Scandinavian Journal of Occupational Therapy. 2014; 21: 11–19

ORIGINAL ARTICLE

In search of good ideas for occupational therapy Previously published in Scandinavian Journal of Occupational Therapy 1994; 1: 7-15

EMERITA J. YERXA From the University of Southern California, Bishop, Callfornia, USA

Abstract This paper explores the scholarly process by which good ideas may be sought for the future development of occupational therapy as an integrated profession. It is suggested that the assumptions of the science supporting practice need to be made explicit and that new ideas be generated which fit the dilemmas and puzzles of occupational therapy practice and are compatible with its view of human beings.

Key words: values, science, scholarship, epistemology

In the past five years, I have worked as an academic in occupational therapy in England, Canada, Finland, Sweden, and Australia. These experiences have filled me with new pride and respect for our profession and excitement about its current and potential contributions. Occupational therapists in many countries share a unique set of values, including commitment to a good quality of life for people who have disabilities. But, occupational therapy is also confronting extraordinary challenges both within the profession and in the external world of the health care system. Internally we ask, what do we want our profession to be? Which characteristics do we want to nurture and which do we want to change? How do we know that our practice helps patients? How are we different from physiotherapists, physicians, and physical scientists? Externally, we practice in a health care system which is changing dramatically, sometimes drastically, as the world’s population ages, the costs of providing care increase, and technology advances to prolong life. All over the world occupational therapists search for ideas which can cast light on these issues. Should occupational therapy become more technical, effcient, and focused on acuity (reflecting recent changes

in the health care system)?; more like physiotherapy and medicine? Or, should occupational therapy develop in a different direction, searching more broadly and deeply to understand the occupational needs of human beings who have chronic disabilities? As occupational therapy education becomes incorporated into universities instead of free-standing schools, entering the realm of degrees and graduate programs, new questions arise regarding how the knowledge from our field contributes to the wisdom represented by the university. What is the appropriate course of study (curriculum) to prepare occupational therapists for a practice that will meet the changing need of people in the year 2030 or 2040? The responses of our profession to these internal and external challenges today will profoundly affect the contribution which occupational therapy makes to patients and society in the 21st century. Model of an integrated profession Historically, occupational therapy arose in recognition of the universal human need for activity (1) and the belief that activity organizes and integrates human beings into the normal routines and rhythms of their

Correspondence: E. J. Yerxa, University of Southern California Route 1, 196 Columbine Bishop, CA 93514, USA Tel: +1 619 873 7592

ISSN 1103-8128 print/ISSN 1651-2014 online Ó 2014 Informa Healthcare DOI: 10.3109/11038128.2014.952882

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culture (2). Subsequently, occupational therapy practice, based on these beliefs, developed in different configurations in most countries of the world. Since we are practical and doing-oriented people, practice is the most obvious implementation of our belief in the inherent wholesomeness of activity (3). Practice is what most occupational therapists perceive as “the profession”. Yet, practice is not the entire profession. If it were we could use an apprenticeship system to teach all one needs to know on the job. When we scratch beneath the surface we find that practice, which may look as simple as teaching someone a basic skill, is really based upon complex ideas equivalent in sophistication to the complexity of the human being learning to act on the environment. Looking this complexity straight in the eye reveals that we need a model of an integrated profession (Figure 1). In this model, practice is both the source and final common pathway of ideas. Practice creates the puzzles, frustrations, critical incidents or irritations which raise new questions for the profession. In the realm of ideas we seek to explain, understand, create new approaches or have a better grasp on the issues arising in practice. It is also where we make ethical decisions about which ideas might serve practice appropriately because they reflect our value system and are good for patients. The third component of an integrated profession is research. Here the profession evaluates its ideas to assess which ones contribute to the vitality and effectiveness of practice by helping patients. Ideas tested in the crucible of research are returned to the profession by researchers who publish them and by incorporation into the curriculum. The fourth component is education. Our schools pump new ideas and energy into practice through the fresh perspectives and curiosity of students. Much of the research is contributed by academics who are

expected to generate new knowledge as part of their job descriptions. These contributions assure that the entire profession and its practice keep growing, becoming better able to serve humankind and to communicate the essence of that service to the public. In occupational therapy, frequently we have viewed practice and education in a closed loop (see Figure 2). Educators have tried to transmit what is currently being done or is “in vogue” in practice, while practice has sought students who were well prepared with the techniques needed for immediate clinical application. It is obvious that this closed loop is more likely to produce clones of current practice than generating exciting new ideas and fresh approaches. Besides, it cannot succeed because no educational program can possibly prepare students to be proficient in all the skills required for the myriad forms of occupational therapy practice. As pragmatic people many occupational therapists become frustrated and exasperated by those who focus on the “idea” or “research” components of the continuum. When they hear about “theories”, “frames of reference”, or “models”, their first reaction is often skepticism. Such concepts seem vague, “head in the clouds”, impractical and irrelevant to practice. Models may be translated into “muddles”, to use Rita Goble’s term, particularly if they are poorly described or if one’s education has been of the closed loop variety. We might say, “So and so’s theories are vague. I don’t see how they can possibly be applied in my practice”. However, ideas and research are the life support system of practice while practice is the living body of the profession. If practice were to try to survive without ideas and research, our profession would not be able to improve, develop and change with the changing world environment. If our ideas and research were not grounded in the honest soil of practice we would fail to fulfill our ethical responsibility to patients and society. Without education we would have no future. Just as our patients need to have a balance of work, rest, sleep and play in their lives [I] our profession requires a balance among practice, ideas, research and education to do the best possible job and to gain the flexibility needed to meet the changing demands of the future.

Figure 1. Model of an integrated profession

Figure 2. A closed loop between practice and education.

Good ideas for occupational therapy Terminology In the realm of ideas confusion often arises because authors use the same words to mean different things. Therefore, the following definitions will be used: Theory A set of related ideas which enable scientists to predict, control, explain or gain a sense of understanding about phenomena (4). An example is sensory integration theory (5), which attempts to explain the process by which sensory integration develops in children, including how that process might go awry and be remediated. Model A concrete representation of the relationships among phenomena using a sensory analog, usually visual, for the sake of explanation. An example is the model of human occupation (6) which enables one to visualize the relationships among levels of the human system and the environment in order to understand “human occupation”. Frame of reference A set of ideas, beliefs, and tools which guide practice and which enable the practitioner to “name and frame” what is relevant to consider in working with patients (7). One example is the occupational behavior frame of reference developed by Mary Reilly (8) and her graduate students at the University of Southern California. This frame of reference uses general system theory as an organizing framework for ideas, especially from history and the social and biological sciences, which are applied to occupational therapy practice. Ideas, which are the thought processes which guide occupational therapists’ practice, may be organized as theories, models, frames of reference or in other configurations (9). These ideas, especially those which have been tested in research are usually considered the science which supports the practice of the field. For example, in another discipline, the science of psychology supports clinical practice in psycho-therapy, psychological testing, child psychology, etc. Similarly, in occupational therapy, practice is supported by both science and art (10). (Art consists of skills which may be intuitive and experiential rather than scientific.) Thus science emanating from the theory of A. Jean Ayres may be employed by occupational therapists in the USA who practice with children who have sensory integrative dysfunction. At the University of Southern California (USC),

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occupational science is being developed as an emerging basic science which seeks to contribute new ideas to occupational therapy practice (11). Kielhofner and his colleagues are developing and refining the Model of Human Occupation at the University of Illinois. If our profession follows the same developmental trajectory as older professions, academic programs will do much of the work to develop the science (based upon the questions encountered in practice). The science will be returned to and applied in practice. For example, at USC, academics and graduate students will develop and test the ideas constituting occupational science which may then be applied to occupational therapy practice. Occupational therapists who practice will decide which ideas from the science are useful. Occupational therapy needs good ideas to guide practice. How and where will these ideas be found? Traditional science Some of our idea people are looking for good ideas in the realm of traditional science (5,9,12,13). Traditional science employs the model of physics as the sine qua non of scientific method (14). According to Reynolds (4), a social psychologist who has explicated this approach, science consists of theory which has been rigorously tested using research methods endorsed by the scientific community. Such theory is built from the smallest fragments up. It begins with concepts which are the words used to classify some aspect of the world of interest to the scientist (4). For example, sensory integration theory uses concepts such as “praxis” or “tactile perception” to describe the sensory processing of children (5). The concepts of the theory are then related to one another in statements which enable scientists to predict, control, explain, and gain a sense of understanding about the world. In order for the theory to gain the confidence of scientists it must be tested in the real world. This is done by developing operational definitions of the concepts (instruments that can measure the concepts precisely). These are then applied in research to see if the statements do enable the scientist to predict or control phenomena. The more research data accumulated, the greater the scientists’ confidence in the validity of the theory. The theory can never be “proven” because it is always possible that it might fail a test in the future (4). But, the theory is more likely to become popular among scientists when many research studies, carried out with appropriate rigor, support its statements. In occupational therapy an idea person developing traditional scientific theory would begin by deciding what is important to note about the world that is

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relevant to occupational therapy. For example, it might be “dexterity”. Then, an operational definition of this concept would be designed (a test of dexterity). Then the test would have to be shown to meet scientific standards of standardization, reliability, and validity. Next the concept would be used in a relational statement, for example, if a person does an activity xthen his or her dexterity will improve. Then, under the rigorous conditions of a research experiment using controls which eliminate the effects of all other so-called “extraneous variables” except the effects of activity x on dexterity, the theoretical statement would be tested. If, in the experiment, the hypothesis (prediction) that activity x improves dexterity is validated by the data then the theory would be supported. When many more experiments produce positive results the confidence of the scientific community in the theory is increased and it gains acceptance. As the theory becomes more popular it might be used with more confidence in some aspect of occupational therapy practice. No single theory or body of scientific ideas is likely to encompass all of the issues arising in practice. This traditional approach to science sounds just like what occupational therapy is looking for. It fits with a view of science which is revered in many parts of the world, hence it seems to legitimize practice by making it more scientific. It is precise and concrete leading to a feeling of confidence and certainty in the ideas constituting the theory. It places occupational therapy theorists in the company of the physical or natural scientists who study concrete things in the real world. In the context of studying human beings it adopts the same assumptions as the behaviorist. In the arena of health care it places occupational therapy theory in the same camp as physical therapy and medicine. Is that the camp in which occupational therapy idea people wish to pitch their tents? Is this approach likely to be a legitimate one for finding good ideas for practice? In order to answer these questions we need to examine some of the assumptions underlying the traditional scientific view of theory and research. By doing this we can assess their compatibility with the practice of and values supporting occupational therapy. The concepts which are considered relevant to traditional theory must be simplified and reduced in order to be measured precisely. Thus, even when dealing with an already simplified idea such as dexterity (in the sense that it is a fragment of all that we could notice and say was important about human beings), the operational definition, the test, which is used, cannot capture the entire concept. It is only one of many possible tests which could be used. Nor can the test encompass the person who is using dexterity

in real life. This view of science requires reductionism. Reductionism is the belief that all fields of knowledge can be reduced to one science, for example physics, which can explain all phenomena (15). In psychology, for example, “Reductionism is the point of view that human behavior can successfully be resolved into its biological components, then in turn be described as chemical and electrical events” [(16), p. 807]. Thus reductionism, required for precision in theory building, simplifies human behavior and omits a great deal of information which may be vital for understanding an individual’s situation. A second assumption of traditional science is that human behavior is determined, that is, caused by identified phenomena. In the case above, the experiment tests the cause-effect relationship between the activity x which is assumed to be the cause of the improved dexterity which is the effect. Dexterity is thus determined by the activity. This view requires that choices to do or not to do, interest in or involvement with the activity be put on hold. Yet, in everyday life people seem to choose what they will or will not do according to their goals (17). They not only respond to objects, activities and people in their environments but they interpret events, making things happen. A third assumption of traditional science concerns the significance of the environment. In order to carry out an experiment which establishes cause-effect relationships for a scientific theory, the experimental conditions, including the environment, must be controlled by the researcher (18). Such control is necessary so that the effects of the environment may be eliminated or measured. Thus the experiment is conducted in a manipulated environment which may be a laboratory or another staged setting. In the sense that human beings live their lives in a variety of contexts, the experiment requires decontextualization, removing the subject from his or her regular environments. The work of Goodall (19) and Fossey (20) demonstrated that even chimpanzees and gorillas were grossly misunderstood when studied in the laboratory or zoo, rather than in their real context, of the bush. Decontextualization in the name of experimental precision raises the same possibility of misunderstanding human beings, only more so because a culture is a significant part of the human environment. A fourth assumption of traditional theorizing has to do with time. Experiments are often conducted within a limited time span in order to exercise the controls necessary for precision (14). Measuring the effects of an experimental treatment over a long period of time introduces the possibility of error because of the potential effects of “extraneous variables”. Consequently, many experiments are performed at one point in time or in a carefully controlled time frame. The experiment is primarily an atemporal method

Good ideas for occupational therapy (21). In the hypothetical example presented regarding dexterity, the “effects” of the activity on dexterity would probably be measured at one point in time but the results generalized to any and all points in time. A view of human subjects as objects is a fifth assumption. As an object the research subject is viewed by the researcher as a “body machine”. Consciousness in the form of motives, opinions, etc., is irrelevant to or even a source of contamination for the experiment (22). In the example of activity influencing dexterity, dexterity would be measured objectively by the precise test. The subjects’ opinions about or experience of the activity would be considered “subjective” therefore irrelevant to the outcome. The role of the researcher is to be the controller, while the subject is supposed to be robot-like in responding to the researcher’s authority. On second glance, traditional scientific theory and its primary method, the experiment, are based upon some assumptions which need to be explored further to see if they will lead to good ideas for occupational therapy. Some of these assumptions are: reductionism, determinism, decontextualism, atemporality, and objectivism. Values supporting occupational therapy practice In a previous publication, some of the values supporting occupational therapy practice were identified (23). I have asked occupational therapists in many countries whether or not they endorse these values, most of which were derived from the historical literature (1,2). The answer has been overwhelmingly affirmative. To review then, these values included a commitment to: pursue life satisfaction for people with severe disability; maintain and enhance health; patient selfdirectedness and responsibility; a generalist, integrated view of patients; therapeutic relationships of mutual cooperation with patients; viewing the patient as a person who acts on the environment; patient productivity and participation; belief in patients’ potential; play and leisure activities as essential components of a balanced life; and, the importance of understanding the subjective perspectives of the patient (23). If these values are important assumptions for practice, then good ideas for occupational therapy need to fit with them comfortably. As we have seen, traditional scienceis also based upon assumptions and beliefs (14). How compatible are the assumptions of traditional science with the values supporting occupational therapy practice? To what extent do the assumptions of reductionism, determinism, decontextualism, atemporality, and objectivism fit with

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our values? The values of occupational therapy seem to be quite different from, in fact, in conflict with those of the physical sciences. In contrast to reductionism, occupational therapy seeks a generalist, integrated view of the person. We are not comfortable reducing people to physical entities. One of the sources of strength for occupational therapy practice internationally has been its insistence upon restoring people to wholeness, in everyday life, in their culture. That goal might require the development of new skills or the discovery of intrinsic motives and interests. The refusal to adopt reductionism in practice enables occupational therapists to treat people flexibly, ethically and realistically (24). Rather than siding with the determinists, occupational therapy practice views patients in a “voluntarist” way (14). We ask our patients “What are your goals? Are you interested in cooking, crafts or sport?“ We design programs so that they fit into the patients’ goals and interests, capitalizing on their intrinsic motivation (25). A study in Sweden supported such a voluntarist approach. It found that in communitybased stroke patients, quality of life was linked not with degree of physical impairment but with the capacity to attain one’s own goals (26). Occupational therapy practice, rather than being decontextualized, cannot succeed unless cognizant of the environments in which the patient wants and needs to function. Even though we might evaluate the patient’s needs in a hospital setting, we are concerned about what the patient is going to be able to do in the home, community, work or school environments (27). We want to know what the demands of these environments might be as well as how the person desires to act on these to gain a sense of competence (28), freedom of choice and satisfaction. Regarding temporality, since the era of Adolph Meyer (1), occupational therapists have viewed the individual as living within the stream of time. Reilly (29) acknowledged three time frames with which occupational therapists are concerned, in the order of increasing spans: learning, development, and evolution. Human beings need to learn skills which enable them to use their time to further their goals (30,31). The skills which children learn through play influence their competency and achievement later as adults. Play, work, and rest have developed, through the course of evolution, as tools of adaptation enabling humans to meet environmental challenges. These categories of human activity are part of the temporality which necessarily is a focus of occupational therapy practice concerned with a balanced, productive, satisfying life. The final assumption of traditional science, objectivism, does not seem to fit with occupational therapists’ valuing of the pursuit of life satisfaction

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and patient self-directedness. These require occupational therapists to both understand and respect the patient’s perspective. In practice, to treat the patient as one who is a pathological body is inconsistent with expecting the individual to take control of his or her life. Also, to utilize occupation as therapy requires that therapists seek to understand patients’ experiences of an occupation in order for it to be therapeutic (32). Thus, rather than adopting generalizations about the effects of specific activities on the body, practice requires that the occupational therapist maintain both an individualized and a social view of the activity in the eyes of that particular patient and his or her culture. Thus, if the values of occupational therapy are to be consistent with our ideas, natural science does not appear to offer a fertile soil for good ideas. On the contrary, if adopted by our idea people and transmitted through education, traditional scientific thinking could ultimately distort practice or make it disappear altogether. Occupational therapy might then be supplanted by physiotherapy, physical medicine, drug therapy, behaviorism, or some hybrid of these. In the USA, the compatibility of traditional science with technological solutions to the eradication of pathology has contributed to increased costs, decreased public satisfaction with the health care system, and a reduction of resources for people who have chronic conditions (33). Many occupational therapists, seeking to practice in the context of acute medicine, responding to the pressures for cost effectiveness, are using modalities resembling those of physical therapy while abandoning purposeful activity (34). Does this incompatibility of the values of occupational therapy with those of traditional science mean that good ideas must be sought outside of science, say in the arts or history? Some scientists would say “Yes”, because they believe that traditional science is science. However, alternatives do exist which offer a different lode from which to mine new ideas compatible with the values of occupational therapy.

these ideas? How well do they fit with the values of occupational therapy and our view of people? Often assumptions are so embedded as “givens” that the scientists themselves are blind to their own beliefs (14). Investigation of compatible ideas needs to be concerned with both the method and the content of science. For example, the ethnographic method of anthropology and its content dealing with culture might be more compatible with occupational therapy than the methods and content of the physical sciences (39). In the USA, the science of occupational therapy is in a confused and confusing state. The synthesis of ideas and methods currently published in the occupational therapy literature resemble a tower of Babel in relation to their content and methods. Some ideas are based upon traditional science while others attempt to blend traditional and new paradigm approaches into an indigestib’ * stew. Authors usually do not identify the differences in assumptions nor investigate underlying values. For these reasons I believe that the science supporting the practice of occupational therapy has not yet been developed. Reilly called this situation a crisis in the Kuhnian sense (40). The major ideas or paradigms published in occupational therapy failed to address the anomalies presented by chronic disabling conditions. Internationally, the practice-ideas-research-education continuum of the profession does seem to be in crisis, since no consensus exists about its content, methods, or appropriate tools. Therefore, I believe that our idea people need to search for ideas in the literature of other disciplines which are relevant to the issues of practice and which ascribe to compatible values. In order to accomplish this, our thinkers need to reaffirm their ethical responsibility as scholars: to contribute to occupational therapy practice, treat human beings in humane ways, and observe appropriate rules of scholarship.

Rules of scholarship New paradigms Some new ways of thinking in science may be more congruent with the values and practice of occupational therapy (35-38). Some of these approaches may be more fruitful for occupational therapy than those of a science based upon physics. They deserve critical investigation by our idea people, researchers, educators, and practitioners. When investigating the puzzles arising from practice and seeking new solutions we need to ask good questions about theories, models, and frames of reference which we discover or invent. For example, what assumptions or beliefs support

In the search for good ideas, both from within the occupational therapy literature and from other disciplines some guidelines might be useful to enlighten investigators. As our patients need to learn rules (11), our idea people also need to learn guidelines. These might be called “rules of scholarship”. I have identified such rules by observing the approach of one of occupational therapy’s most gifted scholars, Mary Reilly. However, the following rules are my interpreta-tion of what I have observed. Dr Reilly is not responsible for them, especially for any mistakes I might have made.

Good ideas for occupational therapy The first rule is reflected in this entire essay. Seek Ideas Which Are Congruent with Your View of Humun Beings. The scholar needs to identify the assumptions and values which support the theory or research approach under consideration. Sometimes this requires great sensitivity and creative detective work, since the theorist or researcher may be unaware of the assumptions which are embedded in his or her scientific approach. But persistence and open mindedness often will reveal the underlying beliefs and lead to a comparison with those of occupational therapy. The second rule is about the richness of ideas. It is Saturate Yourself in the Literature. The concern of occupational therapy with people’s ability to function in their environments with satisfaction to themselves and others, often in the face of chronic disabling conditions, is incredibly challenging and complex. Quality practice in occupational therapy requires a great deal of knowledge. Our idea people need to investigate new ideas widely and in respectful degrees of depth. Select Sources from an Array of Related Disciplines is a third rule. Ideas need to be sought from any discipline which can illuminate the questions arising from practice and which view human beings through ethical lenses. Our search for ideas should not be limited to what has been published in the literature of occupational therapy since it reflects the intellectual schizophrenia of our current thinking. A fourth rule concerns how we treat the literature. Using the values and irritations arising from practice, we need to Synthesize the Literature in New Ways to address the basic issues of occupational therapy. A result of such a synthesis might be a book such as Play as Exploratory Learning (29), a doctoral program (41), a scholarly monograph, or a new model which relates ideas and reflects their complexity. A fifth rule is basic to good scholarship: Use Original Sources and Provide Accurate Citations. This means that our idea people investigate the original works of other scholars instead of relying on secondary sources such as textbooks or quotations by another author. Then, it is vital that all sources be cited accurately and completely so that other scholars might locate them. Engage in An Active Dialogue with Each Author is a sixth rule. This means that a scholar is far from a passive devourer of literature but rather an active, thinking interactor. Eating a meal unselectively may lead to abdominal distress. Similarly, uncritical absorption of incompatible ideas may lead to intellectual indigestion and confusion. It is valuable first to have an active dialogue independently, by raising questions and making notations while reading by oneself. Then, equally important is critically discussing literature with colleagues via journal clubs or

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seminars. I have found that the timing or sequencing of this process is important in nurturing my own creativity. I need to have time to reflect in solitude before entering a discussion with others. When new ideas are germinating, it might be important not to have to present them too early when their newness might rend them fragile to criticism before they are adequately formed. This observation leads directly into rule number seven: be certain that you Understand the Author’s Message Before Applying It or Criticizing It. Often we do not give the author a chance but begin criticizing, or worse, rejecting ideas before we understand the author’s main points. A process called “Learning Through Discussion” (42)” is a useful model. This approach requires students to state an author’s message to the groups’ satisfaction BEFORE applying it to real life or criticizing it. Doing so requires hard intellectual work but leads to greater clarity and useful scholarship. Use Words Accurately is an eighth rule. As scholars it is important to employ good dictionaries and author definitions in order to apply words as they were intended, not according to preconception. In the literature of occupational therapy, words often are used loosely to mean different things, or they are not defined at all. Many of our concepts are so abstract or complex that they defy defining in simple terms (i.e., “play” or “occupation”). In that case it is important that our idea people respect the richness and complexity of words and the ideas for which they stand. Use an Appropriate Level of Discourse: Avoid Reductionism is the ninth rule. Knowledge may be organized into hierarchical levels such as the physical, biological, social, cultural, and spiritual domains (35). When investigating ideas at one level, say the social, it is an error of scholarship to attempt to reduce the concept to the physical level. Thus concepts need to be examined and left in their proper domain of discourse. In occupational therapy, if occupation is viewed as a sociocultural phenomenon, for example, with emphasis on social rules, it would be an error of scholarship to reduce such rules to stimulus-response connections in the central nervous system. Scholars in occupational therapy should be well acquainted with the rules of hierarchy (43) which enable investigation of the relationships among levels. The tenth rule of scholarship is to Maintain an Ethical Perspective on ideas. Since occupational therapy is a practice profession our knowledge is applied to help human beings act on and meet the demands of their environments. As our idea people search for knowledge, they need to maintain an awareness of these goals and the values of the profession. Even though we search for ideas in an array of disciplines,

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the unique synthesis created to address the puzzles of practice needs to be created by people who are committed to occupational therapy practice, especially people who have been socialized into an ethical commitment to the quality of life of people with chronic conditions. Our ideas need to be developed by occupational therapists who are scholars, not members of other disciplines who may not be committed to our ethics or who don’t understand the complexity of our practice puzzles. Understand and Nurture the Traditions and Values of Occupational Therapy is an eleventh rule. Our scholars need to be well acquainted with the history of the profession and how it developed in different countries and cultures. Any basic or graduate study in occupational therapy should develop an appreciation for the traditions of the field and the values of its founders. A final rule is concerned with what to do with the ideas discovered in this quest. It is, Relate Ideas to Occupational Therapy. This rule deals with the “so what?” issues. Scholars need to create syntheses of their work which demonstrate its relevance to occupational therapy. In implementing this rule, graduate students might produce scholarly monographs which synthesize literature from relevant disciplines and show its significance to the issues of occupational therapy possibly with the development of new models of practice. For example, useful syntheses could be published on skill development, temporal adaptation, work, sleep, rest, and leisure. The publication of such monographs would contribute fresh, relevant ideas to all dimensions of occupational therapy practice, continually renewing and refreshing our work with patients. This approach might be called the creation of “generative” theory (14), theory which challenges assumptions and raises fundamental questions; theory at its most creative. Risks and benefits Risks are always involved in taking new pathways into unexplored territory. Following these suggestions might lead some traditional scientists to label occupational therapists as “unscientific”. It could convey an impression that occupational therapy idea people are not rigorous in their scholarship among those for whom “rigor” equals reductionism. It could require that scholars in occupational therapy be prepared to defend their approaches in the new environments of some universities in which traditional scientific thinking is currently in fashion. But, benefits are also on the horizon. Occupational therapy practice could rely on a source of new ideas which enhance practice without needing to be twisted or distorted. A. Jean Ayres, who developed a traditional scientific theory, conducted a practice which was rich in humanistic values in which

the child’s need to act on the environment led the treatment (5). These practice characteristics do not fit with the assumptions of the natural sciences and may have made the theory vulnerable to criticism from natural scientists and physicians. By searching for ideas in disciplines which share the assumptions of occupational therapy we could discover or develop new ideas which are relevant and have a goodness-offit for practice. This search could also lead to new alliances with disciplines which share our view of human beings. Another benefit is that occupational therapy would strengthen its flexibility and adaptability in the face of changing societal conditions and needs. Robinson (24), a British social scientist predicted that occupational therapy’s grounding in activity and its view of self-directed human beings would make it more adaptable than other disciplines (such as physiotherapy or physical medicine) in meeting the changing practices of rehabilitation. Searching for new ideas in fertile, compatible soil could also help occupational therapy transmit its identity to the public with greater clarity and help differentiate our practice from that of physiotherapy and medicine. Perhaps most importantly, this new approach to the search for ideas could provide better opportunities for our patients. Instead of reducing these people to diseased organ systems, we could strengthen our traditional humanistic valuing of our patients as whole human beings who need and want to engage in a pattern of daily life activities in their own environments, to be reconnected to the routines of their own culture. Conclusions The search for good ideas in occupational therapy requires that we view the profession as integrated: constituted of a balance among the components of practice, ideas, research, and education. Practice leads the search for good ideas through the puzzles and dilemmas presented by our patients. The ideas we need to support practice are only in their infancy. They are in need of further development by occupational therapists who are scholars. The model of science which our idea people use in their search needs to be compatible with the ethics and values of practice. Hence I have suggested that we search for new scientific paradigms which will enable our profession to concern itself with the complexity of how people learn to act on their environments, necessary for the study of occupation. The assumptions underlying the science which supports the practice of occupational therapy need to be made explicit so that they can be critically evaluated. In this sense we need a transparent science which will enable the profession to assess whether the values and beliefs supporting our

Good ideas for occupational therapy ideas contribute to our ethical responsibility to patients. Adopting rules of scholarship will enable our scholars to generate new ideas which “fit” the dilemmas and puzzles of practice. Such an approach will provide rich, creative new perspectives which can enhance practice and assure that the occupational therapy profession will be flexible and adaptable in meeting the needs of a rapidly changing society of the 21st century. These will certainly include the question of how people with chronic disabilities will be helped in compassionate ways to achieve their own purposes in an increasingly complex world.

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