Occupational Therapy
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Occupational Therapy
Occupational therapy
US Navy Occupational therapists working with outpatients.png
US Navy Occupational therapists providing treatment to outpatients
ICD-9-CM 93.83
MeSH D009788

Occupational therapy (OT) is the use of assessment and intervention to develop, recover, or maintain the meaningful activities, or occupations, of individuals, groups, or communities. It is an allied health profession performed by occupational therapists. OTs often work with people with mental health problems, disabilities, injuries, or impairments.[1]

The American Occupational Therapy Association defines an occupational therapist as someone who "helps people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities (occupations). Common occupational therapy interventions include helping children with disabilities to participate fully in school and social situations, injury rehabilitation, and providing supports for older adults experiencing physical and cognitive changes."[2]

Typically, occupational therapists are university-educated professionals and must pass a licensing exam to practice.[3] Occupational therapists often work closely with professionals in physical therapy, speech therapy, audiology, nursing, social work, clinical psychology, and medicine.


Early history

The earliest evidence of using occupations as a method of therapy can be found in ancient times. In c. 100 BCE, Greek physician Asclepiades treated patients with a mental illness humanely using therapeutic baths, massage, exercise, and music. Later, the Roman Celsus prescribed music, travel, conversation and exercise to his patients. However, by medieval times the use of these interventions with people with mental illness was rare, if not nonexistent.[4]

In 18th-century Europe, revolutionaries such as Philippe Pinel and Johann Christian Reil reformed the hospital system. Instead of the use of metal chains and restraints, their institutions used rigorous work and leisure activities in the late 18th century. This was the Moral Treatment era, developed in Europe during the Age of Enlightenment, where the roots of occupational therapy lie.[5] Although it was thriving in Europe, interest in the reform movement fluctuated in the United States throughout the 19th century. It re-emerged in the early decades of the 20th century as Occupational Therapy.

The Arts and Crafts movement that took place between 1860 and 1910 also impacted occupational therapy. In the US, a recently industrialized country, the arts and crafts societies emerged against the monotony and lost autonomy of factory work.[6] Arts and crafts were used as a way of promoting learning through doing, provided a creative outlet, and served as a way to avoid boredom during long hospital stays.

Development into a health profession

Occupational therapy. Toy making in psychiatric hospital. World War 1 era.

The health profession of occupational therapy was conceived in the early 1910s as a reflection of the Progressive Era. Early professionals merged highly valued ideals, such as having a strong work ethic and the importance of crafting with one's own hands with scientific and medical principles.[4] The National Society for the Promotion of Occupational Therapy, now called the American Occupational Therapy Association (AOTA), was founded in 1917 and the profession of Occupational Therapy was officially named in 1920.[]

Occupational therapy during WWI: bedridden wounded are knitting.

The emergence of occupational therapy challenged the views of mainstream scientific medicine. Instead of focusing purely on the medical model, occupational therapists argued that a complex combination of social, economic, and biological reasons cause dysfunction. Principles and techniques were borrowed from many disciplines--including but not limited to physical therapy, nursing, psychiatry, rehabilitation, self-help, orthopedics, and social work--to enrich the profession's scope. Between 1900 and 1930, the founders defined the realm of practice and developed supporting theories. By the early 1930s, AOTA had established educational guidelines and accreditation procedures.[7]

World War I forced the new profession to clarify its role in the medical domain and to standardize training and practice. In addition to clarifying its public image, occupational therapy also established clinics, workshops, and training schools nationwide. Due to the overwhelming number of wartime injuries, "reconstruction aides" (an umbrella term for occupational therapy aides and physiotherapy aides) were recruited by the Surgeon General. Between 1917 and 1920, nearly 148,000 wounded men were placed in hospitals upon their return to the states. The success of the reconstruction aides, largely made up of women trying to "do their bit" to help with the war effort, was a great accomplishment.[]

There was a struggle to keep people in the profession during the post-war years. Emphasis shifted from the altruistic war-time mentality to the financial, professional, and personal satisfaction that comes with being a therapist. To make the profession more appealing, practice was standardized, as was the curriculum. Entry and exit criteria were established, and the American Occupational Therapy Association advocated for steady employment, decent wages, and fair working conditions. Via these methods, occupational therapy sought and obtained medical legitimacy in the 1920s.[4]

The profession has continued to grow and expand its scope and settings of practice. Occupational science, the study of occupation, was created in 1989 as a tool for providing evidence-based research to support and advance the practice of occupational therapy, as well as offer a basic science to study topics surrounding "occupation".[8]

Philosophical underpinnings

The philosophy of occupational therapy has evolved over the history of the profession. The philosophy articulated by the founders owed much to the ideals of romanticism,[9]pragmatism[10] and humanism, which are collectively considered the fundamental ideologies of the past century.[11][12][13]

One of the most widely cited early papers about the philosophy of occupational therapy was presented by Adolf Meyer, a psychiatrist who had emigrated to the United States from Switzerland in the late 19th century and who was invited to present his views to a gathering of the new Occupational Therapy Society in 1922. At the time, Dr. Meyer was one of the leading psychiatrists in the United States and head of the new psychiatry department and Phipps Clinic at Johns Hopkins University in Baltimore, Maryland.[14][15]

William Rush Dunton, a supporter of the National Society for the Promotion of Occupational Therapy, now the American Occupational Therapy Association, sought to promote the ideas that occupation is a basic human need, and that occupation is therapeutic. From his statements came some of the basic assumptions of occupational therapy, which include:

  • Occupation has a positive effect on health and well-being.
  • Occupation creates structure and organizes time.
  • Occupation brings meaning to life, culturally and personally.
  • Occupations are individual. People value different occupations.[16]

These assumptions have been developed over time and are the basis of the values that underpin the Codes of Ethics issued by the national associations. The relevance of occupation to health and well-being remains the central theme.

In the 1950s, criticism from medicine and the multitude of disabled World War II veterans resulted in the emergence of a more reductionistic philosophy. While this approach led to developments in technical knowledge about occupational performance, clinicians became increasingly disillusioned and re-considered these beliefs.[17][18] As a result, client centeredness and occupation have re-emerged as dominant themes in the profession.[19][20][21] Over the past century, the underlying philosophy of occupational therapy has evolved from being a diversion from illness, to treatment, to enablement through meaningful occupation.[16]

Three commonly mentioned philosophical precepts of occupational therapy are that occupation is necessary for health, that its theories are based on holism and that its central components are people, their occupations (activities), and the environments in which those activities take place. However, there have been some dissenting voices. Mocellin, in particular, advocated abandoning the notion of health through occupation as he proclaimed it obsolete in the modern world. As well, he questioned the appropriateness of advocating holism when practice rarely supports it.[22][23][24] Some values formulated by the American Occupational Therapy Association have been critiqued as being therapist-centric and do not reflect the modern reality of multicultural practice.[25][26][27]

In recent times occupational therapy practitioners have challenged themselves to think more broadly about the potential scope of the profession, and expanded it to include working with groups experiencing occupational injustice stemming from sources other than disability.[28] Examples of new and emerging practice areas would include therapists working with refugees,[29] children experiencing obesity,[30] and people experiencing homelessness.[31]

Practice frameworks

An occupational therapist works systematically with a client through a sequence of actions called the occupational therapy process. There are several versions of this process as described by numerous scholars. All practice frameworks include the components of evaluation (or assessment), intervention, and outcomes.This process provides a framework through which occupational therapists assist and contribute to promoting health and ensures structure and consistency among therapists.

The Occupational Therapy Practice Framework (OTPF) is the core competency of occupational therapy in the United States.The OPTF framework is divided into two sections: domain and process. The domain includes environment, client factors, such as the individual's motivation, health status, and status of performing occupational tasks. The domain looks at the contextual picture to help the occupational therapist understand how to diagnose and treat the patient. The process is the actions taken by the therapist to implement a plan and strategy to treat the patient.[32]

The Canadian Model of Client Centered Enablement (CMCE) embraces occupational enablement as the core competency of occupational therapy[16] and the Canadian Practice Process Framework (CPPF)[16] as the core process of occupational enablement in Canada.The Canadian Practice Process Framework (CPPF)[16] has eight action points and three contextual element which are: set the stage, evaluate, agree on objective plan, implement plan, monitor/modify, and evaluate outcome. A central element of this process model is the focus on identifying both client and therapists strengths and resources prior to developing the outcomes and action plan.


The American Occupational Therapy Association's practice framework identifies the following Occupations:[32]

  • Activities of daily living (ADLs)
    • Bathing, showering, Toileting and toilet hygiene, Dressing, Feeding, Functional mobility/transfers, Personal device care, Personal hygiene and grooming
  • Instrumental activities of daily living (IADLs)
    • Care of others, Care of pets, Child rearing, Communication management, Driving and community mobility, Financial management, Health management and maintenance, Home establishment and managements, Meal preparation and cleanup, Medication management, Religious and spiritual activities and expression, Safety and emergency maintenance, Shopping
  • Rest and sleep
    • Rest, Sleep preparation, Sleep participation
  • Education
  • Work
    • Employment interests and pursuits, Employment seeking and acquisition, Job performance, Retirement preparation and adjustment, Volunteer exploration, Volunteer participation
  • Play
    • Play exploration, Play participation
  • Leisure
    • Leisure exploration, Leisure participation
  • Social participation
    • Community, Family, Peer, friend

Practice settings

Occupational therapists work in a wide variety of practice settings, including: hospitals, long-term care facilities, schools, outpatient clinics, and the community (e.g. home care). The Canadian Institute for Health Information (CIHI) found that between 2006-2010 nearly half (45.6%) of occupational therapists worked in hospitals, 31.8% worked in the community, and 11.4% worked in a professional practice.[33]

Areas of practice

The broad spectrum of OT practice makes it difficult to categorize the areas of practice, especially considering the differing health care systems globally. In this section, the categorization from the American Occupational Therapy Association is used.

Children and youth

Tire Swing used during occupational therapy with children

In 1951, Joan Erikson became director of activities for the "severely disturbed children and young adults" at the Austen Riggs Center. At that time, "occupational therapy" was used "for keeping patients busy on useless tasks." Erikson "brought in painters, sculptors, dancers, weavers, potters and others to create a program that provided real therapy."[34]

Occupational therapists work with infants, toddlers, children, and youth and their families in a variety of settings including schools, clinics, and homes.[35] Occupational therapists assist children and their caregivers to build skills that enable them to participate in meaningful occupations. These occupations may include: feeding, playing, socializing, and attending school.[36]

Occupational therapy with children and youth may take a variety of forms. For example:[35][36]

Health and wellness

The practice area of Health and Wellness is emerging steadily due to the increasing need for wellness-related services in occupational therapy. A connection between wellness and physical health, as well as mental health, has been found; consequently, helping to improve the physical and mental health of clients can lead to an increase in overall well-being.[37]

As a practice area, health and wellness can include a focus on:[37][38]

  • Prevention of disease and injury
  • Prevention of secondary conditions (co-morbidity)
  • Promotion of the well-being of those with chronic illnesses e.g. sexual rehabilitation
  • Reduction of health care disparities or inequalities
  • Enhancement of factors that impact quality of life
  • Promotion of healthy living practices, social participation, and occupational justice
Occupational therapist conducting a group intervention on interpersonal relationship building

Mental health

Mental health and the moral treatment era have been recognized as the root of occupational therapy.[39] According to the World Health Organization, mental illness is one of the fastest growing forms of disability.[40] OTs focus on prevention and treatment of mental illness in all populations.[41] In the U.S., military personnel and veterans are populations that can benefit from occupational therapy, but currently this is an under served practice area.[42]

Mental health illnesses that may require occupational therapy include schizophrenia and other psychotic disorders, depressive disorders, anxiety disorders, eating disorders, trauma- and stressor-related disorders (e.g. post traumatic stress disorder or acute stress disorder), obsessive-compulsive and related disorders such as hoarding, and neurodevelopmental disorders such as autism spectrum disorder, attention deficit/hyperactivity disorder and learning disorders.[43]

Productive aging

Occupational therapists work with older adults to maintain independence, participate in meaningful activities, and live fulfilling lives. Some examples of areas that occupational therapists address with older adults are driving, aging in place, low vision, and dementia or Alzheimer's Disease (AD).[44] When addressing driving, driver evaluations are administered to determine if drivers are safe behind the wheel. To enable independence of older adults at home, occupational therapists perform falls risk assessments, assess clients functioning in their homes, and recommend specific home modifications. When addressing low vision, occupational therapists modify tasks and the environment.[45] While working with individuals with AD, occupational therapists focus on maintaining quality of life, ensuring safety, and promoting independence.

Adult Rehabilitation

Occupational therapists address the need for rehabilitation following an injury or impairment. When planning treatment, occupational therapists address the physical, cognitive, psychosocial, and environmental needs involved in adult populations across a variety of settings.

Occupational therapy in adult rehabilitation may take a variety of forms:

  • Working with adults with autism at day rehabilitation programs to promote successful relationships and community participation through instruction on social skills[46]
  • Increasing the quality of life for an individual with cancer by engaging them in occupations that are meaningful, providing anxiety and stress reduction methods, and suggesting fatigue management strategies[47]
  • Coaching individuals with hand amputations how to put on and take off a myoelectrically controlled limb as well as training for functional use of the limb[47]
  • As for paraplegics, there are such things as sitting cushion and pressure sore prevention. Prescription of these aids is the common job for paraplegics.
  • Using and implementing new technology such as speech to text software and Nintendo Wii video games[48]
  • Communicating via telehealth methods as a service delivery model for clients who live in rural areas[49]
  • Working with adults who have had a stroke to regain strength, endurance, and range of motion on their affected side.[50]

Travel occupational therapy

Because of the rising need for occupational therapists in the U.S.,[51] many facilities are opting for travel occupational therapists--who are willing to travel, often out of state, to work temporarily in a facility. Assignments can range from 8 weeks to 9 months, but typically last 13-26 weeks in length.[52] Most commonly (43%), travel occupational therapists enter the industry between the ages of 21-30.[53]

Work and industry

Occupational therapists work with clients who have had an injury and are returning to work. OTs perform assessments to simulate work tasks in order to determine best matches for work, accommodations needed at work, or the level of disability. Work conditioning and work hardening are interventions used to restore job skills that may have changed due to an illness or injury. Occupational therapists can also prevent work related injuries through ergonomics and on site work evaluations.[54]


Worldwide, there is a range of qualifications required to practice occupational therapy. Many countries require a bachelor's degree (e.g. Australia). In the United States and Canada, a master's degree is required to practice. In Europe, a bachelor's degree or a master's degree is accepted.[55]

The OT curriculum focuses on the theoretical basis of occupation and the clinical skills require to practice occupational therapy. Students must have knowledge of physiology, anatomy, medicine, psychology, and neurology to understand interventions and their client's medical history. All OT education programs include periods of clinical education, consisting of direct work with a practicing OT.[55] In countries such as Canada and the United States, OT students must pass a national qualifying examination in order to practice.

Theoretical frameworks

Occupational therapists use theoretical frameworks to frame their practice. Note that terminology differs between scholars. An incomplete list of theoretical bases for framing a human and their occupations include the following:

Frames of reference and generic models

Frames of reference or generic models are the overarching title given to a collation of compatible knowledge, research and theories that form conceptual practice.[56] More generally they are defined as "those aspects which influence our perceptions, decisions and practice".[57]

  • Person Environment Occupation Performance Model
    • The Person Environment Occupation Performance model (PEOP) was originally published in 1991 (Charles Christiansen & M. Carolyn Baum[58]) and describes an individual's performance based on four elements including: environment, person, performance and occupation. The model focuses on the interplay of these components and how this interaction works to inhibit or promote successful engagement in occupation.[59]

Occupation-Focused Practice Models

  • Occupational Therapy Intervention Process Model (OTIPM) (Anne Fisher and others)
  • Occupational Performance Process Model (OPPM)
  • Model of Human Occupation (MOHO) (Gary Kielhofner and others)
    • MOHO was first published in 1980. It explains how people select, organise and undertake occupations within their environment. The model is supported with evidence generated over thirty years and has been successfully applied throughout the world.[60]
  • Canadian Model of Occupational Performance and Engagement (CMOP-E)
  • Occupational Performances Model - Australia (OPM-A) (Chris Chapparo & Judy Ranka)
    • The OPM(A) was conceptualized in 1986 with its current form launched in 2006. The OPM(A) illustrates the complexity of occupational performance, the scope of occupational therapy practice, and provides a framework for occupational therapy education.[61]
  • Kawa (River) Model (Michael Iwama)
  • Biomechanical Frame of Reference
    • The Biomechanical Frame of Reference is primarily concerned with motion during occupation. It is used with individuals who experience limitations in movement, inadequate muscle strength or loss of endurance in occupations. The Frame of Reference was not originally compiled by Occupational Therapists, and therapists should translate it to the Occupational Therapy perspective,[62] to avoid the risk of movement or exercise becoming the main focus.[63]
  • Rehabilitative (compensatory)
  • Neurofunctional (Gordon Muir Giles and Clark-Wilson)
  • Dynamic Systems Theory
  • Client-Centered Frame of Reference
    • This Frame of Reference is developed from the work of Carl Rogers. It views the client as the center of all therapeutic activity, and the client's needs and goals direct the delivery of the Occupational Therapy Process.[64]
  • Cognitive-Behavioural Frame of Reference
  • Ecology of Human Performance Model
  • The Recovery Model


The International Classification of Functioning, Disability and Health (ICF) is a framework to measure health and ability by illustrating how these components impact one's function. This relates very closely to the Occupational Therapy Practice Framework, as it is stated that "the profession's core beliefs are in the positive relationship between occupation and health and its view of people as occupational beings".[65] The ICF is built into the 2nd edition of the practice framework. Activities and participation examples from the ICF overlap Areas of Occupation, Performance Skills, and Performance Patterns in the framework. The ICF also includes contextual factors (environmental and personal factors) that relate to the framework's context. In addition, body functions and structures classified within the ICF help describe the client factors described in the Occupational Therapy Practice Framework.[66] Further exploration of the relationship between occupational therapy and the components of the ICIDH-2 (revision of the original International Classification of Impairments, Disabilities, and Handicaps (ICIDH), which later became the ICF) was conducted by McLaughlin Gray.[67]

It is noted in the literature that occupational therapists should use specific occupational therapy vocabulary along with the ICF in order to ensure correct communication about specific concepts.[68] The ICF might lack certain categories to describe what occupational therapists need to communicate to clients and colleagues. It also may not be possible to exactly match the connotations of the ICF categories to occupational therapy terms. The ICF is not an assessment and specialized occupational therapy terminology should not be replaced with ICF terminology.[69] The ICF is an overarching framework for current therapy practices.

See also


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