What Is a Worthy Goal of Occupational Therapy?
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Jeffrey Crabtree
ABSTRACT. The construct of functional independence in performance areas has become what some might consider the hallmark of occupational therapy practice. This construct, as a predominant goal, or even ideal, of occupational therapy, however, embodies philosophical assumptions that bear scrutiny. For example, do clients and therapists conceive of function in the same way? When we speak of our clients being independent, do we mean they perform without any help, or do we mean they need appropriate help from persons or technology? In this paper I explore the assumptions underlying the construct of functional independence in performance areas. Further, I clarify why helping clients attain wholeness, autonomy, meaning, and purposiveness despite non-function and dependence forms a better principle of occupational therapy. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@ haworthpressinc.com ]
KEYWORDS. Occupational therapy, functional independence, purposeful activity
INTRODUCTION Our profession, particularly in the United States, as evidenced by much of its literature, appears to believe that functional independence in performance areas amounts to our ultimate goal. To cite a few examples, the American Occupational Therapy Association (AOTA) (1994a) maintained that ‘‘function in performance areas is the ultimate concern of occupation therapy’’ (p. 1047). DiJoseph (1982) asserted Jeffrey Crabtree is an Occupational Therapist in El Paso, TX. Occupational Therapy in Health Care, Vol. 12(2/3) 2000 E 2000 by The Haworth Press, Inc. All rights reserved.
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that independence, gained through purposeful activity, is the essence of occupational therapy. Dutton (1995) echoed this view, with qualifications, when she said that ‘‘while early treatment may be aimed at remediating underlying deficits such as abnormal muscle tone, the ultimate goal of clinical reasoning in occupational therapy is to restore the patient to his or her highest level of functional independence’’ (p. 3). Thornton & Rennie (1988), in their article describing the uniqueness of occupational therapy, stated that ‘‘the first area of consideration for occupational therapists should be the core, occupational performance, which refers to competence in self care, work and play activities’’ (pp. 52-53). Finally, the AOTA (1993) said that occupational therapists help those in the independent living movement ‘‘achieve their goals of living as purposefully and independently as possible’’ (p. 1080), and in long-term care occupational therapists help people with disabilities be as independent as possible (AOTA, 1994b). Typically, in conversation, we do not clarify what we mean when we speak of a client’s function; the term function has become shorthand for bathing, dressing, socialization, shopping, work, play, and all of the other performance areas (AOTA, 1994b, 1994b). We tacitly exclude the many physiological and neurological functions that support cognition, respiration, homeostasis, etc. This tacit understanding of the meaning of function grew out of our practical need to assess ability and measure treatment progress. For example, Sheldon (1935), a teacher of orthopedic physical education, developed a physical achievement record as a means to learn ‘‘what activities were really necessary to [the] personal independence’’ [emphasis added] (p. 6) of ‘‘crippled’’ children in a public school in New Jersey. Later, Brown (1947, 1950a, 1950b, 1951), a physical therapist who knew of Sheldon’s work, writing in the Physical Therapy Review and in the American Journal of Occupational Therapy, developed an activity inventory of daily activities she felt were predictive of future function and independence. (Brown’s inventory included mostly what we think of today as performance areas.) This practical need to assess ability, establish program eligibility, measure treatment progress, and the like, continues to sustain the construct of functional independence in performance areas today (Ottenbacher, Hsu, Granger, & Fiedler, 1996; Kane, Saslow, & Brundage, 1991; Shah & Cooper, 1993; Smith, 1992). Because of its pragmatic value and frequent use, the construct of functional independence in performance areas has gained nearly
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universal acceptance in the profession (Allen, 1992; American Occupational Therapy Association [AOTA], 1979, 1986, 1992, 1993, 1994a, 1995a, 1995b; Cynkin, 1995; Dutton, 1995; Orr & Schkade, 1997; Rogers, 1982; Unsworth, 1993, to name a few references).1 While the construct of functional independence in performance areas seems to have permeated our professional consciousness, we have not fully examined its meaning and the assumptions underlying it, or explored the implication of its use. For example, will a person with a C-1 spinal cord lesion value functional independence in activities of daily living (ADL) the same way a person with a radial nerve injury will? Should the ‘‘ultimate’’ goal or concern of occupational therapy be limited to function, independence, or some theoretical combination of the two? If not, what is the ultimate goal and concern of occupational therapy? This article explores the likely assumptions that underlie the construct of functional independence in performance areas. Further, the article explores broader concerns, such as autonomy, wholeness, meaning, and purposiveness, which best express the ultimate concerns of our profession. ASSUMPTIONS UNDERLYING THE CONSTRUCT OF FUNCTIONAL INDEPENDENCE IN PERFORMANCE AREAS According to the AOTA (1995a) ‘‘function is viewed as the interaction of neural and physiological mechanisms, behavior, and environment’’ (p. 1019). Further, ‘‘occupational therapists address the function of the individual at the occupational performance level where the environmental supports and barriers, the individual’s skills, and the individual’s occupational demands interact’’ (AOTA, 1995a, p. 1019). Fisher (1992) maintains that while a number of professions use the concepts of function, occupational therapy uniquely frames ‘‘function in occupation, or the ability to perform the daily life tasks related to ADLs and IADL, work, and play and leisure’’ (p. 184). These daily life tasks, or performance areas, with their concomitant performance components, compose the proper domain of occupational therapy (AOTA, 1994a; Mosey, 1992). Implicit in this construct is the notion that human endeavors or concerns outside these performance areas are also outside the domain of occupational therapy. However, even if all who receive occupational therapy hope to
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regain function in all or some performance components and areas, their desire to overcome deficits seldom stops there. Persons with performance deficits not only strive for functional independence, they seek and often attain fulfillment in the full range of human potentialities from the spiritual and familial, to the artistic and economic. Independence refers to a state or quality of being in relation to others and the environment, but these states are not mutually exclusive. People can simultaneously be independent and dependent. A client, for example, may independently choose what she wants to wear, but because of performance deficits due to a stroke, be dependent on others to dress. Another client may be physically able to dress, but because of performance deficits due to severe depression, may refuse to dress, and because of this refusal be dependent on others. Most therapists would concede that in these examples, both clients are in ways nonfunctional and functional, dependent and independent, and that to describe these people as functionally independent or dependent does not appropriately and fully characterize these clients. IMPLICATIONS FOR PRACTICE Much of what it means to be human falls outside the construct of functional independence in performance areas. One has only to recall a modern day example, Christopher Reeve, who fractured a cervical vertebra during a horse back riding accident. From the perspective of performance areas, he has severely limited function and is dependent, yet Reeve is a successful speaker, fund raiser, actor, and film director, among only a few of his successes. At several points along the course of his rehabilitation, therapists and physicians likely measured his functional independence in performance areas to plan and execute their interventions. However, Reeve probably never accepted his socalled level of independence or his limited functions as prescriptions for how to live the rest of his life. To Function for What Purpose? At best, the notion of functional independence in performance areas serves our need to measure clients’ performance abilities and improvement more than it serves clients’ abilities to construct and express meaning (Burke & Cassidy, 1991; Coppola, 1998; Radomski, 1995; Spencer, 1993; Whiteneck, 1994). At worst, exclusive pursuit of
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functional independence risks overlooking clients’ subjective constructs of purpose and meaning. Rosenblueth, Wiener, and Bigelow (1943) explain the importance of differentiating purpose from function: The basis of the concept of purpose is the awareness of ‘voluntary activity’ . . . When we perform a voluntary action what we select voluntarily is a specific purpose, not a specific movement. Thus, if we decide to take a glass containing water and carry it to our mouth we do not command certain muscles to contract to a certain degree and in a certain sequence; we merely trip the purpose and the reaction follows automatically. Indeed, . . . when an experimenter stimulates the motor regions of the cerebral cortex he does not duplicate a voluntary reaction; he trips efferent, ‘output’ pathways, but does not trip a purpose, as is done voluntarily. (p. 19) Thus, when we perform, we select a purpose, not a specific function of muscle and nerve. We have many functions, human and nonhuman, available to us to meet a specific purpose (to make or express a particular meaning). For example, when our purpose is to hit a soft ball, we use our many biomechanical functions in addition to the functions of the soft ball pitcher (to throw the ball), the bat (to strike the ball), and the catcher (to catch the ball when we miss). Often therapists and clients use a variety of functions to meet a single purpose. For example, a person with severe loss of physical functions who chooses to live alone in an apartment (a single purpose) must harness many alternate functions. She will use the functional capacity of assistive technology such as an environmental control unit to open and close doors, turn on lights, change TV channels, and dial the telephone. In addition, she may use the strength and experience of a physical therapy assistant to reduce contractures, and use the functional ability of a personal attendant to bathe, dress, and transfer. She employs these many functions, comparatively few her own, to serve the single purpose of living in the community. To Be Independent of What or Whom? We know the myth of independence well; independence and self-reliance maintain a central place in all Americans including our clients.
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This myth seems to have crowded out of many occupational therapists’ consciousness a conception of autonomy that ‘‘acknowledges the essential social nature of human development and recognizes dependence as a nonaccidental feature of the human condition’’ (Agich, 1990, p. 12). If, for whatever reason, we believe independence represents the ideal state of the individual, how do we reconcile our ongoing dependence on food and water, our interdependence on members of our community, and our heightened dependence on others during the beginning and end of our life cycle? As Jonas (1966) put it, ‘‘independence as such cannot be the ultimate good of life, since life is just that mode of material existence in which being has exposed itself to dependence’’ (p. 103). It makes more sense to acknowledge that we are all dependent in various ways and in varying degrees. Our dependency does not significantly increase or decrease from time to time or from person to person over a lifetime. Dependency, to the extent it can be quantified, remains essentially the same throughout life, but is dispersed in different ways and at different times (Kelly, 1955). For example, a fetus is solely dependent on one person, its mother. Once the child is born, he seeks increasingly greater numbers of people and resources to satisfy his needs. As an adult, with respect to any one individual, he is likely more independent than he was with respect to his mother. However, taking all of his relationships and needs into account, the degree to which he is dependent is the same as it has always been; his dependence is now dispersed over a broad range of people and resources. Practice Blind Alleys Theoretically, the logic of the functional independence in performance areas construct would lead therapists to conclude that no reasonable interventions exist outside the construct’s boundary. Yet, it is likely that therapists often treat people who have little function or no independence. Practically, when we impose the construct of functional independence on clients, we risk not asking simple questions like, what do independence and function mean to you? What function and independence tradeoffs do you want to make? Recognition that dependence is a natural feature of the human condition frees some people to choose among otherwise unacceptable choices. Some clients may choose to perform independent of some thing (perhaps a mechanical lift) and cheerfully depend on a person for transfers. Some may choose
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to be independent of some person (perhaps his or her mother) and happily depend on a several assistive devices from a sock aide to a bath bench for dressing and bathing. In practice, both the client and the reflective therapist face a dilemma created by the narrow functional independence construct. For example, after screening a client and deciding that because of the severity of his disability he will not become functionally independent in performance areas, is it appropriate, from either a reimbursement or professional ethic perspective, to treat that person? During treatment of someone that clearly can get no more functional and can gain no more independence, would not clinical reasoning based on this construct dictate the therapist discontinue therapy? In reality, therapists often shrug off this functional independence construct and continue to treat even the most nonfunctional and dependent by any construct because they and their clients have found good reasons to continue therapy.
WHAT DOES IT MEAN TO BE HUMAN? While the topic human meaning is much broader and more complex than can be addressed in this article, a brief discussion of how the construct of functional independence in performance areas falls short of what it means to be a human will help to inform occupational therapy. As Mosey (1992) says, ‘‘a profession’s philosophical assumptions are the basic beliefs it holds about the nature of the individual, the environment, the relationship between the individual and the environment, and the purpose and goals of the profession relative to meeting the needs of society’’ (p. 54). When we base treatment on the functional independence construct, we restrict our view of the human condition. At best this construct barely foreshadows what is of great and lasting importance to those we serve: Their sense of personal autonomy and wholeness and the awareness that they have and pursue purposiveness and meaning. Autonomy in Spite of Dependence Dworkin (1988) conceives of autonomy in a way that sheds light on the differences between independence and autonomy. He says that
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autonomy can be conceived of as a second-order capacity of persons to reflect critically upon their first-order preferences, desires, wishes, and so forth and the capacity to accept or attempt to change these in light of higher-order preferences and values. By exercising such a capacity, persons define their nature, give meaning and coherence to their lives, and take responsibility for the kind of person they are (p. 20). Considering this definition of autonomy, persons might have a powerful automobile and enjoy driving at high speeds (a first-order preference or desire). However, because of their concern for others and awareness that speeding in an automobile is dangerous (their secondorder capacity to reflect critically on first-order preferences), they may choose to drive within the speed limits, and in certain circumstances even slower than the speed limit. They are autonomous because they reflect critically on their first-order preferences and because they choose among different actions or values. As suggested earlier, the functional independence in performance areas construct bestows on the human condition limited possibilities; it overlooks the possibility of reflecting on one’s circumstances and limitations, and of choosing to rise above dependence or poor function. That people are autonomous, or have what Dworkin (1988) considers a second-order capacity to reflect critically on their first-order preferences, wishes, and values, describes a potent resource for moral action. However, perhaps more important for occupational therapy, it describes our clients’ capacity to reflect critically on abilities and disabilities and choose between different self-judgments and personal meanings. Dependence is a natural part of human existence. Dependence is only problematic when it is inappropriately or inadequately dispersed. Problems arise when one is dependent upon an unwanted thing or person, when the composition of dependencies is new or different, or when the amount of dependency on a thing or person is too great or too small. The person with a cervical spinal cord injury who had previously been a successful athlete and had appropriately dispersed his dependencies over family, friends, and community illustrates these problems. During the acute phase of his treatment, he depends on a few new people for all of his needs. He may not like one or more of the people upon whom he depends. As rehabilitation proceeds, he may disperse his dependencies over more, but still unfamiliar, people and
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resources. During this process, he may depend on people to bathe and feed him-- occupations he took pride in doing himself. Even years after his accident and after marriage and raising a family, he may have to disperse his dependencies in ways different from his able-bodied peers. Throughout their lives, as the above example suggests, autonomous people with performance deficits reflect on their first-order preferences, choices, and values regarding independence, and make secondorder choices that help give meaning and coherence to their lives. Occupational therapy offers persons with performance deficits and dependence on others many opportunities to explore both their firstorder preferences and what it will be like for them to make second-order choices. Wholeness Kass (1985) characterizes the relationship of health and wholeness ‘‘as ‘the well-working of the organism as a whole,’ or again, ‘an activity of the living body in accordance with its specific excellences’ ’’ (p. 174). To the extent that wholeness refers to the integrity of a person, it is a relative sense of well being with no prescribed limits or standards. Meyer (1957) describes the human as a whole being that is: constantly changing, it yet maintains a reasonably orderly internal and external structural and functional organization [that] varies according to its own complexity and the situations to be faced. It is a plastic entity with a wide range of differentiation of capacity and function; it is a center of relative but definable spontaneity and responsiveness; it is an object which constitutes itself a subject or agent, more or less self-dependent, and autonomous. (p. 6) A young athlete, for example, may base his sense of wholeness on attaining one physical fete after another. When faced with living the rest of his life with quadriplegia resulting from a sky diving accident, he can still have a sense of personal wholeness. To paraphrase Meyer, this young person’s sense of wholeness can vary depending on his complexity and the situations he faces. Despite potentially devastating personal losses, through the therapeutic use of occupation, he can
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reconstruct for himself a meaningful existence and a sense of wholeness based on new challenges and different performance. As this example illustrates, neither functional independence in performance areas is a sufficient condition for, nor is it a necessary condition of, wholeness. In other words, people measure their sense of personal wholeness by constructs other than whether they have certain functions or a particular level of independence.
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Purposiveness Our profession has a long history of upholding the worth of purposeful activity (Cottrell, 1997). Most authors seem to agree that people naturally engage in purposeful activity, and that purposeful activity is goal-directed. The importance of purpose from the occupational therapy perspective seems best characterized by McNary (1947) when she wrote, ‘‘An activity entered into without a purpose is not occupational therapy. Busy work and idle recreation have their place, but they are not occupational therapy’’ (pp. 10-11). While our literature firmly suggests the value of purpose applied to therapy, further exploration of the construct of purpose will help clarify its application to the human condition. Plants show purposeful activity when they convert water and carbon dioxide into carbohydrates. Guided missiles programmed to seek heat show goal directedness that serves a purpose. How is human purposeful activity different from a plant’s or machine’s? Is that difference important to occupational therapists? Wright’s (1971) differentiation between the terms purposeful and purposive helps answer these questions. He uses the term purposeful when discussing behavior of a living body or of a machine, ‘‘in the sense of being needed for the performance of functions characteristic of certain systems’’ (pp. 59-60). From his perspective, the purposefulness of a plant is different from the purposefulness of a human because of the uniquely different functions characteristic of each system. In this way, the purposefulness of a thing is similar to its capabilities. Wright makes an important distinction, one that we must make if we are to more closely match our philosophical assumptions and our view of the human condition. He says ‘‘behavior and other processes which are in this sense purposeful must be distinguished from behavior which is purposive in the sense of intentionally aiming at ends’’ [emphasis added] (Wright, 1971, p. 60). Said in a different way, humans
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have no control over their purposefulness, which is dictated by the functions characteristic of the human system. For example, we grasp and manipulate objects because we have a thumb that can oppose the other digits-- characteristics of human beings. We do not fly because without feathered extremities and other functions characteristic of birds, human flight is not possible. However, humans control their purposiveness, or intentions and meanings. While it is critically important for occupational therapists to understand the unique functions characteristic of the human, or what Wright calls human purposefulness, we must also identify and understand the unique purposiveness (or intentions and meanings) of each of those we treat. Persons can lose many functions characteristic of being human and yet retain the meanings and purposiveness that mark the depth and breadth of the human spirit. Consequently, as many occupational therapy writers have noted, we must acknowledge and support meaning and purposiveness in therapy. As stated earlier, neither functional independence in performance areas is a sufficient condition for, nor is it a necessary condition of, purposiveness. Thus, a person’s meaning, experienced through purposiveness, can transcend the person’s performance deficits. Meaningfulness The distinction between purposefulness and purposiveness is empty without considering meaningfulness. As Dunning (1973) asserts about humans, ‘‘choice is the vehicle by which he imbues his existence with essence or meaning’’ (p. 22). How human agents choose is a matter of fascinating conjecture, and its exploration outside the scope of this paper. What is important to this discussion is not how we make choices, but why we make choices. Some assert that meaning making is constitutive of humans (Crabtree, 1998; Kramer & Hinojosa, 1995; Mattingly & Fleming, 1994), and further, that we don’t need to be ‘‘motivated’’ to make meaning, it comes naturally. We make choices based upon what meaning we attribute to the alternatives, or what the options mean to us, our family, and others. Meaning, and associated intentions, explain why we act and why we consider one choice over others (Crabtree, 1998). More important, from an occupational therapy point of view, we make and express meaning through occupation. Being human means that in spite of often overwhelming loss of function or demoralizing
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dependence on others, we, through occupation, make meaning in our lives. We can do this in part because we can reflect on our circumstances and limitations and make second-order choices that help us transcend our limitations. Furthermore, constructing and expressing meaning is neither dependent upon all functions characteristic of humans being intact, nor on the person being totally independent. Rather, they are dependent upon a sense of wholeness regardless of how limited or deficient the action. When we help our clients reach some practical level of performance, we at least intuitively, expect them to take action: Return to work, or continue with a craft, or rejoin family and friends, not just to be performing, but because this doing is meaningful. When clients have no skill to restore, we expect they will develop new skills, again, not for the sake of simply being skillful, but because those skills help the client make and express meaning. To help our clients reach those goals, we not only evaluate their function and level of independence, but we help them tap into their sense of autonomy, purposiveness, and wholeness. We show them that through even the most mundane and commonplace performance, they can express their meanings, and that despite their limited function and dependence on others, they are part of a family and the broader community. CONCLUSION I have explored some assumptions underlying the construct of functional independence in performance areas, and proposed that despite its evolution into what some might consider the goal of practice, its restricted range and scope fall short of both the ultimate goal of occupational therapy and of a worthy vision of what it means to be human. Being human signifies far more than being independent in some task or functioning in some particular performance area. Humans choose between possible actions and values; they make choices that give meaning and purpose to their lives despite loss of function or independence. Humans seek wholeness; they strive for personal meaning and integrity despite their deficits and inabilities. Humans yearn for the ‘‘unattainable’’ and pursue practical goals; they marshal all possible resources against great odds to reach the most grand, and sometimes the most simple, objectives. Our construct of practice must not hold our clients back. Rather, our construct must sometimes even rise
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above the level of our clients’ personal expectations. When we help our clients’ express their meanings through occupation, and when, through occupation, we help them construct meaning out of often severely limited function and sometimes total dependence, we have attained an appropriate construct of practice.
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NOTE 1. It is important to note one significant exception-- the Client-centered approach (Canadian Association of Occupational Therapists, 1996; Law, Baptiste, & Mills, 1995) developed in Canada. ‘‘Client-centred practice recognizes the autonomy of individuals, the need for client choice in making decisions about occupational needs, the strengths clients bring to a therapy encounter, the benefits of client-therapist partnership and the need to ensure that services are accessible and fit the context in which a client lives’’ (Law, Baptiste, & Mills, 1995, p. 253). As stated in a Canadian Association of Occupational Therapists Position Statement (1994) ‘‘Occupational therapists’ broad vision is to enable people who face emotional, physical or social barriers to develop healthy patterns of occupation. The aim is to enable people to choose meaningful occupations which develop their personal and social resources for health’’ (p. 295). Therapist presumptions about function and independence or dependence are essentially irrelevant in the client-centered construct.
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Smith, R. O. (1992). The science of occupational therapy assessment. Occupational Therapy Journal of Research, 12(1), 3-15. Spencer, J. C. (1993). The usefulness of qualitative methods in rehabilitation: Issues of meaning, of context, and of change. Archives of Physical Medicine and Rehabilitation, 74(2), 119-126. Thornton, G. & Rennie, H. (1988). Activities of daily living: An area of occupational therapy expertise. Australian Occupational Therapy Journal, 35(2), 49-53. Unsworth, C. A. (1993). The concept of function. British Journal of Occupational Therapy, 56(8), 287-292. Whiteneck, (1994). Measuring what matters: Key rehabilitation outcomes. Archives of Physical Medicine and Rehabilitation, 75(10), 1073-1076. Wright, G. H. (1971, 1993). Explanation and understanding. Ithaca, NY: Cornell University Press.
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Jeffrey Crabtree
ABSTRACT. The construct of functional independence in performance areas has become what some might consider the hallmark of occupational therapy practice. This construct, as a predominant goal, or even ideal, of occupational therapy, however, embodies philosophical assumptions that bear scrutiny. For example, do clients and therapists conceive of function in the same way? When we speak of our clients being independent, do we mean they perform without any help, or do we mean they need appropriate help from persons or technology? In this paper I explore the assumptions underlying the construct of functional independence in performance areas. Further, I clarify why helping clients attain wholeness, autonomy, meaning, and purposiveness despite non-function and dependence forms a better principle of occupational therapy. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@ haworthpressinc.com ]
KEYWORDS. Occupational therapy, functional independence, purposeful activity
INTRODUCTION Our profession, particularly in the United States, as evidenced by much of its literature, appears to believe that functional independence in performance areas amounts to our ultimate goal. To cite a few examples, the American Occupational Therapy Association (AOTA) (1994a) maintained that ‘‘function in performance areas is the ultimate concern of occupation therapy’’ (p. 1047). DiJoseph (1982) asserted Jeffrey Crabtree is an Occupational Therapist in El Paso, TX. Occupational Therapy in Health Care, Vol. 12(2/3) 2000 E 2000 by The Haworth Press, Inc. All rights reserved.
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that independence, gained through purposeful activity, is the essence of occupational therapy. Dutton (1995) echoed this view, with qualifications, when she said that ‘‘while early treatment may be aimed at remediating underlying deficits such as abnormal muscle tone, the ultimate goal of clinical reasoning in occupational therapy is to restore the patient to his or her highest level of functional independence’’ (p. 3). Thornton & Rennie (1988), in their article describing the uniqueness of occupational therapy, stated that ‘‘the first area of consideration for occupational therapists should be the core, occupational performance, which refers to competence in self care, work and play activities’’ (pp. 52-53). Finally, the AOTA (1993) said that occupational therapists help those in the independent living movement ‘‘achieve their goals of living as purposefully and independently as possible’’ (p. 1080), and in long-term care occupational therapists help people with disabilities be as independent as possible (AOTA, 1994b). Typically, in conversation, we do not clarify what we mean when we speak of a client’s function; the term function has become shorthand for bathing, dressing, socialization, shopping, work, play, and all of the other performance areas (AOTA, 1994b, 1994b). We tacitly exclude the many physiological and neurological functions that support cognition, respiration, homeostasis, etc. This tacit understanding of the meaning of function grew out of our practical need to assess ability and measure treatment progress. For example, Sheldon (1935), a teacher of orthopedic physical education, developed a physical achievement record as a means to learn ‘‘what activities were really necessary to [the] personal independence’’ [emphasis added] (p. 6) of ‘‘crippled’’ children in a public school in New Jersey. Later, Brown (1947, 1950a, 1950b, 1951), a physical therapist who knew of Sheldon’s work, writing in the Physical Therapy Review and in the American Journal of Occupational Therapy, developed an activity inventory of daily activities she felt were predictive of future function and independence. (Brown’s inventory included mostly what we think of today as performance areas.) This practical need to assess ability, establish program eligibility, measure treatment progress, and the like, continues to sustain the construct of functional independence in performance areas today (Ottenbacher, Hsu, Granger, & Fiedler, 1996; Kane, Saslow, & Brundage, 1991; Shah & Cooper, 1993; Smith, 1992). Because of its pragmatic value and frequent use, the construct of functional independence in performance areas has gained nearly
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universal acceptance in the profession (Allen, 1992; American Occupational Therapy Association [AOTA], 1979, 1986, 1992, 1993, 1994a, 1995a, 1995b; Cynkin, 1995; Dutton, 1995; Orr & Schkade, 1997; Rogers, 1982; Unsworth, 1993, to name a few references).1 While the construct of functional independence in performance areas seems to have permeated our professional consciousness, we have not fully examined its meaning and the assumptions underlying it, or explored the implication of its use. For example, will a person with a C-1 spinal cord lesion value functional independence in activities of daily living (ADL) the same way a person with a radial nerve injury will? Should the ‘‘ultimate’’ goal or concern of occupational therapy be limited to function, independence, or some theoretical combination of the two? If not, what is the ultimate goal and concern of occupational therapy? This article explores the likely assumptions that underlie the construct of functional independence in performance areas. Further, the article explores broader concerns, such as autonomy, wholeness, meaning, and purposiveness, which best express the ultimate concerns of our profession. ASSUMPTIONS UNDERLYING THE CONSTRUCT OF FUNCTIONAL INDEPENDENCE IN PERFORMANCE AREAS According to the AOTA (1995a) ‘‘function is viewed as the interaction of neural and physiological mechanisms, behavior, and environment’’ (p. 1019). Further, ‘‘occupational therapists address the function of the individual at the occupational performance level where the environmental supports and barriers, the individual’s skills, and the individual’s occupational demands interact’’ (AOTA, 1995a, p. 1019). Fisher (1992) maintains that while a number of professions use the concepts of function, occupational therapy uniquely frames ‘‘function in occupation, or the ability to perform the daily life tasks related to ADLs and IADL, work, and play and leisure’’ (p. 184). These daily life tasks, or performance areas, with their concomitant performance components, compose the proper domain of occupational therapy (AOTA, 1994a; Mosey, 1992). Implicit in this construct is the notion that human endeavors or concerns outside these performance areas are also outside the domain of occupational therapy. However, even if all who receive occupational therapy hope to
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regain function in all or some performance components and areas, their desire to overcome deficits seldom stops there. Persons with performance deficits not only strive for functional independence, they seek and often attain fulfillment in the full range of human potentialities from the spiritual and familial, to the artistic and economic. Independence refers to a state or quality of being in relation to others and the environment, but these states are not mutually exclusive. People can simultaneously be independent and dependent. A client, for example, may independently choose what she wants to wear, but because of performance deficits due to a stroke, be dependent on others to dress. Another client may be physically able to dress, but because of performance deficits due to severe depression, may refuse to dress, and because of this refusal be dependent on others. Most therapists would concede that in these examples, both clients are in ways nonfunctional and functional, dependent and independent, and that to describe these people as functionally independent or dependent does not appropriately and fully characterize these clients. IMPLICATIONS FOR PRACTICE Much of what it means to be human falls outside the construct of functional independence in performance areas. One has only to recall a modern day example, Christopher Reeve, who fractured a cervical vertebra during a horse back riding accident. From the perspective of performance areas, he has severely limited function and is dependent, yet Reeve is a successful speaker, fund raiser, actor, and film director, among only a few of his successes. At several points along the course of his rehabilitation, therapists and physicians likely measured his functional independence in performance areas to plan and execute their interventions. However, Reeve probably never accepted his socalled level of independence or his limited functions as prescriptions for how to live the rest of his life. To Function for What Purpose? At best, the notion of functional independence in performance areas serves our need to measure clients’ performance abilities and improvement more than it serves clients’ abilities to construct and express meaning (Burke & Cassidy, 1991; Coppola, 1998; Radomski, 1995; Spencer, 1993; Whiteneck, 1994). At worst, exclusive pursuit of
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functional independence risks overlooking clients’ subjective constructs of purpose and meaning. Rosenblueth, Wiener, and Bigelow (1943) explain the importance of differentiating purpose from function: The basis of the concept of purpose is the awareness of ‘voluntary activity’ . . . When we perform a voluntary action what we select voluntarily is a specific purpose, not a specific movement. Thus, if we decide to take a glass containing water and carry it to our mouth we do not command certain muscles to contract to a certain degree and in a certain sequence; we merely trip the purpose and the reaction follows automatically. Indeed, . . . when an experimenter stimulates the motor regions of the cerebral cortex he does not duplicate a voluntary reaction; he trips efferent, ‘output’ pathways, but does not trip a purpose, as is done voluntarily. (p. 19) Thus, when we perform, we select a purpose, not a specific function of muscle and nerve. We have many functions, human and nonhuman, available to us to meet a specific purpose (to make or express a particular meaning). For example, when our purpose is to hit a soft ball, we use our many biomechanical functions in addition to the functions of the soft ball pitcher (to throw the ball), the bat (to strike the ball), and the catcher (to catch the ball when we miss). Often therapists and clients use a variety of functions to meet a single purpose. For example, a person with severe loss of physical functions who chooses to live alone in an apartment (a single purpose) must harness many alternate functions. She will use the functional capacity of assistive technology such as an environmental control unit to open and close doors, turn on lights, change TV channels, and dial the telephone. In addition, she may use the strength and experience of a physical therapy assistant to reduce contractures, and use the functional ability of a personal attendant to bathe, dress, and transfer. She employs these many functions, comparatively few her own, to serve the single purpose of living in the community. To Be Independent of What or Whom? We know the myth of independence well; independence and self-reliance maintain a central place in all Americans including our clients.
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This myth seems to have crowded out of many occupational therapists’ consciousness a conception of autonomy that ‘‘acknowledges the essential social nature of human development and recognizes dependence as a nonaccidental feature of the human condition’’ (Agich, 1990, p. 12). If, for whatever reason, we believe independence represents the ideal state of the individual, how do we reconcile our ongoing dependence on food and water, our interdependence on members of our community, and our heightened dependence on others during the beginning and end of our life cycle? As Jonas (1966) put it, ‘‘independence as such cannot be the ultimate good of life, since life is just that mode of material existence in which being has exposed itself to dependence’’ (p. 103). It makes more sense to acknowledge that we are all dependent in various ways and in varying degrees. Our dependency does not significantly increase or decrease from time to time or from person to person over a lifetime. Dependency, to the extent it can be quantified, remains essentially the same throughout life, but is dispersed in different ways and at different times (Kelly, 1955). For example, a fetus is solely dependent on one person, its mother. Once the child is born, he seeks increasingly greater numbers of people and resources to satisfy his needs. As an adult, with respect to any one individual, he is likely more independent than he was with respect to his mother. However, taking all of his relationships and needs into account, the degree to which he is dependent is the same as it has always been; his dependence is now dispersed over a broad range of people and resources. Practice Blind Alleys Theoretically, the logic of the functional independence in performance areas construct would lead therapists to conclude that no reasonable interventions exist outside the construct’s boundary. Yet, it is likely that therapists often treat people who have little function or no independence. Practically, when we impose the construct of functional independence on clients, we risk not asking simple questions like, what do independence and function mean to you? What function and independence tradeoffs do you want to make? Recognition that dependence is a natural feature of the human condition frees some people to choose among otherwise unacceptable choices. Some clients may choose to perform independent of some thing (perhaps a mechanical lift) and cheerfully depend on a person for transfers. Some may choose
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to be independent of some person (perhaps his or her mother) and happily depend on a several assistive devices from a sock aide to a bath bench for dressing and bathing. In practice, both the client and the reflective therapist face a dilemma created by the narrow functional independence construct. For example, after screening a client and deciding that because of the severity of his disability he will not become functionally independent in performance areas, is it appropriate, from either a reimbursement or professional ethic perspective, to treat that person? During treatment of someone that clearly can get no more functional and can gain no more independence, would not clinical reasoning based on this construct dictate the therapist discontinue therapy? In reality, therapists often shrug off this functional independence construct and continue to treat even the most nonfunctional and dependent by any construct because they and their clients have found good reasons to continue therapy.
WHAT DOES IT MEAN TO BE HUMAN? While the topic human meaning is much broader and more complex than can be addressed in this article, a brief discussion of how the construct of functional independence in performance areas falls short of what it means to be a human will help to inform occupational therapy. As Mosey (1992) says, ‘‘a profession’s philosophical assumptions are the basic beliefs it holds about the nature of the individual, the environment, the relationship between the individual and the environment, and the purpose and goals of the profession relative to meeting the needs of society’’ (p. 54). When we base treatment on the functional independence construct, we restrict our view of the human condition. At best this construct barely foreshadows what is of great and lasting importance to those we serve: Their sense of personal autonomy and wholeness and the awareness that they have and pursue purposiveness and meaning. Autonomy in Spite of Dependence Dworkin (1988) conceives of autonomy in a way that sheds light on the differences between independence and autonomy. He says that
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autonomy can be conceived of as a second-order capacity of persons to reflect critically upon their first-order preferences, desires, wishes, and so forth and the capacity to accept or attempt to change these in light of higher-order preferences and values. By exercising such a capacity, persons define their nature, give meaning and coherence to their lives, and take responsibility for the kind of person they are (p. 20). Considering this definition of autonomy, persons might have a powerful automobile and enjoy driving at high speeds (a first-order preference or desire). However, because of their concern for others and awareness that speeding in an automobile is dangerous (their secondorder capacity to reflect critically on first-order preferences), they may choose to drive within the speed limits, and in certain circumstances even slower than the speed limit. They are autonomous because they reflect critically on their first-order preferences and because they choose among different actions or values. As suggested earlier, the functional independence in performance areas construct bestows on the human condition limited possibilities; it overlooks the possibility of reflecting on one’s circumstances and limitations, and of choosing to rise above dependence or poor function. That people are autonomous, or have what Dworkin (1988) considers a second-order capacity to reflect critically on their first-order preferences, wishes, and values, describes a potent resource for moral action. However, perhaps more important for occupational therapy, it describes our clients’ capacity to reflect critically on abilities and disabilities and choose between different self-judgments and personal meanings. Dependence is a natural part of human existence. Dependence is only problematic when it is inappropriately or inadequately dispersed. Problems arise when one is dependent upon an unwanted thing or person, when the composition of dependencies is new or different, or when the amount of dependency on a thing or person is too great or too small. The person with a cervical spinal cord injury who had previously been a successful athlete and had appropriately dispersed his dependencies over family, friends, and community illustrates these problems. During the acute phase of his treatment, he depends on a few new people for all of his needs. He may not like one or more of the people upon whom he depends. As rehabilitation proceeds, he may disperse his dependencies over more, but still unfamiliar, people and
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resources. During this process, he may depend on people to bathe and feed him-- occupations he took pride in doing himself. Even years after his accident and after marriage and raising a family, he may have to disperse his dependencies in ways different from his able-bodied peers. Throughout their lives, as the above example suggests, autonomous people with performance deficits reflect on their first-order preferences, choices, and values regarding independence, and make secondorder choices that help give meaning and coherence to their lives. Occupational therapy offers persons with performance deficits and dependence on others many opportunities to explore both their firstorder preferences and what it will be like for them to make second-order choices. Wholeness Kass (1985) characterizes the relationship of health and wholeness ‘‘as ‘the well-working of the organism as a whole,’ or again, ‘an activity of the living body in accordance with its specific excellences’ ’’ (p. 174). To the extent that wholeness refers to the integrity of a person, it is a relative sense of well being with no prescribed limits or standards. Meyer (1957) describes the human as a whole being that is: constantly changing, it yet maintains a reasonably orderly internal and external structural and functional organization [that] varies according to its own complexity and the situations to be faced. It is a plastic entity with a wide range of differentiation of capacity and function; it is a center of relative but definable spontaneity and responsiveness; it is an object which constitutes itself a subject or agent, more or less self-dependent, and autonomous. (p. 6) A young athlete, for example, may base his sense of wholeness on attaining one physical fete after another. When faced with living the rest of his life with quadriplegia resulting from a sky diving accident, he can still have a sense of personal wholeness. To paraphrase Meyer, this young person’s sense of wholeness can vary depending on his complexity and the situations he faces. Despite potentially devastating personal losses, through the therapeutic use of occupation, he can
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reconstruct for himself a meaningful existence and a sense of wholeness based on new challenges and different performance. As this example illustrates, neither functional independence in performance areas is a sufficient condition for, nor is it a necessary condition of, wholeness. In other words, people measure their sense of personal wholeness by constructs other than whether they have certain functions or a particular level of independence.
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Purposiveness Our profession has a long history of upholding the worth of purposeful activity (Cottrell, 1997). Most authors seem to agree that people naturally engage in purposeful activity, and that purposeful activity is goal-directed. The importance of purpose from the occupational therapy perspective seems best characterized by McNary (1947) when she wrote, ‘‘An activity entered into without a purpose is not occupational therapy. Busy work and idle recreation have their place, but they are not occupational therapy’’ (pp. 10-11). While our literature firmly suggests the value of purpose applied to therapy, further exploration of the construct of purpose will help clarify its application to the human condition. Plants show purposeful activity when they convert water and carbon dioxide into carbohydrates. Guided missiles programmed to seek heat show goal directedness that serves a purpose. How is human purposeful activity different from a plant’s or machine’s? Is that difference important to occupational therapists? Wright’s (1971) differentiation between the terms purposeful and purposive helps answer these questions. He uses the term purposeful when discussing behavior of a living body or of a machine, ‘‘in the sense of being needed for the performance of functions characteristic of certain systems’’ (pp. 59-60). From his perspective, the purposefulness of a plant is different from the purposefulness of a human because of the uniquely different functions characteristic of each system. In this way, the purposefulness of a thing is similar to its capabilities. Wright makes an important distinction, one that we must make if we are to more closely match our philosophical assumptions and our view of the human condition. He says ‘‘behavior and other processes which are in this sense purposeful must be distinguished from behavior which is purposive in the sense of intentionally aiming at ends’’ [emphasis added] (Wright, 1971, p. 60). Said in a different way, humans
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have no control over their purposefulness, which is dictated by the functions characteristic of the human system. For example, we grasp and manipulate objects because we have a thumb that can oppose the other digits-- characteristics of human beings. We do not fly because without feathered extremities and other functions characteristic of birds, human flight is not possible. However, humans control their purposiveness, or intentions and meanings. While it is critically important for occupational therapists to understand the unique functions characteristic of the human, or what Wright calls human purposefulness, we must also identify and understand the unique purposiveness (or intentions and meanings) of each of those we treat. Persons can lose many functions characteristic of being human and yet retain the meanings and purposiveness that mark the depth and breadth of the human spirit. Consequently, as many occupational therapy writers have noted, we must acknowledge and support meaning and purposiveness in therapy. As stated earlier, neither functional independence in performance areas is a sufficient condition for, nor is it a necessary condition of, purposiveness. Thus, a person’s meaning, experienced through purposiveness, can transcend the person’s performance deficits. Meaningfulness The distinction between purposefulness and purposiveness is empty without considering meaningfulness. As Dunning (1973) asserts about humans, ‘‘choice is the vehicle by which he imbues his existence with essence or meaning’’ (p. 22). How human agents choose is a matter of fascinating conjecture, and its exploration outside the scope of this paper. What is important to this discussion is not how we make choices, but why we make choices. Some assert that meaning making is constitutive of humans (Crabtree, 1998; Kramer & Hinojosa, 1995; Mattingly & Fleming, 1994), and further, that we don’t need to be ‘‘motivated’’ to make meaning, it comes naturally. We make choices based upon what meaning we attribute to the alternatives, or what the options mean to us, our family, and others. Meaning, and associated intentions, explain why we act and why we consider one choice over others (Crabtree, 1998). More important, from an occupational therapy point of view, we make and express meaning through occupation. Being human means that in spite of often overwhelming loss of function or demoralizing
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dependence on others, we, through occupation, make meaning in our lives. We can do this in part because we can reflect on our circumstances and limitations and make second-order choices that help us transcend our limitations. Furthermore, constructing and expressing meaning is neither dependent upon all functions characteristic of humans being intact, nor on the person being totally independent. Rather, they are dependent upon a sense of wholeness regardless of how limited or deficient the action. When we help our clients reach some practical level of performance, we at least intuitively, expect them to take action: Return to work, or continue with a craft, or rejoin family and friends, not just to be performing, but because this doing is meaningful. When clients have no skill to restore, we expect they will develop new skills, again, not for the sake of simply being skillful, but because those skills help the client make and express meaning. To help our clients reach those goals, we not only evaluate their function and level of independence, but we help them tap into their sense of autonomy, purposiveness, and wholeness. We show them that through even the most mundane and commonplace performance, they can express their meanings, and that despite their limited function and dependence on others, they are part of a family and the broader community. CONCLUSION I have explored some assumptions underlying the construct of functional independence in performance areas, and proposed that despite its evolution into what some might consider the goal of practice, its restricted range and scope fall short of both the ultimate goal of occupational therapy and of a worthy vision of what it means to be human. Being human signifies far more than being independent in some task or functioning in some particular performance area. Humans choose between possible actions and values; they make choices that give meaning and purpose to their lives despite loss of function or independence. Humans seek wholeness; they strive for personal meaning and integrity despite their deficits and inabilities. Humans yearn for the ‘‘unattainable’’ and pursue practical goals; they marshal all possible resources against great odds to reach the most grand, and sometimes the most simple, objectives. Our construct of practice must not hold our clients back. Rather, our construct must sometimes even rise
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above the level of our clients’ personal expectations. When we help our clients’ express their meanings through occupation, and when, through occupation, we help them construct meaning out of often severely limited function and sometimes total dependence, we have attained an appropriate construct of practice.
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NOTE 1. It is important to note one significant exception-- the Client-centered approach (Canadian Association of Occupational Therapists, 1996; Law, Baptiste, & Mills, 1995) developed in Canada. ‘‘Client-centred practice recognizes the autonomy of individuals, the need for client choice in making decisions about occupational needs, the strengths clients bring to a therapy encounter, the benefits of client-therapist partnership and the need to ensure that services are accessible and fit the context in which a client lives’’ (Law, Baptiste, & Mills, 1995, p. 253). As stated in a Canadian Association of Occupational Therapists Position Statement (1994) ‘‘Occupational therapists’ broad vision is to enable people who face emotional, physical or social barriers to develop healthy patterns of occupation. The aim is to enable people to choose meaningful occupations which develop their personal and social resources for health’’ (p. 295). Therapist presumptions about function and independence or dependence are essentially irrelevant in the client-centered construct.
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American Occupational Therapy Association. (1994b). Position paper: Broadening the construct of independence. American Journal of Occupational Therapy, 48(11), 1035-1036. American Occupational Therapy Association. (1995a). Position paper: Occupational Performance: Occupational therapy’s definition of function. American Journal of Occupational Therapy, 49(10), 1019-1020. American Occupational Therapy Association. (1995b). Position paper: Broadening the construct of independence. American Journal of Occupational Therapy, 49(10), 1014. Brown, M. E. (1947). Daily activity testing and teaching. The Physiotherapy Review, 27(4), 249-253. Brown, M. E. (1950a). Daily activity inventory and progress record for those with atypical movement. American Journal of Occupational Therapy, 4(5), 195-204. Brown, M. E. (1950b). Daily activity inventory and progress record for those with atypical movement (Part II). American Journal of Occupational Therapy, 4(6), 261-272. Brown, M. E. (1951). Daily activity inventory and progress record for those with atypical movement (Part III). American Journal of Occupational Therapy, 5(1), 23-38. Burke, J. P. & Cassidy, J. C. (1991). Disparity between reimbursement-driven practice and humanistic values of occupational therapy. American Journal of Occupational Therapy, 45(2), 173-176. Canadian Association of Occupational Therapists. (1994). Position statement on everyday occupations and health. Canadian Journal of Occupational Therapy, 61(5), 294-295. Canadian Association of Occupational Therapists. (1996). Profile of occupational therapy practice in Canada. Canadian Journal of Occupational Therapy, 63(2), 79-95. Coppola, S. (1998). Clinical interpretation of ‘‘Occupational and well-being in dementia: The experience of day-care staff.’’ American Journal of Occupational Therapy, 52(6), 435-438. Cottrell, R. P. (Ed.). (1996). Perspectives on purposeful activity: Foundations and future of occupational therapy. Bethesda, MD: American Occupational Therapy Association. Crabtree, J. L. (1998). The end of occupational therapy. American Journal of Occupational Therapy, 52(3), 205-214. Cynkin, S. (1995). Activities. In C. B. Royeen (Ed.). AOTA Self-Study Series. The practice of the future: Putting occupation back into therapy (pp. 7.1-7.52). Rockville, MD: American Occupational Therapy Association. DiJoseph, L. M. (1982). Independence through activity: Mind, body, and environment interaction in therapy. American Journal of Occupational Therapy, 36(11), 740-744. Dunning, R. E. (1973). Philosophy and occupational therapy. American Journal of Occupational Therapy, 27(1), 18-23. Dutton, R. (1995). Clinical reasoning in physical disabilities. Baltimore: Williams & Wilkins.
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