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New Models and Frameworks in Occupational Therapy: Embracing New Perspectives

Heather Kuhaneck 8-28-24

(image generated by Dall-E)

The field of occupational therapy (OT) is constantly evolving, driven by new research, new technology that changes practice, changes in the healthcare needs of the population, and changes in the laws that guide our work. Additionally, new theories, models, and perspectives enhance our understanding of occupation and its impact on health and well-being. Among these new perspectives, is the growing critique of many of the basic tenets of occupational therapy, which are grounded in the ideals and standards of the Global North.

If you are unfamiliar with the term Global North, or the Brandt line see https://worldpopulationreview.com/country-rankings/global-north-countries and https://www.pnas.org/doi/full/10.1073/pnas.2119373119 and https://apnews.com/article/what-is-global-south-19fa68cf8c60061e88d69f6f2270d98b and https://www.bbc.co.uk/bitesize/guides/zq8gj6f/revision/1). 

Hammell (2023a, 2019, 2015; 2014; 2009a, b) and many others (see list of additional readings) assert that our theories and practices must be broadened to incorporate other world views if we are to be a fully inclusive profession. She encourages occupational therapists in the Global North to educate themselves on the theories, views, and practices of occupational therapists elsewhere (for example Brazil, South Africa) and to look with a more critical eye at the values, beliefs, and practices fostered by the dominance of the Northern world view. She criticizes the fixation of the occupational therapy profession on promoting independence and the specific forms or identified typical categories of occupation. She also argues for occupational therapy to take a larger interest in occupations concerned with belonging, such as caring for others, connecting with nature, connecting with ancestors, and occupations that foster collaboration, and strengthen social ties.

Although some of the traditional models of occupational therapy, such as PEO, do consider the environmental context, our models separate the individual from the environment, whereas in many other traditions humans are considered inseparable from their environments (Hammell, 2015). The profession, particularly in the health care system of the U.S., continues to emphasize the individual and family as primarily responsible for occupational problems. Because of this preoccupation with the individual, our occupational therapy interventions frequently focus on addressing the individual/family in terms of remediation or compensation (McColl, 2021).

However, if occupational therapy’s true domain of concern is the enhancement of human wellbeing through occupational engagement, then our views must be expanded. To this end, Hammell has outlined a new model or framework; The Occupation, Capability and Wellbeing Framework for Occupational Therapy (Hammell, 2023a). This framework, likely not yet fully integrated into OT programs in the United States, offers a unique perspective that speaks to a growing awareness of diverse philosophies and the need to consider occupational rights as a core concern of occupational therapy. This post delves into Hammell’s model and its application for an OT curriculum in the U.S.

The Occupation, Capability and Wellbeing Framework for Occupational Therapy

What Is It?

The Occupation, Capability and Wellbeing Framework for Occupational Therapy (OCWFOT, Hammell, 2023a) is a model of occupational therapy that embraces the idea that difficulties in access to varied human occupations are not only the issue of the individual or family, but are often caused by structural and environmental issues. The OCWFOT considers occupation as a determinant of wellbeing and therefore emphasizes occupational engagement.  Occupational engagement is dependent on both abilities and opportunities. OCWFOT utilizes a strengths-based approach to occupational therapy, and promotes assessment and intervention practices that support individual, family and collective capacities, capabilities and resources. It is based in Sen’s capabilities approach and focuses on growing an individual’s capability to engage in occupation. Capabilities include not only one’s abilities but also their opportunities. Therefore it encourages occupational therapists to consider the structural inequities that constrain choices and opportunities, and advances the idea of structural competence as a core competency for occupational therapists. OCWFOT proposes that capabilities are shaped by the interactions between an individual’s abilities and their societal position and circumstances. It is relationships that support one’s ability to make choices and one’s autonomy is thereby fostered by relationships.

The framework is equity focused because occupations are socially determined and are hindered or constrained by all of the “isms” (sexism, colonialism, racism, ableism and disablism, ageism, heteronormativity and gender binarism) as well as patriarchy and misogyny, class and caste inequities, and poverty. The framework promotes the identification of the contextual factors that support and hinder people’s choices and options and the influences that allow people to achieve well being through engagement in the valued occupations that matter to them. It is aligned with ideals of social justice and prompts occupational therapists to evaluate their own practices and principles in relation to how services are provided (Hammell, 2017). (For example, are OT services only available based on the ability to pay?) Lastly, as occupational therapy is a global profession, OCWFOT is situated in beliefs and values both of the Global North and the Global South and ensures that occupational therapists respect the values of those using our services.

OCWFOT was developed using a qualitative approach and review of literature. It proposes 4 phases for its use in occupational therapy:

  1. Identifying what matters (to a person or a collective- how will their well being and engagement in living be enlarged)
  2. Assessing capabilities (individual/family/group/community characteristics and strengths assets and limitations as well as environmental factors and barriers)- with examination of the environment as equally important as the individual/family/group
  3. Interventions (aimed at addressing what matters most and informed by knowledge that occupational engagement requires both abilities and opportunities)
  4. Assessment of outcomes (of outcomes greater than just physical function or independence in self-care- how well were the service users desired outcomes achieved)

Why Use It?

If we wish to change occupational therapy practice to truly be more inclusive, than the future practitioners, our current students, must be taught the necessary skills to think critically and challenge assumptions that maintain the status quo (Hammell, 2023a; 2020).  This requires that students read a variety of literature from outside the U.S. and be exposed to critiques that include views other than those of the Global North.

Usually in these posts, this section provides evidence to support the use of the technique, strategy, or method discussed in the post. However, for this week, we will discuss some of the traditional beliefs or values of occupational therapy that may be viewed with a more critical eye as the reason to “use” this framework in your teaching (Gupta & Taff, 2015; Hammell, 2023a,b; Hammell 2015; 2013; McColl, 2021; Restall & Egan, 2021).

  1. An individual’s ability to perform self-care independently and engage in productive occupations as a core concern of occupational therapy is an ableist premise.
  2. The idea that independence is universally valued or desired disregards those who may not be able to, or even wish to become independent. It neglects cultural values of interdependence.
  3. The focus of occupational therapy on assessment and treatment of “difference” equates typical or normal with the ideal and supports the notion that disability is an inherently inferior way of being.
  4. A primary consideration of occupational performance “components” of an individual, negates the reality of the structural issues that actually constrain people’s access to occupations.
  5. The current “traditional” categories of occupation offer an incomplete view of what is actually important and relevant to many individuals in terms of their well-being and are not based in evidence.
  6. Therapists working within our common rehabilitation models and structures benefit from the current state of the profession, and gain status, prestige, and economic benefits from these practices.
  7. A variety of institutional rules, healthcare funding practices, social policies and the like often dictate the possibilities for occupational therapy and do not fully allow for the true collaboration meant to underpin ‘client-centered’ practices.  This may be particularly relevant for the consideration of which occupations are included in our assessment and treatment practices, and which are not included. It forces us to reflect upon what is truly meant by client-centered and if we should be using that term at all.

WFOT has recently stated that it is the obligation of occupational therapy to promote occupational rights and that “occupational rights are secured by identifying and addressing the capabilities, opportunities, and freedom of choice for individuals, communities and populations to participate in society” (WFOT, 2019; and see Sen 2003).  As OT faculty, it is our job to ensure that students are equipped with the knowledge they need to join the global community of occupational therapy to move OT forward.

How to Use It?  Implications for OT curricula

Although we must teach what is required by ACOTE, and prepare OT students for their national certification exam, OT educational programs can and should expose students to differing worldviews, alternative modes of assessment and intervention, and writings from authors in disability studies and social occupational therapy in addition to the more traditional content of OT curricula.

  • Models: Incorporate OCWFOT (and the Kawa Model for another example) into teaching about the models of occupational therapy OR boldly and courageously institute this model as the primary model for teaching about the occupational therapy process, with other models taught as part of OT history.
  • Readings: Intentionally expose students to a variety of readings from outside the U.S. such as those listed in the references and resources list to ensure that students are familiar with diverse approaches to practice and are able to critique the more traditional ideas they are learning. The reference list from Hammell (2023a) is a good place to start.
  • Assessment: While students will enter a healthcare system that values standardized assessment and individual measures of performance, our students must also be taught assessment practices that are strengths focused, culturally relevant, and that seek to find out both the individual’s and the community’s constraints AND resources. The focus of assessment could move to what matters most for the individual and their community, and what motivates their choices (Hammell, 2023a). The focus on the need for standardized assessment that “finds” problems with individuals and considers them as deviant from the norm, is in itself problematic.
  • Advocacy: Include a wide variety of methods and strategies of advocacy within the curriculum. Advocacy should be considered a primary method of intervention. Service learning in occupational therapy programs could engage students in community advocacy and policy work to address systemic barriers to occupational participation and well-being.

Conclusion

Occupational therapy continues to evolve and is enriched by new models and frameworks that enhance our understanding of occupation and its impact on well-being. Hammell’s framework (along with other innovative thinking from around the world,) provides valuable opportunities for students to learn about promoting occupational rights. By integrating new models into our U.S. OT education, the future scope of occupational therapy may be broadened to better support the diverse needs of our population and enhance their well-being.

References

Gupta, J., & Taff, S. D. (2015). The illusion of client-centred practice. Scandinavian Journal of Occupational Therapy, 22(4), 244-251.

Hammell, K. W. (2023a). Focusing on “what matters”: the Occupation, Capability and Wellbeing Framework for Occupational Therapy. Cadernos Brasileiros de Terapia Ocupacional, 31, e3509. https://doi.org/10.1590/2526-8910.ctoAO269035092

Hammell, K. W. (2023b). A call to resist occupational therapy’s promotion of ableism. Scandinavian Journal of Occupational Therapy, 1-13.

Hammell, K. W. (2020). Engagement in living: critical perspectives on occupation, rights and wellbeing. Ottawa: CAOT.

Hammell, K. R. (2017). Critical reflections on occupational justice: toward a rights-based approach to occupational opportunities. Canadian Journal of Occupational Therapy, 84(1), 47-57.

Hammell, K. W. (2015). Respecting global wisdom: enhancing the cultural relevance of occupational therapy’s theoretical base. British Journal of Occupational Therapy, 78(11), 718-721.

Hammell, K. W. (2009a). Self-care, productivity, and leisure, or dimensions of occupational experience. Rethinking occupational “categories”. Canadian Journal of Occupational Therapy, 76(2), 107-114.

Hammell, K. W. (2009b). Sacred texts: a skeptical exploration of the assumptions underpinning theories of occupation. Canadian Journal of Occupational Therapy, 76(1), 6-22.

McColl, M. A. (2021). What can occupational therapy & disability studies contribute to one another? Canadian Journal of Occupational Therapy, 88(1), 4-11.

Motimele, M. (2022). Engaging with occupational reconstructions: A perspective from the Global South. Journal of Occupational Science, 29(4), 478-481.

Restall GJ, & Egan MY. (2021). Collaborative Relationship-Focused Occupational Therapy: Evolving Lexicon and Practice. Canadian Journal of Occupational Therapy, 88, 220-230. doi:10.1177/00084174211022889

Whalley Hammell, K. R. (2012). Client-centred practice in occupational therapy: Critical reflections. Scandinavian Journal of Occupational Therapy, 20(3), 174–181. https://doi.org/10.3109/11038128.2012.752032

World Federation of Occupational Therapists – WFOT. (2019). Position statement: occupational therapy and human rights (revised). WFOT. Retrieved in 2024, Aug 21, from https://wfot.org/resources/occupational-therapy-and-human-rights

Additional Resources

Ahmed-Landeryou, M. J. (2024). A critical reflection from inside, looking back and forward: Theorising perspectives on decolonizing occupational science theory and practice. Journal of Occupational Science, 31(1), 32-46.

Beagan, B. L., Sibbald, K. R., Pride, T. M., & Bizzeth, S. R. (2022). Client-Centered Practice when Professional and Social Power are Uncoupled: The Experiences of Therapists from Marginalized Groups. The Open Journal of Occupational Therapy, 10(4), 1-14. https://doi.org/10.15453/2168-6408.1955

Correia, R. L., Wertheime, L. G., Morrison, R., & Silva, C. R. (2021). Contemporary perspectives of occupational therapy in Latin America: Contributions to the glocal dialogue. South African Journal of Occupational Therapy, 51(4), 41-50.

Gerlach, A. J., Teachman, G., Laliberte-Rudman, D., Aldrich, R. M., & Huot, S. (2018). Expanding beyond individualism: engaging critical perspectives on occupation. Scandinavian Journal of Occupational Therapy, 25(1), 35-43.

Grenier, M. L. (2020). Cultural competency and the reproduction of White supremacy in occupational therapy education. Health Education Journal, 79(6), 633-644.

Guajardo Córdoba, A., & Malfitano, A. P. S. (2023). A critical approach to the foundations of occupational therapy: contributions to an Alternative Occupational Therapy. Cadernos Brasileiros de Terapia Ocupacional, 31, e3491.

Hammell, K. W. (2020a). Action on the social determinants of health: Advancing occupational equity and occupational rights. Cadernos Brasileiros de Terapia Ocupacional. 28(1), 378-400. https://doi.org/10.4322/2526-8910.ctoARF2052

Hammell, K. W. (2020b). Making choices from the choices we have: the contextual-embeddedness of occupational choice. Canadian Journal of Occupational Therapy, 87(5), 400-411.

Hammell, K. W. (2019). Building globally relevant occupational therapy from the strength of our diversity. World Federation of Occupational Therapists Bulletin, 75(1), 13-26.

Hammell, K. W. (2008). Reflections on… well-being and occupational rights. Canadian Journal of Occupational Therapy, 75(1), 61-64.

Magalhães, L., Farias, L., Rivas-Quarneti, N., Alvarez, L., & Malfitano, A. P. S. (2019). The development of occupational science outside the Anglophone sphere: Enacting global collaboration. Journal of Occupational Science, 26(2), 181-192.

Sen, A. (2003). Development as capability expansion. In S. Fukuda-Parr & A. K. S. Kumar (Eds.), Readings in human development (pp. 41-58). New York: Oxford University Press.

Simaan, J. (2020). Decolonising occupational science education through learning activities based on a study from the Global South. Journal of Occupational Science, 27(3), 432-442.

Whalley, Hammell K.W. & Iwama, M.K. (2012) Well-being and occupational rights: An imperative for critical occupational therapy, Scandinavian Journal of Occupational Therapy, 19, 385-394. doi: 10.3109/11038128.2011.611821

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