed therapists in the clinic engaging patients in, “restorative programs involving walking and upper extremity exercises and some grooming activities”.

According to these students, it seems that occupations that were meaningful to the patients were rarely used. Seldom was there collaboration between patients and therapists regarding treatment planning. Therapists designed treatment plans, which often were identical for all patients and frequently in the form of checklists of exercises and activities. This type of treatment plan did not encourage discussion of the interventions with patients. One student described the therapists’ behavior in the facility where she completed her affiliation as follows: “They threw activities at patients and went to the office to do their own things. They did not seem to want to know patients. For example, one patient liked sewing activities but this was never picked on by the therapists". Another student stated that her supervisor, “…had no patience with patients”. Such feedback suggests that in these students’ experience, in their clinical affiliation, attempts to take patient’s interests into consideration, to individualize therapeutic interventions to the specific needs of the patient, and to contextualize therapy were often not made. 

In this paper, it is argued that infusing a philosophical perspective might help establish a clearer, more unified view of the human being as an occupational being, improve therapists’ understanding of the nature of interaction between humans and their environment, and clarify the end to which this interaction takes place. It is proposed that the wisdom of the founders of occupational therapy such as Pinel (1962) and Tuke (1964), who founded the moral treatment movement, which was the precursor of occupational therapy, and Barton (1980), Dunton (1957a; 1957b), and others who formalized occupational therapy at the turn of the 20th century, be consulted, to ensure uniqueness of occupational therapy based on a sound philosophical framework. A literature review reveals that these patrons of the profession emphasized centrality of the mind in occupational therapy intervention. For instance, Pinel (1962, p. 193-194) described this primary focus on the mind using occupation thus: It was pleasing to observe the silence and tranquility which prevailed in the asylum de Bicetre, when nearly all patients were supplied by the tradesmen of Paris with employments which fixed their attention, and allured them to exertion by the prospects of a trifling gain.  

According to the above statement by Pinel, the goal of intervention at the Bicetre was to arrest patients’ attention. Attention is a function of the mind, and therefore, it can be argued that the intervention focused primarily on facilitating proper functioning of the mind and through the mind, appropriate functioning of the body. Similarly, Samuel Tuke (1964, pp. 151-152) explains the treatment of patients with depression thus, “Every means is taken to seduce the mind from its favourite but unhappy musings, by bodily exercise, walks, conversation, reading, and other innocent recreations.” Once again, the focus of intervention by Tuke was the mind, using occupational activities that require mind-body involvement. Similarly, in the principles of occupational therapy that were formulated after formal founding of the profession in the 20th century, the importance of motivating patients, even when the intended purpose of therapy was to facilitate physical rehabilitation, was emphasized. In this regard, Licht (1957) stated that:

… In motivating the patients to accept and benefit from occupational therapy, there should be a skillful blending of two important elements: first, meeting the individual interests and abilities, and secondly, providing activity which will attain the prescribed objective in terms of physical and mental treatment. If the former is lacking, the patient might be better handled by exercise alone.

 Thus, once again, the primary focus of therapy is motivation since this is primary to engagement in any occupational endeavor. To motivate the patient, the mind must be engaged through exploration of individual interests and abilities. It is therefore clear that historically, the primary focus in occupational therapy was engagement of the mind, and through the mind, facilitation of a holistic mind-body function. The proposed conceptual model aims at emphasizing that approach to therapy, irrespective of the field of practice (whether physical disabilities, geriatrics, psychosocial, home health, etc.). In this regard the model would offer practicing therapists one more way of conceptualizing therapy where the human mind is seen as an instrument for human functioning and adaptation to the environment. The theoretical core that supports the outlined conceptual model will be formulated from constructs/concepts derived from the historical literature of occupational therapy, the philosophy of pragmatism, and the complex dynamical adaptive systems theory.

Justification for the chosen sources of the theoretical core           
The historical literature of occupational therapy from which the theoretical constructs/concepts will be chosen goes back to the moral treatment movement in Europe in the second half of the 18th century. For the first time, occupation was used as therapy to treat the mentally ill by the founders of this movement such as Pinel and Tuke (Bing, 1981; Bockoven, 1971; Hergehahn, 1997; Peloquin, 1991). This movement was part of an effort to reform mental health in France and England (Bing, 1981; Hergenhahn, 1997). Before the moral treatment movement, the mentally ill were believed to be possessed by evil spirits, or that they were being punished for the sins of their parents and grandparents. Bloodletting, flogging, and other cruel forms of treatment were used in an attempt to expel evil spirits from the patients (Bruce & Borg, 2002; Hergenhahn, 1997). Patients were restrained physically because they were believed to be violent and unmanageable by other methods. In their reform efforts, Pinel in France and Tuke in England introduced use of occupation, decent food, kindness, and a comfortable environment as methods of treating the patients and prohibited use of restraints and other forms of cruel treatment (Pinel, 1962; Tuke, 1964).

The principles of moral treatment were introduced in the United States of America by the Quakers, who had either visited mental health institutions where such principles were used, or had been educated in Europe (Bing, 1981; Bruce & Borg, 2002, Creek, 2002). By the second half of the 19th century, however, due to a variety of reasons, the moral treatment movement died in the USA. The principles of moral treatment were re-discovered at the turn of the 20th century by the founders of formal occupational therapy, such as Dunton and Barton. Evidence of this rediscovery of the moral treatment principles is best illustrated by Dunton (1957a, p. 4) who stated that: “The activity programs for mental patients were termed work-cure, moral treatment, ergotherapy and many other names.” He continued to demonstrate his acquaintance with the works of the founders of the moral treatment movement by writing: “Philippe Pinel was probably the first to express the more modern viewpoint in 1791 (2), in that part of his Treatise on Moral Treatment of Insanity.” Such historical connections give credence to the statement by Bockoven (1971, p. 223) that: “It appears almost conspicuously evident that moral treatment could be reasonably described in philosophy and practice as comprehensive occupational therapy program.” For a conceptual model, such as the one proposed here, to be complete, it is necessary that its constructs be derived from the entire occupational therapy history dating back to the moral treatment era.

Apart from the moral treatment movement however, it has been suggested that the American philosophy of pragmatism influenced the development of occupational therapy significantly. For example, Breines (1986) argues that the roots of the profession are to a large extent to be found in pragmatism. This is evident in the fact that historically many important personalities in occupational therapy history, such as Julia Lanthrop and Jane Addams who ran the “Hull House” in Chicago, were associated with leading pragmatic philosophers such as John Dewey and George Herbert Mead, who also participated in the social experiments at the “Hull House”. The goal of the “Hull House” project was to help integrate poor emigrants into the American culture using occupations (Breines, 1986; West, 1989). Also, Eleanor Clarke Slagle, who greatly influenced the development of occupational therapy for more than 30 years (Bing, 1981), studied at the Chicago school of Civics and Philanthropy with Jane Addams and Julia Lanthrop, and was also associated with the “Hull House” (Breines, 1986). Furthermore, Adolf Meyer, who wrote “The Philosophy of Occupational Therapy” (Meyer, 1977), was a close associate of Jane Addams, Eleanor Clarke Slagle, Julia Lanthrop, and was acquainted to pragmatic philosophers William James, Charles Sanders Peirce, and John Dewey. With these historical connections between influential personalities in occupational therapy and the pragmatic philosophers, it is reasonable to assume that as Breines (1986) asserts, occupational therapy was application of pragmatic principles in the field of health.

If we accept the argument that the philosophy of pragmatism was a major influence in the development of occupational therapy, we have also to accept the influence to occupational therapy, through pragmatism, of British empiricism especially the philosophy of John Locke, and Darwin’s theory of evolution. Both British empiricism and Darwin’s theory of evolution were significant influences to the development of the philosophy of pragmatism (Buchler, 1955; Fisch, 1996). Indeed, the founder of pragmatism, Charles Sanders Peirce (1955), considered Darwin’s work to be extremely important because, according to him, Darwin “…proposed to apply the statistical method to biology” in his theory of the evolution of species. The influence of empiricism and Darwinism is illustrated in all the pragmatists’ literature in their emphasis on the value of experience in helping the human being to interact with and control his/her environment. It is especially evident in the literature of John Dewey, who went on to propose that the human being is not removed from nature but is part of it, and the human mind is an instrument used to facilitate adaptation to the environment (Dewey, 1957; 1996a). The construct of instrumentalism is a core construct in the proposed conceptual model.

Acknowledging the influence of Darwin’s theory of evolution in pragmatism and through pragmatism in occupational therapy is the basis of including the complex adaptive dynamical systems theory in this conceptual model. Complex adaptive dynamical systems theory is based on the notion of adaptation to the environment (Waldrop, 1992). Complex systems interact with the environment, reorganizing and continually emerging in new forms as they adapt to their environment. This notion seems to be a modern extension of the construct of adaptation that was central to Darwin’s theory of evolution (Darwin, 1985). According to Darwin, species interact with the environment adaptively. Those that are able to evolve are able to adapt effectively and survive. Those that are not able to evolve become extinct. The complex dynamical adaptive systems theory adds the dimension of complexity to the construct of adaptation.

Above then, is the rationale for the choice of the historical literature of occupational therapy, the literature of the philosophy of pragmatism, and the complex dynamical adaptive systems theory as the sources of the theoretical core for the proposed conceptual model of practice. Details of the constructs/concepts chosen from the above sources, the theoretical core, and application of the model will be discussed in later papers.

Conclusion
The purpose of this paper was to present an argument for a new conceptual model of practice in occupational therapy which focuses on the mind as an instrument for human adaptation to the environment through occupational functioning. A literature review indicated that involvement of occupational therapy in mental health has declined significantly over time. The decline in occupational therapy involvement in mental health, combined with increasing emphasis of occupational therapy education and practice on understanding the medical aspects of clients with a seeming de emphasis on their occupational functioning, indicates a possible problem with professional identity.

It was argued that a conceptual model based on the pragmatic construct of instrumentalism, that emphasizes centrality of the mind in occupational functioning, would be in keeping with the historical origins and the philosophy of the profession. Such a model would help enhance professional identity. A diagrammatic illustration of the proposed model was presented and explained. A theoretical core of the conceptual model, the specific guidelines for practice, and recommendations for type II applied scientific inquiry to assess adequacy of the guidelines (Mosey, 1996), will be presented in subsequent papers.
 
 

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