Occupational
Therapy and brain injury
Having made this point that it is possible to understand behaviour
through normal channels, it is but a short step to say that behaviour
can also be controlled through the normal channels. It does not
require long years of training in particular therapeutic techniques,
but it requires a certain heed be taken of the details of ordinary
behaviour.
We are perfectly familiar with the sorts of happenings
which induce or occasion people to do things. If we were not,
we could not get them to do what we wish, and the ordinary dealings
between people could not exist. Customers could not purchase,
officers could not command, friends could not converse, or children
play, unless they knew how to get other people and themselves
to do things at particular junctures. (Ryle 1986 P. 109).
The practitioner here is someone who takes this common knowledge
to a new level of consciousness, such that they can actually create
the situations which will bring about the kind of outcomes that
their client needs. There is not much literature which can be
easily found about the ways that the practitioner operates when
they are working. I do not doubt that the work is being done,
but it rarely finds its way into the published literature. Dickson
(1998) gives one example in her description of work with a community
programme
It is clearer to me now that there are also sometimes conditions
or circumstances in peoples lives that preclude them from being
involved in activities with a ‘real’ purpose and
that the need for this involvement can be responded to. At Step
Ahead we made poppies to sell to the craft shop; not to improve
problem solving ability or self esteem or because it related
to their occupational roles. We made munch lunch to feed the
membership, to help newcomers feel at home and to provide a
good reason for coming along; not to learn cooking skills or
increase one’s confidence in their occupations, though
these may come out of the process.
It seems to me that these ‘real’ purposes are
derived from a common shared meaning that belongs quite naturally
to the activity, for example, preparing food to share with others
or an artefact to enjoy, give away, trade or barter. Having
ordinary everyday reasons for doing things was the outcome here
and enabling this involvement to occur involved careful facilitation.
This enabling role is easy to describe but difficult to
explain. Making things happen involves being mindful of a myriad
of factors that influence engagement yet seems so ordinary,
so commonplace. It involves knowing what needs to be done and
how to create it, what pitfalls might arise and how to avert
them. Most importantly, it involves enabling the recipients
of the service to become fully involved and fine tuning the
experience to ensure that it retains its ‘reality’.
There are vignettes in the intellectual disability literature
which show that this kind of understanding is being used in practice.
This kind of practice is not based on some notion of therapy or
education, the idea is not to create a job for the practitioner,
but to provide real engagement for the client. The following story
makes the point well, if one ignores the practitioner's continued
focus on assertiveness and friendship.
Arthur is 40 years old and lives in his own home with two
other men. He loves books and history, and has a fascination
with cemetries and death. He was described by the staff as hesitant
to try new things. They said, '‘we have to go slow with
Arthur.'’ Arthur also tended to be a '‘yes-man,'’
willing to comply with whatever staff asked or expected him
to do. Staff had been working on the goal of Arthur being more
‘assertive’ for quite some time.
An appropriate behavioural intervention for Arthur might
include various social skills programs for assertiveness training
and desensitization to novelty; in fact, various social skills
programs had been tried to improve his assertiveness. A different
approach was taken when his agency started to focus on people
having more friends and being more a part of their community.
Using his interest in books to hopefully lead to more social
relationships, Arthur was assisted in beginning to volunteer
at the community library. He had the job of dusting the book
shelves; he reported on the importance of his visits to the
library. After his first visit the staff inquired as to how
it went. Arthur replied, ‘the books were really dusty.
They really needed me.’
Arthur also almost immediately began to assert himself
more. When the library staff gave him a name tag with his name
misspelled, he immediately requested a new one. In addition,
there was a marked transformation in his hesitancies.
Staff were willing to go with Arthur for as long as necessary,
but after just two visits Arthur told them that they didn't
need to come along anymore- he could walk by himself and handle
it by himself. One staff said, ‘but Arthur what about
walking home? It will be dark out.’ Arthur told her firmly,
‘But Sandy, there are street lights!”
Arthur’s sense of playing a valued role at the library
catalyzed a whole new lifestyle for him. Whereas many of these
changes could have been produced with enough programming time,
when he had a chance to participate and contribute in a community
setting totally separate from his agency programs, a qualitative
shift happened that programming could not provide. Programs,
no matter how good they are, and no matter how good their results
are, perseverate the model of providing programs. Within the
programming paradigm, the only thing programs lead to is the
next program. (Weiss 1982)
This reminder of the different kinds of paradigms within which
it is possible to work brings me to the stage where I need to
make some points about the things which I have not been attempting
to do here. I choose these particular aspects because I expect
the reader to point out that these are things that I have somehow
missed. These points have consumed a great deal of my time and
energy, but they are not the focus of this thesis.
Next page: The person with brain injury
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