Scandinavian Journal of Occupational Therapy
ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: http://www.tandfonline.com/loi/iocc20
Participatory citizenship: Critical perspectives on client-centred occupational therapy Hetty Fransen, Nick Pollard, Sarah Kantartzis & Inés Viana-Moldes To cite this article: Hetty Fransen, Nick Pollard, Sarah Kantartzis & Inés Viana-Moldes (2015) Participatory citizenship: Critical perspectives on client-centred occupational therapy, Scandinavian Journal of Occupational Therapy, 22:4, 260-266 To link to this article: http://dx.doi.org/10.3109/11038128.2015.1020338
Published online: 04 May 2015.
Submit your article to this journal
Article views: 246
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iocc20 Download by: [Universite Laval]
Date: 06 November 2015, At: 23:20
Scandinavian Journal of Occupational Therapy. 2015; 22: 260–266
ORIGINAL ARTICLE
Participatory citizenship: Critical perspectives on client-centred occupational therapy
HETTY FRANSEN1, NICK POLLARD2, SARAH KANTARTZIS3 & INÉS VIANA-MOLDES4
Downloaded by [Universite Laval] at 23:20 06 November 2015
1
Department of Occupational Therapy, Ecole Supérieure des Sciences et Techniques de la Santé de Tunis, University of Tunis El Manar, Tunis, Tunisia, 2Occupational Therapy, Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK, 3Division of Occupational Therapy and Arts Therapies, Queen Margaret University, Edinburgh, UK, and 4 Department of Health Sciences, Faculty of Health Sciences, University of A Coruña, La Coruna, Spain
Abstract Background/aims: This article aims to discuss client-centred practice, the current dominant approach within occupational therapy, in relation to participatory citizenship. Occupational therapists work within structures and policies that set boundaries on their engagement with clients, while working with complex, multidimensional social realities. Methods: The authors present a critical discussion shaped by their research, including a survey, discussions at workshops at international conferences, and critical engagement with the literature on occupational therapy, occupation, and citizenship. Conclusion: A focus on citizenship suggests reframing professional development based on the participation in public life of people as citizens of their society. While occupational therapists often refer to clients in the context of communities, groups, families, and wider society, the term clientcentred practice typically represents a particular view of the individual and may sometimes be too limited in application for a more systemic and societal approach. Significance: The authors question the individual focus which has, until recently, been typical of client-centred occupational therapy. Placing citizenship at the core of intervention is a transformative process that assumes all people are citizens and conceives of health as a collective issue, influencing the way we educate, do research, and practise.
Key words: Collective, dis-citizenship, inequalities, professional development, participation, paradigms, occupational justice
Introduction Client-centred practice underpins occupational therapy, as stated by the World Federation of Occupational Therapists (1) and is frequently referred to in core practice frameworks, primarily in Anglophone countries. However, there are many different definitions of client and client-centred practice, as well as tensions and contradictions between the theoretical concept and the realities of practice. In the marketplace client relationships accompany a direct payment for services. Neoliberalism suggests that the principal way by which most clients are empowered is through choosing how their money is spent with whichever service provider. The phrase “client-centred” implies
an intent of the therapist towards the client without defining that intent. In healthcare the client is “the patient”, but the payment for treatment frequently comes from the occupational therapist’s employer, who may be another agency with an influence on the outcomes for the client. Thus, client choices may not be always evident in the situations in which occupational therapists work. The term client is used in many different healthcare systems in which the access that people have to services varies greatly. Many people cannot access services, such as occupational therapy, because they are impoverished, lack entitlement for referral under their particular health systems, or they live in locations where services are not available. Working around this fragmented
Correspondence: Nick Pollard, Senior Lecturer, Occupational Therapy, Faculty of Health and Wellbeing, Robert Winston Building, Sheffield Hallam University, 11-19 Broomhall Road, Sheffield S10 2BP, UK. Tel: +44 114 2252416. E-mail: [email protected] (Received 24 October 2014; accepted 12 February 2015) ISSN 1103-8128 print/ISSN 1651-2014 online 2015 Informa Healthcare DOI: 10.3109/11038128.2015.1020338
Downloaded by [Universite Laval] at 23:20 06 November 2015
Participatory citizenship network of client relations requires an imaginative approach to what Rudman (2) suggests is a gap in occupational therapy between intent and enactment. Yet citizenship presents similar theoretical and practical issues to client-centredness. Participatory citizenship may be defined as: “Participation in civil society, community and/or political life, characterised by mutual respect and non-violence and in accordance with human rights and democracy” ((3), p. 12). Within Europe, where the authors’ investigations have primarily been centred, there are diverse conceptions of citizenship. These are linked to historical and cultural factors as well as to considerable inequalities in opportunity, wealth, and health. This combination of diverse political, social, and cultural traditions and very different health systems generates many positions. Therefore, while citizenship is a significant issue for occupational therapy in order to promote and ensure participation in occupation and sustainable health, the relationship is complex and the actions undertaken will depend on context. Furthermore, there may be perspectives where a focus on citizenship as part of an ideological component of Western democracy needs critical investigation before it might be recognized as being beneficial or useful. For example, some individuals might perceive basic health promotion and survival as more immediate than citizenship rights. Occupational therapists work within policies and structures that set boundaries on their engagement with clients (4,5), who are often, because of their stigmatized status as others (6), in situations of inequity. Inequity results from a combination of social and economic factors such as poverty and lack of access to education. These produce combined effects across communities and amongst individuals, but also restrict access to health through occupation by the operation of unequal status (7). Therefore, it has been argued that occupational therapists should act for social and political changes based on the principles of occupational justice (8). These social differences realized through occupational injustices require the profession to develop a transformative and critical position around the conception of client-centred practice from the perspective of citizenship. The authors are engaged in the exploration of the relationship between occupation, occupational therapy, and citizenship related to their work in a project group of the European Network of Occupational Therapy in Higher Education (ENOTHE). This Citizenship Group, whose members have varying viewpoints arising from the countries in which they work and from which they originate (Fransen: Tunisia/Netherlands; Kantartzis: UK/Greece; Pollard: UK; Viana-Moldes: Spain/Brazil), was established to explore the position of occupational therapy
261
research, education, and practice in relation to citizenship as a response to the European Year of Citizens in 2013. They prepared a statement on citizenship (9), conducted a survey, and held several workshops at international conferences incorporating discussions with practitioners, educators, and students. The current discussion is built upon these data and shaped by a critical engagement with the literature on citizenship. Defining client-centred practice and citizenship Client-centred practice Client-centred practice emerged in the second part of the twentieth century as a reaction to the dominant prescriptive medical model on cure. Carl Rogers (1902–1987), known as the creator of client-centred therapy, rejected the negative view of human behaviour: “In my earlier professional years I was asking the question: How can I treat to cure, or change this person? Now I would phrase this question in this way: How can I provide a relationship which this person may use for his own personal growth?” ((10), p. 32). Rogers recognized that clients have the power and motivation to help themselves and can be given responsibility to solve their own problems. Taking a humanist, non-directive approach, therapists focused on concerns as expressed by the client, understanding and explaining their human behaviour and mental processes. This approach was centred on the individuality of people and on the qualities that can positively fulfil their lives. During the 1980s client-centred principles were embraced in occupational therapy as being concordant with those of the profession (11,12). A number of elements are seen to influence the successful implementation of client-centred practice, with the aim to enable clients to participate in their valued occupations. These include respect and value for the client, his/heir identity, and his/her subjective experiences, and the facilitation of mutual dialogue and partnership between the client and the therapist, to enable the client to participate and collaborate in therapy. “Enabling” is the term used for describing therapy that uses participatory, empowerment-oriented approaches ((13), p. 77). Citizenship Many definitions of citizenship exist; the perspective adopted here concerns full participation in society. In the statement “Citizenship: Exploring the contribution of occupational therapy” (9) the authors defined citizenship as follows:
262
H. Fransen et al.
Table I. Citizenship, occupation, and occupational therapy: Key issues. Partnerships: The complex and multidimensional processes of citizenship involve many social actors, and need to be approached from a kaleidoscopic perspective. This calls for collaborative approaches and interdisciplinary/transdisciplinary work
Downloaded by [Universite Laval] at 23:20 06 November 2015
Physical, social, and virtual spaces in which to practise citizenship: Citizenship takes place through a large number of social institutions, for example those providing employment, education, and legal regulation. Equity of access (accessibility) and equity of engagement in the processes of these institutions needs to be ensured. These spaces also promote opportunities for people to share experiences of life with others, in work, leisure, play, intimacy, and creativity Participatory citizenship as a way of being in the world with others: Citizenship is expressed through occupation with others in a social context, and is challenged by inequality, discrimination, and other forms of exclusion or privilege. Empowering citizenship includes: having a voice and being listened to, self-power, decision-making, having control or gaining further control, being free, independence, being capable of fighting for rights, and being recognized and respected as equal citizens and human beings with a contribution to make
Citizenship, in the widest sense, is both a right and a responsibility to participate with others in the cultural, social and economic life and in the public affairs of society. With such a participatory or active concept of citizenship it becomes an educational and negotiated process as well as a regulatory and legal task. It invites people to consider each other as equals, as fellow citizens, and facilitating citizenship as a mutually shared interdependent responsibility. Citizenship enhances civic participation and fosters social cohesion in a time of increasing social and cultural diversity ((9), p. 1). This concept of participatory citizenship is supported by various European citizenship models, including liberal, communitarian, civic republican, and critical citizenship models, and its activities range from informal social interaction, civic engagement, and protest activities to conventional politics (3). Participatory citizenship extends beyond merely political actions such as voting in elections, including participation in everyday social and cultural life, and is interconnected with the concepts of human and occupational rights. Such a conceptualization places citizenship not just as the formal, static status of an individual, but also as a practice, a dynamic and contested process within the larger community (14). This suggests, by an association with practice, that the inclusion or the exclusion of individuals from the status of citizenship is something that is arbitrated at the local contextual level, as much as it might be ordained through the structures of power. The consequences of such arbitration
are experienced in terms of personal identity and belonging, access to resources and facilities, and the experience of personhood and of freedom, that is, the components of agency in the social world. As Devlin and Pothier ((14), p. 2) suggest, “because many persons with disabilities are denied formal and/or substantive citizenship, they are assigned to the status of ‘dis-citizen’, a form of citizenship-minus, a disabling citizenship”. Thus, the starting point of our reflection is participation in contemporary society through occupation, in response to “dis-citizenship”. For occupational therapists, the expression of citizenship through occupation is central. Key issues to consider are: partnerships and collaborative approaches; the spaces in which to practise citizenship; and participatory citizenship as a way of being-in-the-world with others (see Table I) (9). The promotion of participatory citizenship includes essential action and respectful concern for those people restricted not only in access to the community, but also to the processes of citizenship, including social recognition, having a voice and being listened to, and equitable participation in discussion, decisionmaking, conflict resolution, and power (7). This influences the nature of multiple relationships including that of the therapist and “client” as fellow citizens and fellow participants in the construction of their shared world (15). Paradigms and worldviews influencing occupational practice today Client-centred practice (as it emerged from the work of Rogers) (16) is based on theoretical underpinnings that are centred on the individual. It is based in a paradigm that focuses on the development of individual potential with commitment to social values and cultural norms. The training of health workers, such as occupational therapists, is typically based on the capacity to perceive the needs and the ability level of the individual (17). More recently, client-centred practice has also been applied in situations where occupational therapists are working with families, communities, populations, and even institutions. Paradigms are used in science to refer to a theoretical framework, sometimes used more loosely to describe the prevailing view of things. These belief systems are usually seen as “the way things really are” by the groups holding them, and they become the taken-for-granted way of making sense of the world (18). Paradigms in occupational therapy are based onand connected to the paradigms and worldviews ofsociety, and are influenced by the exchange of underpinning ideas from economics, politics, and education, as well as health sciences. Askew and
Downloaded by [Universite Laval] at 23:20 06 November 2015
Participatory citizenship Carnell (19) developed a fourfold classification of paradigms or ideologies – liberatory, social justice, client-centred, and functionalist – based on a matrix that maps beliefs and knowledge with the role of education in society. These four ideologies have also influenced the historical and contemporary practices of occupational therapy, as part of the broader beliefs and concepts concerning health and the way professionals should practise and society should deliver services. Within this classification (19), client-centred and functionalist paradigms tend to work towards the intrinsic axis of social regulation. However, the concept of citizenship belongs to a different paradigm, that of social justice, which, together with the liberatory paradigm, works along the extrinsic axis of radical change. While the client-centred paradigm focuses on individual potential, abilities, and perceived needs, the functionalist paradigm tends to be mechanistic, focused on learning how to do rather than reflecting on why things are done. These paradigms are intrinsic because they provide a focus that does not look beyond the task, and their effect is to atomize rather than contextualize practice. However, in the liberatory view, individual change is a prerequisite for change in society, a wider and extrinsic focus, reflected in the skills of the health worker for reflection and the analysis of experience, particularly in relation to the person’s lived experience of inequality. The social justice paradigm goes further in encouraging responsibility for changing society, and where the development of social awareness and skills in the professional potentially enables the critical analysis of social injustice in society (15,20). Rather than assuming that social issues such as inequality are inevitable, the social justice tradition makes them the focus of investigation and action. One of the leading figures in this tradition is Paulo Freire, generally known as the father of empowerment. He emphasizes dialogue (involving respect and working with each other) and informed action (developing consciousness and hope, in order to have the power to transform daily reality), in order to change the social and political structures that perpetuate inequality and injustice (21). Therefore, it becomes necessary to question the assumption that occupational therapy is naturally client-centred. A second assumption to be questioned is that the possibilities for fulfilment are intrinsic to every individual in his/her unique reality. A number of authors have contributed to this debate with discussions of how medical dominance, market-driven economies, insurance, laws, and political conditions influence the successful implementation of clientcentred practice and may overrule good intentions (12,13). However, as in Mortenson and Dyck’s study
263
(22), structural issues are more often considered as issues influencing the possibility of client-centred practice, rather than as a need to question such practice as the only possible approach. A third assumption relates to client-centred practice as it has extended its focus from the individual to the family and the community. However, it should be questioned whether this is a suitable paradigm for social change such as health promotion or community development (23,24). Models of practice which focus on individuals and their occupations may not be appropriate for understanding the cultural dynamics of collective occupation and may be too limited to guide practice addressing issues of participation in community and inclusive citizenship. From a paradigmatic point of view, the knowledge base of client-centred practice is related to a subjective and individual perspective, whereas a community or society approach asks for an appreciation of the social dynamics based on an extrinsic and sociological context. Many authors from South America and Africa have described their practice (including education and research) grounded in a social and transformative approach (15,20,21,25,26) and not within client-centredness. A fourth assumption, linked to the previous ones, is based in a worldview that places the individual at the centre, with the responsibility and the potential to pursue change and to develop his/her abilities to the fullest. However, not all persons and communities have this view of life. Alternative views may place the person embedded in his/her relationship with others, including the therapeutic relationship, both in the present and through time, and not separated from the world around him/her (27). Such a view may influence the therapeutic relationship, its responsibility, and its directionality. Critical issues and dilemmas The enactment of the principles of citizenship from an occupational perspective presents challenges to the profession of occupational therapy and has considerable implications for client-centred practice. Consequently the concept of citizenship raises dilemmas, ethical issues, and problems of education and of practice for the occupational therapist. Client-centred practice and dis-citizenship The assumptions and paradigmatic perspectives described lead us to deconstruct the dominant influences on professional roles underpinning clientcentred practice, in favour of considerations embedded in perspectives of participatory citizenship. Addressing inequalities, professional power relationships, and
Downloaded by [Universite Laval] at 23:20 06 November 2015
264
H. Fransen et al.
occupational justice requires a transformative approach, questioning the social order beyond the individual’s occupational performance. The transformative paradigm provides such a framework for examining assumptions that explicitly address issues of power and occupational justice (28). The objective becomes participation of all citizens, including dis-citizens. Examination of forms of dis-citizenship requires an exploration of processes of access and exclusion (29). We need to consider what makes a citizen belong, and to consider the rights and responsibilities associated with these, for example for people with disabilities. Siebers (30) argues that people with disabilities are often regarded as separate from the rest of humanity. This separation presents a challenge to the utopian perspective of Rawls (31), because the exclusions of people with disabilities are revealed as social constructions. In turn, exclusions can often be internalized as negative personal identifications, as Goffman (6) suggests. Forms of disability can be manifest as concrete physical differences that act as a constraint upon social identity; they are issues that cannot be altered by the theory of social constructionism, and that are beyond current medicine or other therapeutic interventions. As Siebers (30) notes, because humans differ in size and shape, many features of their social environment exclude them from the social possibilities and the physical spaces of Rawls’ shared, wellordered society. These exclusions become aspects of individual and group identity. Until a principle of fairness and justice is politically enacted, excluded citizens will protest from the basis of identity politics that challenge concepts of well-orderedness. As a consequence, perhaps few disability theorists would use client-centred terminology. Although people with disabilities have coined the term “nothing about us, without us”, an identity based on experiences of exclusion does not suggest a conformity to centrally held values, rather it suggests that that identity has components constructed outside and not within the system that serves the majority.
Partnership approaches It might be argued that client-centred practice has many similarities to the presentation of citizenship in this paper (see Table I). Partnership and collaboration, a participatory approach, and empowerment are mentioned as being at the core of client-centred practice, as they are at the core of citizenship approaches. However, these words express different concepts in each approach. Partnership, in clientcentred practice, focuses on the relationship between the client and the therapist, with the aim to enable clients to participate in their valued occupations.
Related to participatory citizenship, collaborative partnerships point to cross-sectorial collaborations for effective and sustainable solutions, in order to tackle complex and multidimensional health, social, and development issues. Partnership may be described as an ongoing working relationship where risks and benefits are shared (32), even if in reality this may be difficult to achieve. The assumption underpinning this partnership approach is that comprehensive and widespread cross-sector collaboration is needed to make sustainable development initiatives imaginative, coherent, and integrated enough to tackle the most intractable problems, such as poverty, exclusion, and marginalization. Even within the person–therapist relationship such a partnership approach acknowledges both persons as primarily citizens living within complex and interrelated worlds. Participation and occupation The importance of participation in the occupational therapy process inevitably requires critical consideration. Participation is a social process that can range from empowerment to forced participation, exploitation, and manipulation (33). These complexities have not been adequately considered in occupational definitions of participation. It is possible that a person may experience multiple patterns of interdependence, mutual dependence, and concurrent forms of social participation depending on the contexts through which he/she moves and transacts his/her relationships. As discussed earlier, the concepts of participation and partnership need to be explored and our occupational knowledge base and competences broadened to the systematic and societal level of cross-sectorial collaboration. The authors also recognize the need for occupational therapy and occupational science to conceptualize the occupational nature of active citizenship, located as a practice in the interconnectedness of the individual and the larger community. Participation and citizenship are dialectical constructions with a dynamic relationship in their impact on health that depends on social determinants (34). The health system itself, as an institution, contributes to this dynamic through its own part in the production of health inequities (7,34). Action, public spaces, and the experience of living together Action is an important concept in the occupational therapy goal of facilitating participation in everyday occupations. The ultimate ideal of a citizenship perspective is full participation for all, in all the diverse occupations offered within public spaces. This
Downloaded by [Universite Laval] at 23:20 06 November 2015
Participatory citizenship includes consideration of educational, health, administrative, and work institutions, the regulations and policy that govern the activities that can or should take place within them, and the relationships that are so constructed. Arendt (35) discussed action as the coming together of people based on their equality and plurality, and the power that emerges from this coming together to create and sustain the common or public world. The importance of this public world has been emphasized as the place where the previously unnoticed can act and be heard, and have voice and visibility, claiming both the space for and entry to political life (36). At the same time the public world often operates a meritocracy and makes minor assumptions regarding inclusion and equality, which prevent those who are overlooked from participating, for example nonattendance might be the result of inaccessibility rather than lack of interest. A combination of such exclusions can render the invisible more invisible, and promote greater inequality. People differ in their needs, wants, and abilities, including their capacity to live alongside others. Citizenship is not only about rights but also about how individual duties are related to collective responsibility in the society to which a person belongs, individual and collective decisions concerning social participation and transformation, and the extent to which these decisions are made operational through governance. The tensions in how people relate to others can be seen in the intentionality of collective relationships on a continuum between liberating and oppressive relationships (37). The collective, through informal networks of daily occupation, can not only exclude on the basis of social norms regarding acceptable behaviour according to gender, age, and nationality, but also regarding perceived threats to the interests of the dominant members of the community (38). Everyone is, at all times, a participating citizen but the quality of participation varies depending on how individuals are perceived by others within the broader social collective. Reframing professional development There is growing insight into the potential of occupation as an essential and enriching part of the establishment and development of inclusive societies. The awakening of consciousness and focus on restricted participation, limited citizenship, and social exclusion is congruent with the awakening of occupational justice in the field of occupational science and occupational therapy, and the debate about reengaging with the profession’s roots in social justice (39). Occupational injustice is regarded as a social condition rather than a psychological state inhibiting individual potential to meet aspirations. It entails a rights-based approach to intervention, with a focus on
265
the concepts of power, participation, and a redistributive paradigm to guide practice. Justice becomes more than an implicit foundation of occupational therapy as merely client-centred: it is made explicit, central to the profession’s development of appropriate social approaches that address both individual and community needs. The recognition that the participation of people in public life as citizens of their society is constructed and shaped by social, political, cultural, economic, and racial/ethnic values indicates the importance of power and privilege as social determinants. Occupational therapy and occupational science, in order to develop effective approaches towards overcoming barriers to participatory citizenship, could develop occupational indicators of health and full citizenship. These could be, for example, around the ideas of autonomy, interdependence, participation, and partnerships, which are contained in some ideas of clientcentred practice and of citizenship. These concepts appear significant for the critical dialogues that will shape future directions and challenges for the profession, and look beyond an individual rights-based approach to tackling the sense of belonging to a common future. A robust understanding of underpinning worldviews and paradigms will serve occupational therapy to reinterpret its existing knowledge and philosophy, and reposition itself with renewed emphasis. The authors consider occupational therapy as a set of practices that are part of the public space. A public space involves a coming together of diverse people to initiate and develop action in the common world. Participatory citizenship implies the active involvement of citizens, including all people, in the life, activity, and decision-making of their communities, to be interconnected and shaping their world and future together. Rather than as clients, or as subjects who are the objects of a client-centred health practice, these diverse people are conceived as citizens and health as a collective issue. This is a transformative process that will influence the way we educate, do research, and practise. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References 1. World Federation of Occupational Therapists. Position statement. Client-centredness in occupational therapy 2010. Available from http://www.wfot.org/ResourceCentre.aspx. 2. Rudman D. Embracing and enacting an ‘occupational imagination’: Occupational science as transformative. J Occup Sci 2014;21:378–88.
Downloaded by [Universite Laval] at 23:20 06 November 2015
266
H. Fransen et al.
3. Hoskins B, Kerr D. Final study summary and policy recommendations. Participatory citizenship in the European Union. European Commission, Europe for Citizens Programme. 2012. Available from http://ec.europa.eu/citizenship/pdf/report_4_ final_study_summary_and_policy_recommendations_.pdf. 4. Hammell KW. Reflections on. . .well-being and occupational rights. Can J Occup Ther 2008;75:61–4. 5. Townsend E, Langille L, Ripley D. Professional tensions in client-centred practice: Using institutional ethnography to generate understanding and transformation. Am J Occup Ther 2003;57:17–28. 6. Goffman E. Stigma: Notes on the management of a spoiled identity. Harmondsworth: Penguin; 1968. 7. Marmot M, Allen J, Goldblatt P, Boyce T, McNeish D, Grady M, et al. Fair society, healthy lives. London: The Marmot Review; 2010. Available from http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmotreview. 8. Pollard N, Sakellariou D, Kronenberg F. Political competence in occupational therapy. In Pollard N, Sakellariou D, Kronenberg F, eds. A political practice of occupational therapy. Edinburgh: Elsevier/Churchill Livingstone; 2008. pp 21–38. 9. Fransen H, Kantartzis S, Pollard N, Viana Moldes I. Citizenship: Exploring the contribution of Occupational Therapy [Internet]. ENOTHE. 2013. cited 2014 Oct 16. Available from http://www.enothe.eu/index.php?page = activities/meet/ ac13/default. English, French, Spanish. 10. Rogers C. On becoming a person. A therapist’s view of psychotherapy. New York: Houghton Mifflin; 1961/2012. 11. Law M. Client-centred occupational therapy. Thorofare. NJ: Slack; 1998. 12. Parker DM. An exploration of client-centred practice in occupational therapy: Perspectives and impact. [PhD thesis] Birmingham: University of Birmingham; 2012. 13. Townsend E, Wilcock AA. Occupational justice and clientcentred practice: A dialogue-in-progress. Can J Occup Ther 2004;71:75–87. 14. Devlin R, Pothier D. Introduction: Towards a critical theory of citizenship. In Devlin R, Pothier D, eds. Critical disability theory. Essays in philosophy, politics, policy and law. Vancouver: UBC Press; 2006. pp 1–22. 15. Oliver F, Nicacio F. Autonomía, derechos y participación social: Directrices para la atención y rehabilitación psicosocial de base comunitaria/territorial [Autonomy, rights and social participation: Guidelines for the attention and psychosocial rehabilitation based on a community/territorial approach]. In Paganizzi y Otros L, ed. Terepia occupacional psycosocial: Escenarios clínicos y comunitarios [Psychosocial occupational therapy: Clinic and community scenarios]. Buenos Aires: Polemos; 2007. pp 1–138; Spanish. 16. Rogers CR. Client-centered therapy. Boston: HoughtonMifflin; 1951. 17. Molineux M, Baptiste S. Emerging occupational therapy practice: Building on the foundations and seizing the opportunities. In Thew M, Edwards M, Baptiste S, Molineux M, eds. Role emerging occupational therapy. Chichester: Wiley-Blackwell; 2011. pp 3–14. 18. Hicks D. Radical education. In Ward S, ed. A student’s guide to education studies. 2nd ed. London: Routledge; 2004. 19. Askew S, Carnell E. Transforming learning: Individual and global change. London: Cassel; 1998. 20. Francisco B. Terapia ocupacional [Occupational therapy]. 1a ed. Sao Paulo: Papirus; 1988; Portuguese.
21. Freire P. The pedagogy of the oppressed. Harmondsworth: Penguin; 1972. 22. Mortenson WB, Dyck I. Power and client-centred practice: An insider exploration of occupational therapists’ experiences. Can J Occup Ther 2006;73:261–71. 23. Leclair LL. Re-examining concepts of occupation in occupation-based models: Occupational therapy and community development. Can J Occup Ther 2010;77:15–21. 24. Holmberg V, Ringsberg KC. Occupational therapists as contributors to health promotion. Scand J Occup Ther 2014;21: 108–15. 25. Dias-Barros D, Garcês-Ghirardi MI, Esquerdo-Lopes R. Social occupational therapy: A social-historical perspective. In Kronenberg F, Simó S, Pollard N, eds. Occupational therapy without borders. Learning from the spirit of survivors. Edinburgh: Elsevier/Churchill Livingstone; 2005. pp 140–51. 26. Watson R, Swartz L. eds. Transformation through occupation. London: Whurr; 2004. 27. Fransen H. Challenges for occupational therapy in community based rehabilitation: Occupation in a community approach to handicap in development. In Kronenberg F, Simó S, Pollard N, eds. Occupational therapy without borders. Learning from the spirit of survivors. Edinburgh: Elsevier/Churchill Livingstone; 2005. pp 166–82. 28. Mertens DM. Transformative paradigm: Mixed methods and social justice. J Mixed Methods Res 2007;1:212–25. 29. Kabeer N. Citizenship and the boundaries of the acknowledge community: Identify, affiliation and exclusion. IDS working paper 171. Brighton: Institute of Development Studies; 2002. Available from http://www.ids.ac.uk/files/ dmfile/Wp171.pdf. 30. Siebers T. Disability theory. Ann Arbour: University of Michigan Press; 2008. 31. Rawls J. Political liberalism. New York: Columbia University Press; 2005. 32. Tennyson R. The partnering toolbook. An essential guide for cross sector partnerships. The Partnering Initiative. 2003. Available from http://thepartneringinitiative.org/tpi-tools/toolbook-series/the-partnering-toolbook/. 33. Arnstein SR. A ladder of citizen participation. J Am Plann Assoc, 1969;35:216–24. 34. Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2. Geneva: WHO; 2010. Available from http://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf. 35. Arendt H. The Human Condition. 2nd ed. Chicago: The University of Chicago Press; 1958. 36. Beltrán C. Going public. hannah arendt, immigrant action, and the space of appearance. Polit Theory 2009; 37:595–622. 37. Ramugondo E, Kronenberg F. Explaining collective occupations from a human relations perspective: Bridging the individual-collective dichotomy. J Occup Sci 2015;22: 3–16. 38. Kantartzis S. Reconceptualising occupation: An ethnographic study of daily life in a Greek town. Leeds: Leeds Metropolitan University; PhD thesis 2013. 39. Frank G, Zemke R. Occupational therapy foundations for political engagement and social transformation. In Pollard N, Sakellariou D, Kronenberg F, eds. A political practice of occupational therapy. Edinburgh: Elsevier/Churchill Livingstone; 2008. pp 111–36.
ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: http://www.tandfonline.com/loi/iocc20
Participatory citizenship: Critical perspectives on client-centred occupational therapy Hetty Fransen, Nick Pollard, Sarah Kantartzis & Inés Viana-Moldes To cite this article: Hetty Fransen, Nick Pollard, Sarah Kantartzis & Inés Viana-Moldes (2015) Participatory citizenship: Critical perspectives on client-centred occupational therapy, Scandinavian Journal of Occupational Therapy, 22:4, 260-266 To link to this article: http://dx.doi.org/10.3109/11038128.2015.1020338
Published online: 04 May 2015.
Submit your article to this journal
Article views: 246
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iocc20 Download by: [Universite Laval]
Date: 06 November 2015, At: 23:20
Scandinavian Journal of Occupational Therapy. 2015; 22: 260–266
ORIGINAL ARTICLE
Participatory citizenship: Critical perspectives on client-centred occupational therapy
HETTY FRANSEN1, NICK POLLARD2, SARAH KANTARTZIS3 & INÉS VIANA-MOLDES4
Downloaded by [Universite Laval] at 23:20 06 November 2015
1
Department of Occupational Therapy, Ecole Supérieure des Sciences et Techniques de la Santé de Tunis, University of Tunis El Manar, Tunis, Tunisia, 2Occupational Therapy, Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK, 3Division of Occupational Therapy and Arts Therapies, Queen Margaret University, Edinburgh, UK, and 4 Department of Health Sciences, Faculty of Health Sciences, University of A Coruña, La Coruna, Spain
Abstract Background/aims: This article aims to discuss client-centred practice, the current dominant approach within occupational therapy, in relation to participatory citizenship. Occupational therapists work within structures and policies that set boundaries on their engagement with clients, while working with complex, multidimensional social realities. Methods: The authors present a critical discussion shaped by their research, including a survey, discussions at workshops at international conferences, and critical engagement with the literature on occupational therapy, occupation, and citizenship. Conclusion: A focus on citizenship suggests reframing professional development based on the participation in public life of people as citizens of their society. While occupational therapists often refer to clients in the context of communities, groups, families, and wider society, the term clientcentred practice typically represents a particular view of the individual and may sometimes be too limited in application for a more systemic and societal approach. Significance: The authors question the individual focus which has, until recently, been typical of client-centred occupational therapy. Placing citizenship at the core of intervention is a transformative process that assumes all people are citizens and conceives of health as a collective issue, influencing the way we educate, do research, and practise.
Key words: Collective, dis-citizenship, inequalities, professional development, participation, paradigms, occupational justice
Introduction Client-centred practice underpins occupational therapy, as stated by the World Federation of Occupational Therapists (1) and is frequently referred to in core practice frameworks, primarily in Anglophone countries. However, there are many different definitions of client and client-centred practice, as well as tensions and contradictions between the theoretical concept and the realities of practice. In the marketplace client relationships accompany a direct payment for services. Neoliberalism suggests that the principal way by which most clients are empowered is through choosing how their money is spent with whichever service provider. The phrase “client-centred” implies
an intent of the therapist towards the client without defining that intent. In healthcare the client is “the patient”, but the payment for treatment frequently comes from the occupational therapist’s employer, who may be another agency with an influence on the outcomes for the client. Thus, client choices may not be always evident in the situations in which occupational therapists work. The term client is used in many different healthcare systems in which the access that people have to services varies greatly. Many people cannot access services, such as occupational therapy, because they are impoverished, lack entitlement for referral under their particular health systems, or they live in locations where services are not available. Working around this fragmented
Correspondence: Nick Pollard, Senior Lecturer, Occupational Therapy, Faculty of Health and Wellbeing, Robert Winston Building, Sheffield Hallam University, 11-19 Broomhall Road, Sheffield S10 2BP, UK. Tel: +44 114 2252416. E-mail: [email protected] (Received 24 October 2014; accepted 12 February 2015) ISSN 1103-8128 print/ISSN 1651-2014 online 2015 Informa Healthcare DOI: 10.3109/11038128.2015.1020338
Downloaded by [Universite Laval] at 23:20 06 November 2015
Participatory citizenship network of client relations requires an imaginative approach to what Rudman (2) suggests is a gap in occupational therapy between intent and enactment. Yet citizenship presents similar theoretical and practical issues to client-centredness. Participatory citizenship may be defined as: “Participation in civil society, community and/or political life, characterised by mutual respect and non-violence and in accordance with human rights and democracy” ((3), p. 12). Within Europe, where the authors’ investigations have primarily been centred, there are diverse conceptions of citizenship. These are linked to historical and cultural factors as well as to considerable inequalities in opportunity, wealth, and health. This combination of diverse political, social, and cultural traditions and very different health systems generates many positions. Therefore, while citizenship is a significant issue for occupational therapy in order to promote and ensure participation in occupation and sustainable health, the relationship is complex and the actions undertaken will depend on context. Furthermore, there may be perspectives where a focus on citizenship as part of an ideological component of Western democracy needs critical investigation before it might be recognized as being beneficial or useful. For example, some individuals might perceive basic health promotion and survival as more immediate than citizenship rights. Occupational therapists work within policies and structures that set boundaries on their engagement with clients (4,5), who are often, because of their stigmatized status as others (6), in situations of inequity. Inequity results from a combination of social and economic factors such as poverty and lack of access to education. These produce combined effects across communities and amongst individuals, but also restrict access to health through occupation by the operation of unequal status (7). Therefore, it has been argued that occupational therapists should act for social and political changes based on the principles of occupational justice (8). These social differences realized through occupational injustices require the profession to develop a transformative and critical position around the conception of client-centred practice from the perspective of citizenship. The authors are engaged in the exploration of the relationship between occupation, occupational therapy, and citizenship related to their work in a project group of the European Network of Occupational Therapy in Higher Education (ENOTHE). This Citizenship Group, whose members have varying viewpoints arising from the countries in which they work and from which they originate (Fransen: Tunisia/Netherlands; Kantartzis: UK/Greece; Pollard: UK; Viana-Moldes: Spain/Brazil), was established to explore the position of occupational therapy
261
research, education, and practice in relation to citizenship as a response to the European Year of Citizens in 2013. They prepared a statement on citizenship (9), conducted a survey, and held several workshops at international conferences incorporating discussions with practitioners, educators, and students. The current discussion is built upon these data and shaped by a critical engagement with the literature on citizenship. Defining client-centred practice and citizenship Client-centred practice Client-centred practice emerged in the second part of the twentieth century as a reaction to the dominant prescriptive medical model on cure. Carl Rogers (1902–1987), known as the creator of client-centred therapy, rejected the negative view of human behaviour: “In my earlier professional years I was asking the question: How can I treat to cure, or change this person? Now I would phrase this question in this way: How can I provide a relationship which this person may use for his own personal growth?” ((10), p. 32). Rogers recognized that clients have the power and motivation to help themselves and can be given responsibility to solve their own problems. Taking a humanist, non-directive approach, therapists focused on concerns as expressed by the client, understanding and explaining their human behaviour and mental processes. This approach was centred on the individuality of people and on the qualities that can positively fulfil their lives. During the 1980s client-centred principles were embraced in occupational therapy as being concordant with those of the profession (11,12). A number of elements are seen to influence the successful implementation of client-centred practice, with the aim to enable clients to participate in their valued occupations. These include respect and value for the client, his/heir identity, and his/her subjective experiences, and the facilitation of mutual dialogue and partnership between the client and the therapist, to enable the client to participate and collaborate in therapy. “Enabling” is the term used for describing therapy that uses participatory, empowerment-oriented approaches ((13), p. 77). Citizenship Many definitions of citizenship exist; the perspective adopted here concerns full participation in society. In the statement “Citizenship: Exploring the contribution of occupational therapy” (9) the authors defined citizenship as follows:
262
H. Fransen et al.
Table I. Citizenship, occupation, and occupational therapy: Key issues. Partnerships: The complex and multidimensional processes of citizenship involve many social actors, and need to be approached from a kaleidoscopic perspective. This calls for collaborative approaches and interdisciplinary/transdisciplinary work
Downloaded by [Universite Laval] at 23:20 06 November 2015
Physical, social, and virtual spaces in which to practise citizenship: Citizenship takes place through a large number of social institutions, for example those providing employment, education, and legal regulation. Equity of access (accessibility) and equity of engagement in the processes of these institutions needs to be ensured. These spaces also promote opportunities for people to share experiences of life with others, in work, leisure, play, intimacy, and creativity Participatory citizenship as a way of being in the world with others: Citizenship is expressed through occupation with others in a social context, and is challenged by inequality, discrimination, and other forms of exclusion or privilege. Empowering citizenship includes: having a voice and being listened to, self-power, decision-making, having control or gaining further control, being free, independence, being capable of fighting for rights, and being recognized and respected as equal citizens and human beings with a contribution to make
Citizenship, in the widest sense, is both a right and a responsibility to participate with others in the cultural, social and economic life and in the public affairs of society. With such a participatory or active concept of citizenship it becomes an educational and negotiated process as well as a regulatory and legal task. It invites people to consider each other as equals, as fellow citizens, and facilitating citizenship as a mutually shared interdependent responsibility. Citizenship enhances civic participation and fosters social cohesion in a time of increasing social and cultural diversity ((9), p. 1). This concept of participatory citizenship is supported by various European citizenship models, including liberal, communitarian, civic republican, and critical citizenship models, and its activities range from informal social interaction, civic engagement, and protest activities to conventional politics (3). Participatory citizenship extends beyond merely political actions such as voting in elections, including participation in everyday social and cultural life, and is interconnected with the concepts of human and occupational rights. Such a conceptualization places citizenship not just as the formal, static status of an individual, but also as a practice, a dynamic and contested process within the larger community (14). This suggests, by an association with practice, that the inclusion or the exclusion of individuals from the status of citizenship is something that is arbitrated at the local contextual level, as much as it might be ordained through the structures of power. The consequences of such arbitration
are experienced in terms of personal identity and belonging, access to resources and facilities, and the experience of personhood and of freedom, that is, the components of agency in the social world. As Devlin and Pothier ((14), p. 2) suggest, “because many persons with disabilities are denied formal and/or substantive citizenship, they are assigned to the status of ‘dis-citizen’, a form of citizenship-minus, a disabling citizenship”. Thus, the starting point of our reflection is participation in contemporary society through occupation, in response to “dis-citizenship”. For occupational therapists, the expression of citizenship through occupation is central. Key issues to consider are: partnerships and collaborative approaches; the spaces in which to practise citizenship; and participatory citizenship as a way of being-in-the-world with others (see Table I) (9). The promotion of participatory citizenship includes essential action and respectful concern for those people restricted not only in access to the community, but also to the processes of citizenship, including social recognition, having a voice and being listened to, and equitable participation in discussion, decisionmaking, conflict resolution, and power (7). This influences the nature of multiple relationships including that of the therapist and “client” as fellow citizens and fellow participants in the construction of their shared world (15). Paradigms and worldviews influencing occupational practice today Client-centred practice (as it emerged from the work of Rogers) (16) is based on theoretical underpinnings that are centred on the individual. It is based in a paradigm that focuses on the development of individual potential with commitment to social values and cultural norms. The training of health workers, such as occupational therapists, is typically based on the capacity to perceive the needs and the ability level of the individual (17). More recently, client-centred practice has also been applied in situations where occupational therapists are working with families, communities, populations, and even institutions. Paradigms are used in science to refer to a theoretical framework, sometimes used more loosely to describe the prevailing view of things. These belief systems are usually seen as “the way things really are” by the groups holding them, and they become the taken-for-granted way of making sense of the world (18). Paradigms in occupational therapy are based onand connected to the paradigms and worldviews ofsociety, and are influenced by the exchange of underpinning ideas from economics, politics, and education, as well as health sciences. Askew and
Downloaded by [Universite Laval] at 23:20 06 November 2015
Participatory citizenship Carnell (19) developed a fourfold classification of paradigms or ideologies – liberatory, social justice, client-centred, and functionalist – based on a matrix that maps beliefs and knowledge with the role of education in society. These four ideologies have also influenced the historical and contemporary practices of occupational therapy, as part of the broader beliefs and concepts concerning health and the way professionals should practise and society should deliver services. Within this classification (19), client-centred and functionalist paradigms tend to work towards the intrinsic axis of social regulation. However, the concept of citizenship belongs to a different paradigm, that of social justice, which, together with the liberatory paradigm, works along the extrinsic axis of radical change. While the client-centred paradigm focuses on individual potential, abilities, and perceived needs, the functionalist paradigm tends to be mechanistic, focused on learning how to do rather than reflecting on why things are done. These paradigms are intrinsic because they provide a focus that does not look beyond the task, and their effect is to atomize rather than contextualize practice. However, in the liberatory view, individual change is a prerequisite for change in society, a wider and extrinsic focus, reflected in the skills of the health worker for reflection and the analysis of experience, particularly in relation to the person’s lived experience of inequality. The social justice paradigm goes further in encouraging responsibility for changing society, and where the development of social awareness and skills in the professional potentially enables the critical analysis of social injustice in society (15,20). Rather than assuming that social issues such as inequality are inevitable, the social justice tradition makes them the focus of investigation and action. One of the leading figures in this tradition is Paulo Freire, generally known as the father of empowerment. He emphasizes dialogue (involving respect and working with each other) and informed action (developing consciousness and hope, in order to have the power to transform daily reality), in order to change the social and political structures that perpetuate inequality and injustice (21). Therefore, it becomes necessary to question the assumption that occupational therapy is naturally client-centred. A second assumption to be questioned is that the possibilities for fulfilment are intrinsic to every individual in his/her unique reality. A number of authors have contributed to this debate with discussions of how medical dominance, market-driven economies, insurance, laws, and political conditions influence the successful implementation of clientcentred practice and may overrule good intentions (12,13). However, as in Mortenson and Dyck’s study
263
(22), structural issues are more often considered as issues influencing the possibility of client-centred practice, rather than as a need to question such practice as the only possible approach. A third assumption relates to client-centred practice as it has extended its focus from the individual to the family and the community. However, it should be questioned whether this is a suitable paradigm for social change such as health promotion or community development (23,24). Models of practice which focus on individuals and their occupations may not be appropriate for understanding the cultural dynamics of collective occupation and may be too limited to guide practice addressing issues of participation in community and inclusive citizenship. From a paradigmatic point of view, the knowledge base of client-centred practice is related to a subjective and individual perspective, whereas a community or society approach asks for an appreciation of the social dynamics based on an extrinsic and sociological context. Many authors from South America and Africa have described their practice (including education and research) grounded in a social and transformative approach (15,20,21,25,26) and not within client-centredness. A fourth assumption, linked to the previous ones, is based in a worldview that places the individual at the centre, with the responsibility and the potential to pursue change and to develop his/her abilities to the fullest. However, not all persons and communities have this view of life. Alternative views may place the person embedded in his/her relationship with others, including the therapeutic relationship, both in the present and through time, and not separated from the world around him/her (27). Such a view may influence the therapeutic relationship, its responsibility, and its directionality. Critical issues and dilemmas The enactment of the principles of citizenship from an occupational perspective presents challenges to the profession of occupational therapy and has considerable implications for client-centred practice. Consequently the concept of citizenship raises dilemmas, ethical issues, and problems of education and of practice for the occupational therapist. Client-centred practice and dis-citizenship The assumptions and paradigmatic perspectives described lead us to deconstruct the dominant influences on professional roles underpinning clientcentred practice, in favour of considerations embedded in perspectives of participatory citizenship. Addressing inequalities, professional power relationships, and
Downloaded by [Universite Laval] at 23:20 06 November 2015
264
H. Fransen et al.
occupational justice requires a transformative approach, questioning the social order beyond the individual’s occupational performance. The transformative paradigm provides such a framework for examining assumptions that explicitly address issues of power and occupational justice (28). The objective becomes participation of all citizens, including dis-citizens. Examination of forms of dis-citizenship requires an exploration of processes of access and exclusion (29). We need to consider what makes a citizen belong, and to consider the rights and responsibilities associated with these, for example for people with disabilities. Siebers (30) argues that people with disabilities are often regarded as separate from the rest of humanity. This separation presents a challenge to the utopian perspective of Rawls (31), because the exclusions of people with disabilities are revealed as social constructions. In turn, exclusions can often be internalized as negative personal identifications, as Goffman (6) suggests. Forms of disability can be manifest as concrete physical differences that act as a constraint upon social identity; they are issues that cannot be altered by the theory of social constructionism, and that are beyond current medicine or other therapeutic interventions. As Siebers (30) notes, because humans differ in size and shape, many features of their social environment exclude them from the social possibilities and the physical spaces of Rawls’ shared, wellordered society. These exclusions become aspects of individual and group identity. Until a principle of fairness and justice is politically enacted, excluded citizens will protest from the basis of identity politics that challenge concepts of well-orderedness. As a consequence, perhaps few disability theorists would use client-centred terminology. Although people with disabilities have coined the term “nothing about us, without us”, an identity based on experiences of exclusion does not suggest a conformity to centrally held values, rather it suggests that that identity has components constructed outside and not within the system that serves the majority.
Partnership approaches It might be argued that client-centred practice has many similarities to the presentation of citizenship in this paper (see Table I). Partnership and collaboration, a participatory approach, and empowerment are mentioned as being at the core of client-centred practice, as they are at the core of citizenship approaches. However, these words express different concepts in each approach. Partnership, in clientcentred practice, focuses on the relationship between the client and the therapist, with the aim to enable clients to participate in their valued occupations.
Related to participatory citizenship, collaborative partnerships point to cross-sectorial collaborations for effective and sustainable solutions, in order to tackle complex and multidimensional health, social, and development issues. Partnership may be described as an ongoing working relationship where risks and benefits are shared (32), even if in reality this may be difficult to achieve. The assumption underpinning this partnership approach is that comprehensive and widespread cross-sector collaboration is needed to make sustainable development initiatives imaginative, coherent, and integrated enough to tackle the most intractable problems, such as poverty, exclusion, and marginalization. Even within the person–therapist relationship such a partnership approach acknowledges both persons as primarily citizens living within complex and interrelated worlds. Participation and occupation The importance of participation in the occupational therapy process inevitably requires critical consideration. Participation is a social process that can range from empowerment to forced participation, exploitation, and manipulation (33). These complexities have not been adequately considered in occupational definitions of participation. It is possible that a person may experience multiple patterns of interdependence, mutual dependence, and concurrent forms of social participation depending on the contexts through which he/she moves and transacts his/her relationships. As discussed earlier, the concepts of participation and partnership need to be explored and our occupational knowledge base and competences broadened to the systematic and societal level of cross-sectorial collaboration. The authors also recognize the need for occupational therapy and occupational science to conceptualize the occupational nature of active citizenship, located as a practice in the interconnectedness of the individual and the larger community. Participation and citizenship are dialectical constructions with a dynamic relationship in their impact on health that depends on social determinants (34). The health system itself, as an institution, contributes to this dynamic through its own part in the production of health inequities (7,34). Action, public spaces, and the experience of living together Action is an important concept in the occupational therapy goal of facilitating participation in everyday occupations. The ultimate ideal of a citizenship perspective is full participation for all, in all the diverse occupations offered within public spaces. This
Downloaded by [Universite Laval] at 23:20 06 November 2015
Participatory citizenship includes consideration of educational, health, administrative, and work institutions, the regulations and policy that govern the activities that can or should take place within them, and the relationships that are so constructed. Arendt (35) discussed action as the coming together of people based on their equality and plurality, and the power that emerges from this coming together to create and sustain the common or public world. The importance of this public world has been emphasized as the place where the previously unnoticed can act and be heard, and have voice and visibility, claiming both the space for and entry to political life (36). At the same time the public world often operates a meritocracy and makes minor assumptions regarding inclusion and equality, which prevent those who are overlooked from participating, for example nonattendance might be the result of inaccessibility rather than lack of interest. A combination of such exclusions can render the invisible more invisible, and promote greater inequality. People differ in their needs, wants, and abilities, including their capacity to live alongside others. Citizenship is not only about rights but also about how individual duties are related to collective responsibility in the society to which a person belongs, individual and collective decisions concerning social participation and transformation, and the extent to which these decisions are made operational through governance. The tensions in how people relate to others can be seen in the intentionality of collective relationships on a continuum between liberating and oppressive relationships (37). The collective, through informal networks of daily occupation, can not only exclude on the basis of social norms regarding acceptable behaviour according to gender, age, and nationality, but also regarding perceived threats to the interests of the dominant members of the community (38). Everyone is, at all times, a participating citizen but the quality of participation varies depending on how individuals are perceived by others within the broader social collective. Reframing professional development There is growing insight into the potential of occupation as an essential and enriching part of the establishment and development of inclusive societies. The awakening of consciousness and focus on restricted participation, limited citizenship, and social exclusion is congruent with the awakening of occupational justice in the field of occupational science and occupational therapy, and the debate about reengaging with the profession’s roots in social justice (39). Occupational injustice is regarded as a social condition rather than a psychological state inhibiting individual potential to meet aspirations. It entails a rights-based approach to intervention, with a focus on
265
the concepts of power, participation, and a redistributive paradigm to guide practice. Justice becomes more than an implicit foundation of occupational therapy as merely client-centred: it is made explicit, central to the profession’s development of appropriate social approaches that address both individual and community needs. The recognition that the participation of people in public life as citizens of their society is constructed and shaped by social, political, cultural, economic, and racial/ethnic values indicates the importance of power and privilege as social determinants. Occupational therapy and occupational science, in order to develop effective approaches towards overcoming barriers to participatory citizenship, could develop occupational indicators of health and full citizenship. These could be, for example, around the ideas of autonomy, interdependence, participation, and partnerships, which are contained in some ideas of clientcentred practice and of citizenship. These concepts appear significant for the critical dialogues that will shape future directions and challenges for the profession, and look beyond an individual rights-based approach to tackling the sense of belonging to a common future. A robust understanding of underpinning worldviews and paradigms will serve occupational therapy to reinterpret its existing knowledge and philosophy, and reposition itself with renewed emphasis. The authors consider occupational therapy as a set of practices that are part of the public space. A public space involves a coming together of diverse people to initiate and develop action in the common world. Participatory citizenship implies the active involvement of citizens, including all people, in the life, activity, and decision-making of their communities, to be interconnected and shaping their world and future together. Rather than as clients, or as subjects who are the objects of a client-centred health practice, these diverse people are conceived as citizens and health as a collective issue. This is a transformative process that will influence the way we educate, do research, and practise. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References 1. World Federation of Occupational Therapists. Position statement. Client-centredness in occupational therapy 2010. Available from http://www.wfot.org/ResourceCentre.aspx. 2. Rudman D. Embracing and enacting an ‘occupational imagination’: Occupational science as transformative. J Occup Sci 2014;21:378–88.
Downloaded by [Universite Laval] at 23:20 06 November 2015
266
H. Fransen et al.
3. Hoskins B, Kerr D. Final study summary and policy recommendations. Participatory citizenship in the European Union. European Commission, Europe for Citizens Programme. 2012. Available from http://ec.europa.eu/citizenship/pdf/report_4_ final_study_summary_and_policy_recommendations_.pdf. 4. Hammell KW. Reflections on. . .well-being and occupational rights. Can J Occup Ther 2008;75:61–4. 5. Townsend E, Langille L, Ripley D. Professional tensions in client-centred practice: Using institutional ethnography to generate understanding and transformation. Am J Occup Ther 2003;57:17–28. 6. Goffman E. Stigma: Notes on the management of a spoiled identity. Harmondsworth: Penguin; 1968. 7. Marmot M, Allen J, Goldblatt P, Boyce T, McNeish D, Grady M, et al. Fair society, healthy lives. London: The Marmot Review; 2010. Available from http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmotreview. 8. Pollard N, Sakellariou D, Kronenberg F. Political competence in occupational therapy. In Pollard N, Sakellariou D, Kronenberg F, eds. A political practice of occupational therapy. Edinburgh: Elsevier/Churchill Livingstone; 2008. pp 21–38. 9. Fransen H, Kantartzis S, Pollard N, Viana Moldes I. Citizenship: Exploring the contribution of Occupational Therapy [Internet]. ENOTHE. 2013. cited 2014 Oct 16. Available from http://www.enothe.eu/index.php?page = activities/meet/ ac13/default. English, French, Spanish. 10. Rogers C. On becoming a person. A therapist’s view of psychotherapy. New York: Houghton Mifflin; 1961/2012. 11. Law M. Client-centred occupational therapy. Thorofare. NJ: Slack; 1998. 12. Parker DM. An exploration of client-centred practice in occupational therapy: Perspectives and impact. [PhD thesis] Birmingham: University of Birmingham; 2012. 13. Townsend E, Wilcock AA. Occupational justice and clientcentred practice: A dialogue-in-progress. Can J Occup Ther 2004;71:75–87. 14. Devlin R, Pothier D. Introduction: Towards a critical theory of citizenship. In Devlin R, Pothier D, eds. Critical disability theory. Essays in philosophy, politics, policy and law. Vancouver: UBC Press; 2006. pp 1–22. 15. Oliver F, Nicacio F. Autonomía, derechos y participación social: Directrices para la atención y rehabilitación psicosocial de base comunitaria/territorial [Autonomy, rights and social participation: Guidelines for the attention and psychosocial rehabilitation based on a community/territorial approach]. In Paganizzi y Otros L, ed. Terepia occupacional psycosocial: Escenarios clínicos y comunitarios [Psychosocial occupational therapy: Clinic and community scenarios]. Buenos Aires: Polemos; 2007. pp 1–138; Spanish. 16. Rogers CR. Client-centered therapy. Boston: HoughtonMifflin; 1951. 17. Molineux M, Baptiste S. Emerging occupational therapy practice: Building on the foundations and seizing the opportunities. In Thew M, Edwards M, Baptiste S, Molineux M, eds. Role emerging occupational therapy. Chichester: Wiley-Blackwell; 2011. pp 3–14. 18. Hicks D. Radical education. In Ward S, ed. A student’s guide to education studies. 2nd ed. London: Routledge; 2004. 19. Askew S, Carnell E. Transforming learning: Individual and global change. London: Cassel; 1998. 20. Francisco B. Terapia ocupacional [Occupational therapy]. 1a ed. Sao Paulo: Papirus; 1988; Portuguese.
21. Freire P. The pedagogy of the oppressed. Harmondsworth: Penguin; 1972. 22. Mortenson WB, Dyck I. Power and client-centred practice: An insider exploration of occupational therapists’ experiences. Can J Occup Ther 2006;73:261–71. 23. Leclair LL. Re-examining concepts of occupation in occupation-based models: Occupational therapy and community development. Can J Occup Ther 2010;77:15–21. 24. Holmberg V, Ringsberg KC. Occupational therapists as contributors to health promotion. Scand J Occup Ther 2014;21: 108–15. 25. Dias-Barros D, Garcês-Ghirardi MI, Esquerdo-Lopes R. Social occupational therapy: A social-historical perspective. In Kronenberg F, Simó S, Pollard N, eds. Occupational therapy without borders. Learning from the spirit of survivors. Edinburgh: Elsevier/Churchill Livingstone; 2005. pp 140–51. 26. Watson R, Swartz L. eds. Transformation through occupation. London: Whurr; 2004. 27. Fransen H. Challenges for occupational therapy in community based rehabilitation: Occupation in a community approach to handicap in development. In Kronenberg F, Simó S, Pollard N, eds. Occupational therapy without borders. Learning from the spirit of survivors. Edinburgh: Elsevier/Churchill Livingstone; 2005. pp 166–82. 28. Mertens DM. Transformative paradigm: Mixed methods and social justice. J Mixed Methods Res 2007;1:212–25. 29. Kabeer N. Citizenship and the boundaries of the acknowledge community: Identify, affiliation and exclusion. IDS working paper 171. Brighton: Institute of Development Studies; 2002. Available from http://www.ids.ac.uk/files/ dmfile/Wp171.pdf. 30. Siebers T. Disability theory. Ann Arbour: University of Michigan Press; 2008. 31. Rawls J. Political liberalism. New York: Columbia University Press; 2005. 32. Tennyson R. The partnering toolbook. An essential guide for cross sector partnerships. The Partnering Initiative. 2003. Available from http://thepartneringinitiative.org/tpi-tools/toolbook-series/the-partnering-toolbook/. 33. Arnstein SR. A ladder of citizen participation. J Am Plann Assoc, 1969;35:216–24. 34. Solar O, Irwin A. A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2. Geneva: WHO; 2010. Available from http://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf. 35. Arendt H. The Human Condition. 2nd ed. Chicago: The University of Chicago Press; 1958. 36. Beltrán C. Going public. hannah arendt, immigrant action, and the space of appearance. Polit Theory 2009; 37:595–622. 37. Ramugondo E, Kronenberg F. Explaining collective occupations from a human relations perspective: Bridging the individual-collective dichotomy. J Occup Sci 2015;22: 3–16. 38. Kantartzis S. Reconceptualising occupation: An ethnographic study of daily life in a Greek town. Leeds: Leeds Metropolitan University; PhD thesis 2013. 39. Frank G, Zemke R. Occupational therapy foundations for political engagement and social transformation. In Pollard N, Sakellariou D, Kronenberg F, eds. A political practice of occupational therapy. Edinburgh: Elsevier/Churchill Livingstone; 2008. pp 111–36.
