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Thomas Kinder, an architect, specialized in the design of hospitals, asylums, and sanitariums, therefore contributing ideas of how to engineer or structure the physical environment in support of functional reeducation through engagement in work or leisure activities contributing to the paradigm of the influence of multiple contexts in the performance of occupations (Cole & Tufano, 2020).

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1910s: Need to recognize skilled craftsmen during the industrial revolution

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1910s: Need to recognize skilled craftsmen during the industrial revolution

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"The Guildhall in London and the Hull House in Chicago are examples of establishments that housed the preservation of handcrafts and offered instruction in weaving, woodworking, basketry, printing, and many others" (Cole & Tufano, 2020).

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Hull House | History, Significance, Jane Addams, & Museum

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Hull House, one of the first social settlements in North America. It was founded in Chicago in 1889 by Jane Addams and Ellen Gates Starr to aid needy immigrants. It became a complex, containing a gymnasium, social and cooperative clubs, shops, housing for children, and playgrounds. Learn more about Hull House.

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1919: Pressure to provide evidence for why OT is the cure

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1919: Pressure to provide evidence for why OT is the cure

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William Rush Dunton, a medical doctor, established the profession’s first journal. Reconstruction Therapy, published in 1919, outlined the use of crafts and other occupations in restoring productive functioning to wounded soldiers.

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100 Influential People in Occupational Therapy: William Rush Dunton Jr., MD

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William Rush Dunton Jr. is one of the 100 influential people in occupational therapy’s 100 year history.

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1920s: All men have equal rights; therefore, there is a moral obligation to help "invalids."

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1920s: All men have equal rights; therefore, there is a moral obligation to help "invalids."

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"Adolf Meyer, a psychiatrist, incorporated community-based activities and services to develop skills of everyday life into treatment with his patients" (American Occupational Therapy Association [AOTA], 2017).

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Adolf Meyer, (born September 13, 1866, Niederweningen, Switzerland-died March 17, 1950, Baltimore, Maryland, U.S.), influential Swiss-born American psychiatrist, much of whose teaching has been incorporated into psychiatric theory and practice in the United States, Britain, and other English-speaking nations.

When Meyer emigrated to the United States in 1892, he was already exceptionally well trained in neuroanatomy and neurophysiology, having studied with Auguste-Henri Forel at the University of Zürich, where he earned his medical degree in 1892. In the United States he became acquainted with the thought of the psychologist William James, the philosopher-educator John Dewey, and others who were molding sociological and philosophical tradition in the United States. He fused these various influences into a concept of human behaviour that he called ergasiology, or psychobiology, which seeks a complete integration of the psychological and biological study of human beings.

As neuropathologist at the Illinois Eastern Hospital for the Insane, in Kankakee (1893-95), Meyer emphasized the importance of taking accurate case histories of patients. Before the widespread recognition of the theories of Sigmund Freud, Meyer began suggesting that childhood sexual feelings may precipitate serious mental problems. Gradually he decided that the disorder in mental illness results essentially from personality dysfunction rather than brain pathology. He was chief pathologist of the mental institution at Worcester, Massachusetts (1895-1902), and then became director of pathology for the Pathological Institute of the New York State Hospital Service, Ward's Island (1902-10), and professor of psychiatry at the Cornell University Medical College, New York City (1904-09). As he became more aware of the importance of social environment in the development of mental disorders, his wife ( née Mary Potter Brooks) began visiting patients' families. Her interviews are considered the first effort in psychiatric social work.

In 1910 Meyer became professor of psychiatry at Johns Hopkins University (Baltimore) and later director of its Henry Phipps Psychiatric Clinic (1914). Until he retired in 1941, he impressed generations of students with the idea that, in the diagnosis and treatment of mental illness, account must be taken of the patient as a whole person. His work appears in his Collected Papers, 4 vol. (1950-52), and Psychobiology (1957).

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Adolf Meyer | Psychoanalytic Theory, Mental Hygiene & Psychiatry

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Adolf Meyer, influential Swiss-born American psychiatrist, much of whose teaching has been incorporated into psychiatric theory and practice in the United States, Britain, and other English-speaking nations. When Meyer emigrated to the United States in 1892, he was already exceptionally well

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1920s: Mental Hygiene - Idleness is a precursor to mental illness.

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1920s: Mental Hygiene - Idleness is a precursor to mental illness.

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Eleanor Clarke Slagle ... [one of the founders of occupational therapy,] devised a schedule of daily activity for inpatients in a cheerful and supportive environment as the logical antidote...Tasks were graded to fit the patient’s capabilities, and environments provided both physical and social support for engagement in activities of many types, including crafts, grounds keeping, productive work, and participation in group recreational activities" (Cole & Tufano, 2020).

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100 Influential People in Occupational Therapy: Eleanor Clarke Slagle

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Eleanor Clarke Slagle is one of the 100 influential people in occupational therapy’s 100 year history.

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Reconstruction Aide working with Medical Doctors

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1920-30s: Reconstructing bodies after World War I

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1920-30s: Reconstructing bodies after World War I

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World War I led to the emergence of reconstruction aides, the precursors to modern OTs. "[O]ccupational reconstruction aides quickly learned that as therapists working in health care settings under a doctor’s supervision, they were both more highly respected and better paid" (Cole & Tufano, 2020). This resulted in recognition as a healthcare profession.

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reconstruction aides working with medical doctor

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1930s: Making factory workers more efficient

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1930s: Making factory workers more efficient

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"The biomechanical model, using scientific evidence from time and motion studies in the 1920s, became the basis for activity analysis in occupational therapy and applied to ADL, has become the preferred frame of reference for the treatment of physical disabilities—a trend that continues to the present" (Cole & Tufano, 2020).

Decades later this idea was written as the, "[t]he kinetic model, published by Sidney Licht in 1947, provid[ing] a scientific basis for the analysis of activities using a biomechanical frame of reference. Claire Spackman interpreted this model for treating patients with physical injuries in the first edition of Occupational Therapy, which she edited with Helen Willard in 1947" (Cole & Tufano, 2020).

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1930s: Scientific studies about behavior

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1930s: Scientific studies about behavior

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"Behavior modification was first used as a therapeutic approach in institutions to reinforce desirable behaviors while using negative reinforcement to extinguish undesirable behaviors" (Cole & Tufano, 2020).

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Pavlov's Dog Experiment

Pavlov (1902) started from the idea that there are some things that a dog does not need to learn. For example, dogs don't learn to salivate whenever they see food. This reflex is 'hard-wired' into the dog.

Pavlov showed that dogs could be conditioned to salivate at the sound of a bell if that sound was repeatedly presented at the same time that they were given food.

Pavlov's studies of classical conditioning have become famous since his early work between 1890 and 1930. Classical conditioning is "classical" in that it is the first systematic study of the basic laws of learning (also known as conditioning).

Pavlov's dogs were individually situated in secluded environments, secured within harnesses. A food bowl was positioned before them, and a device was employed to gauge the frequency of their salivary gland secretions.

The data from these measurements were systematically recorded onto a rotating drum, allowing Pavlov to meticulously monitor the rates of salivation throughout the course of the experiments.

First, the dogs were presented with the food, and they salivated. The food was the unconditioned stimulus and salivation was an unconditioned (innate) response. (i.e., a stimulus-response connection that required no learning).

Unconditioned Stimulus (Food) > Unconditioned Response (Salivate)

In his experiment, Pavlov used a metronome as his neutral stimulus. By itself, the metronome did not elicit a response from the dogs.

Neutral Stimulus (Metronome) > No Response

Next, Pavlov began the conditioning procedure, whereby the clicking metronome was introduced just before he gave food to his dogs. After a number of repeats (trials) of this procedure, he presented the metronome on its own.

As you might expect, the sound of the clicking metronome on its own now caused an increase in salivation.

Conditioned Stimulus (Metronome) > Conditioned Response (Salivate)

So, the dog had learned an association between the metronome and the food, and a new behavior had been learned.

Because this response was learned (or conditioned), it is called a conditioned response (and also known as a Pavlovian response). The neutral stimulus has become a conditioned stimulus.

Temporal contiguity

Pavlov found that for associations to be made, the two stimuli had to be presented close together in time (such as a bell).

He called this the law of temporal contiguity. If the time between the conditioned stimulus (bell) and the unconditioned stimulus (food) is too great, then learning will not occur.

'Unconditioning' through experimental extinction

In extinction, the conditioned stimulus (the bell) is repeatedly presented without the unconditioned stimulus (the food).

Over time, the dog stops associating the sound of the bell with the food, and the conditioned response (salivation) weakens and eventually disappears.

In other words, the conditioned response is "unconditioned" or "extinguished."

Spontaneous recovery

Pavlov noted the occurrence of "spontaneous recovery," where the conditioned response can briefly reappear when the conditioned stimulus is presented after a rest period, even though the response has been extinguished.

This discovery added to the understanding of conditioning and extinction, indicating that these learned associations, while they can fade, are not completely forgotten.

Generalization

The principle of generalization suggests that after a subject has been conditioned to respond in a certain way to a specific stimulus, the subject will also respond in a similar manner to stimuli that are similar to the original one.

In Pavlov's famous experiments with dogs, he found that after conditioning dogs to salivate at the sound of a bell (which was paired with food), the dogs would also salivate in response to similar sounds, like a buzzer.

This demonstrated the principle of generalization in classical conditioning.

However, the response tends to be more pronounced when the new stimulus closely resembles the original one used in conditioning.

This relationship between the similarity of the stimulus and the strength of the response is known as the generalization gradient.

This principle has been exemplified in research, including a study conducted by Meulders and colleagues in 2013.

Impact of Pavlov's Research

Ivan Pavlov's key contribution to psychology was the discovery of classical conditioning, demonstrating how learned associations between stimuli can influence behavior.

His work laid the foundation for behaviorism, influenced therapeutic techniques, and informed our understanding of learning and memory processes.

1. Behaviorism: Pavlov's work laid the foundation for behaviorism, a major school of thought in psychology. The principles of classical conditioning have been used to explain a wide range of behaviors, from phobias to food aversions.

2. Therapy Techniques: Techniques based on classical conditioning, such as systematic desensitization and exposure therapy, have been developed to treat a variety of psychological disorders, including phobias and post-traumatic stress disorder (PTSD).

In these therapies, a conditioned response (such as fear) can be gradually "unlearned" by changing the association between a specific stimulus and its response.

3. Little Albert Experiment: The Little Albert experiment, conducted by John B. Watson in 1920, demonstrated that emotional responses could be classically conditioned in humans. A young child, "Little Albert," was conditioned to fear a white rat, which generalized to similar objects.

4. Educational Strategies: Educational strategies, like repetitive learning and rote memorization, can be seen as applications of the principles of classical conditioning. The repeated association between stimulus and response can help to reinforce learning.

5. Marketing and Advertising: Principles from Pavlov's conditioning experiments are often used in advertising to build brand recognition and positive associations.

For instance, a brand may pair its product with appealing stimuli (like enjoyable music or attractive visuals) to create a positive emotional response in consumers, who then associate the product with it.

Critical Evaluation

Pavlovian conditioning is traditionally described as learning an association between a neutral conditioned stimulus (CS) and an unconditioned stimulus (US), such that the CS comes to elicit a conditioned response (CR). This fits many lab studies but misses the adaptive function of conditioning (Domjan, 2005).

From a functional perspective, conditioning likely evolves to help organisms effectively interact with biologically important unconditioned stimuli (US) in their natural environment.

For conditioning to happen naturally, the conditioned stimulus (CS) can't be arbitrary, but must have a real ecological relationship to the US as a precursor or feature of the US object.

Pavlovian conditioning prepares organisms for important biological events by conditioning compensatory responses that improve the organism's ability to cope.

The critical behavior change from conditioning may not be conditioned responses (CRs), but rather conditioned modifications of unconditioned responses (URs) to the US that improve the organism's interactions with it.

Evidence shows conditioning occurs readily with naturalistic CSs, like tastes before illness, infant cues before nursing, prey sights before attack. This conditioning is more robust and resistant to effects like blocking.

Traditional descriptions of Pavlovian conditioning as simply the acquired ability of one stimulus to evoke the original response to another stimulus paired with it are inadequate and misleading (Rescorla, 1988).

New research shows conditioning is actually about learning relationships between events, which allows organisms to build mental representations of their environment.

Just pairing stimuli together doesn't necessarily cause conditioning. It depends on whether one stimulus gives information about the other.

Conditioning rapidly encodes relations among a broad range of stimuli, not just between a neutral stimulus and one eliciting a response. The learned associations allow complex representations of the world.

Recently, Honey et al. (2020, 2022) presented simulations using an alternative model called HeiDI that accounts for Rescorla's findings. HeiDI differs by allowing reciprocal CS-US and US-CS associations. It uses consistent learning rules applied to all stimulus pairs.

The simulations suggest HeiDI explains Rescorla's results via two mechanisms:

1. Changes in US-CS associations during compound conditioning, allowing greater change in some US-CS links

2. Indirect influences of CS-CS associations enabling compounds to recruit associative strength from absent stimuli

HeiDI integrates various conditioning phenomena and retains key Rescorla-Wagner insights about surprise driving learning. However, it moves beyond the limitations of Rescorla-Wagner by providing a framework to address how learning translates into performance.

HeiDI refers to the authors of the model (Honey, Dwyer, Iliescu) as well as highlighting a key feature of the model - the bidirectional or reciprocal associations it proposes between conditioned stimuli and unconditioned stimuli.

H - Honey (the lead author's surname), ei - Bidirectional (referring to the reciprocal associations), D - Dwyer (the second author's surname), I - Iliescu (the third author's surname).

References

Domjan, M. (2005). Pavlovian conditioning: A functional perspective. Annu. Rev. Psychol., 56, 179-206.

Honey, R.C., Dwyer, D.M., & Iliescu, A.F. (2020a). HeiDI: A model for Pavlovian learning and performance with reciprocal associations. Psychological Review, 127, 829-852.

Honey, R. C., Dwyer, D. M., & Iliescu, A. F. (2022). Associative change in Pavlovian conditioning: A reappraisal. Journal of Experimental Psychology: Animal Learning and Cognition.

Meulders A, Vandebroek, N. Vervliet, B. and Vlaeyen, J.W.S. (2013). Generalization Gradients in Cued and Contextual Pain-Related Fear: An Experimental Study in Health Participants. Frontiers in Human Neuroscience, 7(345). 1-12.

Pavlov, I. P. (1897/1902). The work of the digestive glands. London: Griffin.

Pavlov, I. P. (1928). Lectures on conditioned reflexes. (Translated by W.H. Gantt) London: Allen and Unwin.

Pavlov, I. P. (1927). Conditioned Reflexes: An Investigation of the Physiological Activity of the Cerebral Cortex. Translated and edited by Anrep, GV (Oxford University Press, London, 1927).

Rescorla, R. A. (1988). Pavlovian conditioning: It's not what you think it is. American Psychologist, 43(3), 151.

Pavlov, I. P. (1955). Selected works. Moscow: Foreign Languages Publishing House.

Watson, J.B. (1913). Psychology as the behaviorist Views It. Psychological Review, 20, 158-177.

Watson, J. B., & Rayner, R. (1920). Conditioned emotional reactions. Journal of experimental psychology, 3(1), 1.

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Pavlov's Dogs Experiment & Pavlovian Conditioning Response

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Pavlov predicted the dogs would salivate in response to the food in front of them, but he noticed that his dogs would begin to salivate whenever they heard the footsteps of his assistant, who was bringing them the food.

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1940s: Reconstructing bodies, again, after World War II but with social policy change

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1940s: Reconstructing bodies, again, after World War II but with social policy change

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"[T]he New Deal (providing Social Security income for persons with disabilities) and the GI Bill (providing funding for vocational retraining), which facilitated the payment for occupational therapy services in physical rehabilitation and prevocational training programs" (Cole & Tufano, 2020).

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Apply for and manage the VA benefits and services you’ve earned as a Veteran, Servicemember, or family member—like health care, disability, education, and more.

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Late 1940s: Return patients to community living

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Late 1940s: Return patients to community living

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The rehabilitation model in occupational therapy, as developed in workshops like the one led by Spackman in Philadelphia, emphasized analyzing and adapting tasks to help patients maintain their daily activities. This included using compensatory techniques and adaptive equipment to support functioning in work, leisure, and self-care. The ultimate goal was to enable patients to return to competitive employment and live independently in the community (Cole & Tufano, 2020).

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100 Influential People in Occupational Therapy: Clare S. Spackman, MS, OTR

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Clare S. Spackman is one of the 100 influential people in occupational therapy’s 100 year history.

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1950s: Facilitated craft activities were thought of as diagnostic

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1950s: Facilitated craft activities were thought of as diagnostic

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"Occupational therapists worked side by side with psychiatrists in helping patients to reveal and openly discuss their fixations and unconscious conflicts and hopefully to resolve them. Object relations theory, an outgrowth of Freudian psychoanalysis, led to an emphasis in occupational therapy on the 'use of self as a therapeutic tool'” (West, 1959, p. 26)" (Cole & Tufano, 2020).

Gail and Jay Fidler interpreted "psychoanalytic and object relation concepts as part of the communication process with patients in mental health settings" (Cole & Tufano, 2020).

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100 Influential People in Occupational Therapy: Gail Fidler, OTR, FAOTA

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Gail Fidler is one of the 100 influential people in occupational therapy’s 100 year history.

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1950s: Scientific breakthroughs in neurology

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1950s: Scientific breakthroughs in neurology

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"[Margaret] Rood, [an OT and PT,] developed many techniques for facilitating reflex and voluntary movement for persons with various forms of paralysis. Her sensorimo-tor therapy model, published in 1954, served as a basis for many others" (Cole & Tufano, 2020).

Other theoretical developments that were applied to practice later include but are not limited to sensory integration, reflex development model, Bobath’s neurodevelopmental therapy (NDT).

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100 Influential People in Occupational Therapy: Margaret S. Rood, MS, OTR, PT

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Margaret S. Rood is one of the 100 influential people in occupational therapy’s 100 year history.

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1960s: Call for De-Institutionalization due to abuse of authority 

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1960s: Call for De-Institutionalization due to abuse of authority 

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"The focus of occupational therapy in both mental and physical health care settings became the pressing need for patients to acquire skills for independent living in anticipation of their move to the community. Many disabled individuals, having been hospitalized for long periods, also needed to be resocialized, giving rise to the use of group treatment in occupational therapy." (Cole & Tufano, 2020).

"[P]atients and staff met together each day (community meeting) to discuss treatment goals; structure the day’s educational, recreational, and vocational opportunities; encourage mutual responsibility for carrying out these goals; and engage in group problem solving to address issues with living and working together toward recovery (Cole & Tufano, 2020).

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Introduction

With more attention being focused on the quality of care provided to people with serious mental illness, different visions of quality are emerging. In recent years, consumers of mental health services and members of their families have increasingly made their voices heard ( Corrigan & Phalen, 2004). Consumers have fought hard to replace the notion of serious mental illness as a chronic disability with language that is more in keeping with the experience of recovery, arguing that leading a full life that includes civic and social involvement in community is possible ( Deegan, 2003). We propose that, as one specific path to this goal, the therapeutic community model be incorporated into residential programs and evaluated as to its usefulness in building a recovery-oriented system. This report makes explicit the themes of therapeutic communities that are consistent with a recovery-orientation and, more specifically, lead to social integration. We then illustrate their application in a case example.

Therapeutic Communities

Contemporary therapeutic communities evolved from the work of two English psychiatrists, Wilfred Bion and John Rickman, during World War II. Bion and Rickman were asked by the British government to set up a specialized unit within a mental hospital for the rehabilitation of psychologically traumatized soldiers. Their charge was to return the soldiers to the front lines as rapidly as possible. To accomplish this, they set up a special inpatient service where rehabilitation took the form of engaging the soldiers in "soldierly activities," for example, map reading, physical training and grenade practice ( Bion & Rickman, 1943). In addition to these activities, Bion and Rickman held daily group discussions on the difficulties of the "here and now," a term they coined to focus attention on the communal living situation. These group discussions, which were offered in place of conventional psychotherapy, were a form of behavioral feedback in the service of personal accountability. Accountability was seen as improving the cohesion of the group.

The lessons learned by Bion and Rickman about the therapeutic effects of communal living led to the establishment of therapeutic communities in post-war Britain for civilians with mental illnesses. One of these communities became the subject of an anthropological study by Robert Rapoport (1960). The title of Rapoport's seminal book-length report on his research- Community as Doctor- sums up the fundamental premise of contemporary therapeutic communities: living in a community is healing. Based on his observations, Rapoport articulated five themes that characterized the structural organization of the English therapeutic community he studied and the culture it produced. He reported that these themes appeared to have no hierarchy and had "elastic boundaries" that were "flexible enough to provide rationales for various courses of action." (p. 54) They have become the conceptual scaffolding for therapeutic communities today. The themes are summarized below.

Democratization

The theme of democratization refers to the sharing of power among members of a therapeutic community. Rigid hierarchical distinctions between staff and consumers are reduced through sharing living space, eating meals together, and jointly carrying out work projects. Everyone shares in community decision- making. At the individual level, consumers are presumed to be competent to set their own personal goals and to share in treatment decisions that will help them reach those goals.

Acceptance

Acceptance refers to an emphasis on tolerating behaviors that may fall outside social norms, while at the same time managing the anxiety such behaviors may engender in others. Managing both acceptance of individual behavior and community anxiety about safety is accomplished through limit-setting. At least as important to the growth of the community are the rules members themselves make to support individual freedom within the community culture.

Communalism

In a culture that honors both the acceptance of individuals and limit-setting, communalism can take root. Communalism denotes the expectation that all members will work to ensure the community's welfare. The sharing of everyday work experiences and events, or "living-learning," yields situations that offer opportunities for personal growth. Work on behalf of the community also means contributing to the healing environment through creative contributions, and through mutual emotional and instrumental support. When all members share the goal of learning from experience, accountability is a primary therapeutic agent ( Kennard, 1998). As members heal, expectations of contribution to the community increase.

Reality Confrontation

Reality confrontation is the theme closest to the theoretical center of community life. Bion and Rickman observed that communal living engenders experiential learning that in turn, leads to individual healing and change. In the "insistent intimacy" ( DeLeon, 2000) of living and working together, community members are expected to be aware of and comment constructively on their own behavior and that of others. In so doing, they hold themselves and others accountable for the health of the community.

Reciprocal Relationships

Reciprocal relationships represent the community in action. Whether intimate or casual, reciprocal relationships are characterized by the respect and dignity accorded to each party. Rapoport (1960) described the ebb and flow of community life as predictable, not unlike the outside world (thus testifying to the rehabilitative value of communal life). He argued that the experience of resolving difficulties when they arise strengthens personal relationships and community bonds, providing individuals with experiences from which valuable social learning about relationships can take place.

Sources Used

The case to follow draws upon data collected during ethnographic visits to a therapeutic community that served as one data collection site for a study of social integration ( Ware et al. 2007; Ware et al. 2008). The data are seventeen interviews conducted with staff and residents and observations carried out during four days of field work by the research team. These interviews, designed for a different purpose, presented an opportunity to illustrate the principles of therapeutic communities from one that is in operation. The interview excerpts give living examples of the concepts first put forth by Rapoport in 1960. The study was approved by the Committee on Human Studies at Harvard Medical School and by the Institutional Review Board at the Nathan S. Kline Institute for Psychiatric Research. Informed consent was obtained from all study participants using an approved consent form. Participants received $20 in return for their time and effort.

Illustrative Case: Spring Lake Ranch

Spring Lake Ranch, a working farm, is at any one time home to approximately thirty staff and thirty residents who live and work together. Typically, a resident arrives at the Ranch following a psychiatric inpatient stay. Each new arrival is assigned to housing shared with several other residents and a house advisor. New arrivals are expected to join any one of the several work crews. Work crews are made up of 5 or 6 residents and a crew leader, who may be a former resident or a house advisor. House advisors are young adults committed to living and working together with residents. House advisors typically leave after a year or two of employment; the core administrative and supervisory structure is provided by long-term senior staff. Senior staff are hired for their expertise in farming, gardening, cooking for large groups, maintaining buildings and grounds, carpentry, bookkeeping or administrative skills. Neither house advisors nor senior staff are clinically trained. Except for a nurse who over-sees medication, professional medical and mental health services are accessed when needed in a nearby town.

Work crews are charged with carrying out the tasks needed to sustain the community-the theme of "communalism" in action. They cultivate gardens, make hay, care for farm animals, produce maple syrup, and sell Ranch-made products at the local farmer's market. Consumer residents rotate through crews of their choosing each week. Everyone in the community, staff and residents alike, is expected to make a significant contribution. At the Ranch, work is the enactment of communalism. It not only builds community, but also leads to personal growth. One resident explained:

For me, work builds up sort of an emotional bank account, kind of a confidence bank account. When I am working-doing something other than just doing nothing-that goes a long way in giving me sustenance in my life.

Staff report an emphasis on helping residents to understand that reciprocal relationships are based on trust and mutual regard. The development of these relationships cannot be one-sided; thus staff and residents are urged not to ignore uncomfortable situations when, inevitably, they arise. Reality confrontation-constructive feedback on the behavior of others-is used to enhance experiential learning.

The theme of acceptance is realized at the Ranch through decisions to maintain tolerance of a wide range of behaviors. Efforts are made to balance respect for self-determination with the need to keep community members safe. A recent example involves the setting of Ranch policy on illegal drugs. To protect the community from the presence of illegal drugs on the property while not infringing unduly upon individual privacy, members struggled with the question of whether to establish a stricter policy on personal searches or invest more heavily in trust. One staff member, leaning toward "trust," characterized the dilemma this way:

We're due to have a discussion next week [in community meeting]... and the discussion has to do with searches, with searching resident bags and rooms. I know it can sound irresponsible to think that we should cultivate relationships with people so that we can have trusting conversations with them, and that trusting conversation is going to get them to either not bring their dope or [to] hand it over. I still believe that what's important [is] to really work at having a relationship with people so that we can really talk about what we have to.

Democratic governance (democratization) is practiced at Spring Lake Ranch not as an ideal political model, but as a means of realizing community as mutual benefit. At Ranch meetings, each member of the community has one vote. A former Ranch Director has observed that at community meetings...

frequently, opinions are divided along other than staff/resident lines. For example, there may be conflict between men and women, old and young, conservative and liberal, all of which help lessen the often destructive dichotomy between staff and residents and when dealt with creatively, can help draw the community together. ( Wells & Hussey, 1988).

Reducing the "destructive dichotomy between staff and residents" goes beyond voting in meetings. Working together also breaks down distinctions. The extent to which shared tasks can build a sense of commonality and connectedness for residents is aptly illustrated in the following comment by a study interviewee, who said:

When you get out there and start chopping wood, or making maple syrup with Sam and Ed, it's like hanging out with the guys, you know, you're working, you're hanging out, you're having a good time, and you're just like everybody else.

The "Sam" referred to is the Ranch Director, but the speaker does not feel the need to identify roles in this report. His experience is "hanging out with the guys," and feeling "just like everybody else." This example illustrates how reciprocal relationships are embedded in the culture of communal daily activities, present in every encounter. As a quotidian reality, relationships are seldom ideal and often frustrating. However, it is the effort to acquire and maintain reciprocal relationships that builds competence.

In addition to creating experiences of connectedness, collaborating on work tasks also produces substantial practical benefits. The following interview excerpt from a work crew leader provides an example of how staff and residents succeeded collectively in solving a "transport" problem:

I thought that I could get a truck and put this portable thing in it, to carry chickens. We put the portable thing in it, and it was too big. It wouldn't fit into the truck. And I was like, "I don't know what to do now. I don't know how to transport these chickens." And I had three people on my crew, and one of them said, "We could turn it upside down, and put a top on it." And I was like, "Wow, we could do that!' Somebody else said, 'We could get a different truck." And I was like, "We could do that." And somebody else said, "We could get those turkey top things that we use to transport the turkeys." And I was like, "These are great! These are all great! These are so much better than my original plan, and so much nicer that we didn't have to stand here for 20 minutes while I tried to think of some new solution." Ultimately, we used one of their solutions.

In sum, the goal of the Ranch is to move residents toward recovery and social connectedness as a result of their participation in Ranch life.

Discussion

How does this case illustrate services that are more consumer-driven and recovery oriented?

The case illustrates, in the words of therapeutic community members, how each of the themes of therapeutic communities contributes to the development of relationships and thus, to the strength of the community. The theme of democratization removes a major obstacle to the exercise of personal authority. Acceptance reduces restrictions on individual action, even though it also entails communal limit-setting. This loosening of accustomed constraints creates room to maneuver - to experiment with participation in opportunities for productive work and involve oneself in the development of relationships with others. Greater involvement inevitably leads to consequences, such as experiences of success or failure, and to critical feedback ( reality confrontation). As they develop, reciprocal relationships are maintained through accountability, reliability and other virtues that strengthen interpersonal ties and increase a sense of obligation to others with whom one lives in community ( communalism). The opportunity to develop greater autonomy, stronger relationships and a supportive community are all consistent with the goals of consumer-driven recovery services.

What are the Implications for clinical practice?

Social integration, defined as interpersonal connectedness and active citizenship, is integral to recovery. Fostering social integration is a core function of the therapeutic community we studied ( Ware et al., 2007). Proponents of therapeutic communities argue that the essence of community life lies not in the presumption of clinical effectiveness, but in relationships that embody human dignity. The interviews conducted at Spring Lake Ranch suggest that making new connections with others improves understanding of how to initiate and maintain relationships. In this way, growth within community may become the impetus for seeking involvement and active participation in the larger social world. This, we suggest, constitutes empowerment-achieved not as an end in itself, but in the service of social integration for persons marginalized by mental illness.

As clinical practice shifts to emphasize personal empowerment and social integration, mental health professionals will be challenged to find growth opportunities for consumers. If more therapeutic communities are developed, who stands to benefit most from this type of growth opportunity? Therapeutic communities are not for everyone. To benefit, one must participate. However, it is not always evident to prospective members, before the fact, exactly what being a member of a community entails. To reduce referrals that fail, the referring clinician must clearly understand the nature and goals of therapeutic communities and be able to convey the benefits (and expectations) to a prospective member.

A second challenge is determining the best time for a therapeutic community experience. Maximizing the benefits of such an experience requires practice that refers interested individuals at the optimal point in the course of their illness. Is this opportunity best suited to individuals who have just been discharged from an inpatient stay following an acute episode of psychosis? The optimal time for participation in a therapeutic community has yet to be established. However, supported employment advocates are likely to argue for involvement sooner rather than later following hospitalization. Recent research has shown that return to work as soon as possible reduces disability ( Killackey, Jackson, & McGorry, 2007; Nuechterlein et al., 2005; Rinaldi et al., 2004).

Staffing presents a practical challenge for constructing therapeutic communities in the public mental health system. The power inequalities inherent in consumer-staff relationships in public mental health are inconsistent with the therapeutic community model. If the development of reciprocal relationships between staff and consumers is essential, then the challenge is to recruit and train staff in ways that allow the optimum balance of power to be struck. Prioritizing life experience over clinical experience in hiring staff is one way of identifying those likely to prove comfortable working in a therapeutic community framework. Michael Wells, former Spring Lake Ranch Director, has emphasized the importance of a hiring strategy that maximizes diversity. He writes:

...we look for people who are different from one another in ways that mean that they represent as broad a cross section of life as possible. There is even room for those who take a very jaundiced view of mental illness, those who may have experienced problems of their own and especially those who know little about the subject; their ignorance guarantees a fresh perspective to problems most of us insist there is only one way to view ( Wells & Hussey, 1988).

Implications for further research

This paper is not an evaluation of Spring Lake Ranch nor is it an attempt to provide a complete description of its operation. The purpose of the paper is to illustrate, with living examples, the principles of therapeutic communities with the goal of encouraging adoption because of its potential value. That value appears to lie in the realm of social integration rather than clinical improvement, although neither proposition has yet been empirically tested. The available evidence on effectiveness of therapeutic communities suggests both social and clinical positive outcomes ( Rapoport, 1960; Mosher, Menn, & Mathews, 1975; Davies & Campling, 2003; Lees, Manning, & Rawlings, 2004) which justify additional research. Future studies would do well to focus on the relationship between a therapeutic community experience and subsequent involvement in the social world outside treatment. Elucidating the path from community life to social integration will begin to answer the question of whether growth within community becomes the impetus for seeking involvement and active participation in the larger social world.

Conclusion

It has been argued that in this country, with its commercialism, materialism, and individualism, the ideal of community has been crowded out ( Putnam, 2000). A lack of community-mindedness in society at large does not, however, entirely explain why therapeutic communities for individuals with serious mental illness are rare. We have offered a case illustration of one therapeutic community serving persons with serious mental illness to start a discussion of how such communities might promote system transformation.

Contributor Information

Barbara Dickey, Department of Psychiatry, Harvard Medical School, Boston, MA and Cambridge Health Alliance, Cambridge, MA.

Norma C. Ware, Department of Global Health and Social Medicine and Department of Psychiatry, Harvard Medical School, Boston, MA.

References

Bion WR, Rickman J. Intra-group tensions in therapy. Lancet. 1943:678-681.

DeLeon G. The Therapeutic Community: Theory, Model, and Method. New York: Springer Publishing Co; 2000.

Kennard D. An Introduction to Therapeutic Communities. 2. London and Philadelphia: Jessica Kingsley Publishers; 1998.

Killackey E, Jackson HJ, McGorry PD. Results of the first Australian randomised controlled trial of Individual Placement and Support in first episode psychosis. Schizophrenia Bulletin. 2007;33:593.

Nuechterlein KH, Subotnik KL, Ventura J, Gitlin MJ, Green MF, Wallace CJ, et al. Advances in improving and predicting work outcome in recent-onset schizophrenia. Schizophrenia Bulletin. 2005;31:530.

Putnam R. Bowling Alone. New York: Simon and Schuster; 2000.

Rapoport R. Community as Doctor. London: Tavistock; 1960.

Rinaldi M, McNeil K, Firn M, Koletsi M, Perkins R, Singh SP. What are the benefits of evidence-based supported employment for patients with first-episode psychosis? Psychiatric Bulletin. 2004;28:281-284.

Ware NC, Hopper K, Tugenberg T, Dickey B, Fisher D. A theory of social integration as quality of life. Psychiatric Services. 2008;59:1-7. [PMC free article]

Wells M, Hussey K. Ms. Spring Lake Ranch. Cuttingsville, VT: 1988. Unpublished.

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Therapeutic Communities and Mental Health System Reform

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With more attention being focused on the quality of care provided to people with serious mental illness, different visions of quality are emerging. In recent years, consumers of mental health services and members of their families have increasingly made their voices heard ( Corrigan & Phalen, 2004).

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1970s: Too many occupational therapy specialties

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1970s: Too many occupational therapy specialties

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"At the conclusion of the 1970s, the AOTA had established the Representative Assembly and had made an attempt to unify practice through publication of the Uniform Terminology document in 1979" (Cole & Tufano, 2020).

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The American Occupational Therapy Association's Representative Assembly (RA) is responsible for the development and approval of professional policies and standards.

Representative Assembly meeting schedule

The RA meets at least twice a year and is always open for members to observe its proceedings unless it is in executive session. The summer and fall meetings occur online and the spring meeting is held either online, face-to-face, or as a hybrid, beginning just before and/or at the same location as AOTA INSPIRE's Annual Conference & Expo.

RA Fall Virtual Meeting 2023

RA Fall Virtual Meeting 2023

Submit a request for action

Become an active participant in AOTA by submitting a request for action to the Representative Assembly (RA) on professional topics or issues. Any AOTA member may submit a request on a professional topic for consideration by the RA.

Representative Assembly meeting summaries & minutes

RA meetings are held 2 to 3 times per fiscal year and each produces a summary of actions taken. Summaries are posted here for the past three fiscal years.

April 2023 Meeting Summary

RA roster

There is at least one representative from every state plus Puerto Rico and the District of Columbia. Several states have two representatives each based on their membership numbers.

Delaware (2022-2025)
Joanna Eskander Hoh, MS, OTR/L, CPAM DERep@ra.aota.org

Florida (2023-2026)
Jeffrey David Loveland, OTD, MS, OTR/L, FAOTA FLRep@ra.aota.org

Georgia (2023-2024)
Amy Todd, MS, OTR/L, CHT GARep@ra.aota.org

VACANT Maryland (2023-2024)

MDRep@ra.aota.org

Michelle L. Bradshaw, DC, OTR/L New York #1 (2022-2025)
Sean Getty, OTD, OTR/L
NY1Rep@ra.aota.org

New York #2 (2023-2026)

NY2Rep@ra.aota.org

Douglene Jackson, PhD, OTR/L, LMT, ATP
IBPRep@ra.aota.org

Credentials Review and Accountability Committee (CRAC) Chairperson (2022-2024)
Suzanne E. Holm, OTD, OTR/L, BCPR CRACChair@ra.aota.org

ASAP Representative (2023-2026)
Karen J. Hefler, OT, OTR, FAOTA
ASAPRep@ra.aota.org

Consumer Member (2022-2025)
Susan Emerson
ssemerson22@gmail.com

RA Fall Virtual Meeting 2023

RA Fall Virtual Meeting 2023

Submit a request for action

Become an active participant in AOTA by submitting a request for action to the Representative Assembly (RA) on professional topics or issues. Any AOTA member may submit a request on a professional topic for consideration by the RA.

Representative Assembly meeting summaries & minutes

RA meetings are held 2 to 3 times per fiscal year and each produces a summary of actions taken. Summaries are posted here for the past three fiscal years.

April 2023 Meeting Summary

RA roster

There is at least one representative from every state plus Puerto Rico and the District of Columbia. Several states have two representatives each based on their membership numbers.

Delaware (2022-2025)
Joanna Eskander Hoh, MS, OTR/L, CPAM DERep@ra.aota.org

Florida (2023-2026)
Jeffrey David Loveland, OTD, MS, OTR/L, FAOTA FLRep@ra.aota.org

Georgia (2023-2024)
Amy Todd, MS, OTR/L, CHT GARep@ra.aota.org

VACANT Maryland (2023-2024)

MDRep@ra.aota.org

Michelle L. Bradshaw, DC, OTR/L New York #1 (2022-2025)
Sean Getty, OTD, OTR/L
NY1Rep@ra.aota.org

New York #2 (2023-2026)

NY2Rep@ra.aota.org

Douglene Jackson, PhD, OTR/L, LMT, ATP
IBPRep@ra.aota.org

Credentials Review and Accountability Committee (CRAC) Chairperson (2022-2024)
Suzanne E. Holm, OTD, OTR/L, BCPR CRACChair@ra.aota.org

ASAP Representative (2023-2026)
Karen J. Hefler, OT, OTR, FAOTA
ASAPRep@ra.aota.org

Consumer Member (2022-2025)
Susan Emerson
ssemerson22@gmail.com

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The Representative Assembly is AOTA's governance body responsible for the development and approval of professional policies and standards.

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1980s: Provide proof & "three-tracked" thinking

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1980s: Provide proof & "three-tracked" thinking

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"From 1983 to 1984, the AOTF, which was established a few decades earlier, offered grants to occupational therapy researchers for the development of standardized assessment tools for measuring occupational performance" (Cole &Tufano, 2020)

"[I]n order to adhere to the scientific objectivity of the biomedical model,...[occupational therapists use] procedural reasoning to [address] the client’s functional limitations through the specific assessment and intervention techniques appropriate for that area of disability in order to remediate, adapt, or compensate for lost occupational abilities" (Cole & Tufano, 2020).

However, the other two ways of reasoning (interactive & conditional) "tracks more closely resembled the client-centered approach, demonstrating that occupational therapists had retained the ideals of earlier years despite their lack of importance in medical settings" (Cole & Tufano, 2020).

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1980s: Continued proliferation of specialties and theories 

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1980s: Continued proliferation of specialties and theories 

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There were so many new theories and frames of reference that some suggested a need to return to the "original" paradigm of occupational therapy and this caused "[an] resurgence of interest in the history of occupational therapy" (Cole & Tufano, 2020).

"[O]ccupational science, as an academic discipline, is not concerned with practicality or usefulness. It is a purer form of study that seeks a better understanding of the form, function, and meaning of occupation for its own sake" (Cole & Tufano, 2020). This way, occupational therapy could uniformly focus on applying the research in a practical way.

"The Uniform Terminology for Occupational Therapy, Second Edition... [defines the] intersection of occupational performance areas and performance components (Dunn & McGourty, 1989). For example, a child’s sensory awareness (a performance component) could be addressed by occupational therapists during self-care, play, and classroom activities (performance areas). This process clarified occupational therapy’s role in health care by always addressing and reporting occupational therapy interventions in the context of occupations" (Cole & Tufano, 2020).

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1990s: Occupational is the focus & raising the bar.

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1990s: Occupational is the focus & raising the bar.

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"The AOTA began the revision of Uniform Terminology using occupation-based ideas to develop the Occupational Therapy Practice Framework, which was accepted and published in 2002 (Cole & Tufano, 2020).

There was a steady rise in individuals seeking OT education, but this declined drastically when OT transitioned from a bachelor's entry level to a master's entry level in order "[T]o raise the level of professionalism for occupational therapy to that of related health care disciplines such as physical therapy and speech-language therapy" (Cole & Tufano, 2020). Despite this decline, the need for OT services is steadily on the rise.

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The Difference between Physical, Occupational, and Speech Therapy

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Learn about the differences between physical therapy, occupational therapy, and speech therapy and how they work together to rehabilitate patients.

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The World Health Organization defines health as "more than the absence of disease" closely aligning with the principles of the OT Practice Framework.

"Occupation-based models initiated in the 1990s have guided occupational therapists in learning to include contexts and environments within their interventions, embracing the view that their practice also includes adaptation of activity demands or expectations and the removal of environmental and social barriers to occupational justice (Cole & Tufano, 2020).

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Framework of Occupational Justice (FOJ) | OT Theory

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The Framework of Occupational Justice (FOJ) offers an occupational perspective of justice or injustice on everyday occupations. This framework emphasizes on the inclusion of every individual in an occupationally just word (i.e., the environment, such as community and government, in which the individuals can do what they decide to be the most meaningful and useful to themselves, family, communities and nations). It illustrates how the inter-relationships of structural factors and contextual factors support or restrict occupational outcomes and occupational rights. Structural factors include underlying occupational determinants (i.e., type of economy, regional/national/international policies) and occupational instruments or programs (i.e., health and community support, income support, education, employment). Contextual factors include age, gender, sexual orientation, ability/disability, etc. The structural factors, affected by contextual factors, contribute to conditions of occupational justice and lead to occupational outcomes (i.e., justice or injustice). Occupational outcomes of justice are occupational rights including meaning, participation, choice, and balance. There are four cases of occupational injustice: occupational alienation, occupational deprivation, occupational imbalance, and occupational marginalization. This framework suggests that the critical occupational perspective offers new insights of social issues on occupational justices, including injustice of exclusion from everyday occupations with clients who suffer from mental illness. The framework includes three lessons to advocate justice. The first one is that justice requires societal accountability for including all persons in everyday occupations without injustice. Second, societies create institutional changes in housing, employment, community recreation and other policies. Third, justice advances when societies develop programming and conditions to truly engage adults who have mental health issues with ordinary people to support their participation. This framework aims to develop a just society with inclusion of all citizens in everyday occupations.

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2010s: Professional Advocacy - "We can do more than that" ; "We can help with that too."

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2010s: Professional Advocacy - "We can do more than that" ; "We can help with that too."

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The Great Recession, ACA benefits, and technology boom impacted access to care with increasing needs.

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Your membership allows us to be a powerful voice for the profession. We protect your needs and create new opportunities by advocating on your behalf with the public, at state legislatures, and all the way to Capitol Hill. Our wins impact your everyday practice, from billing and compensation to the scope and reach of occupational therapy. AOTA also supports you, as you raise your voice on behalf of the profession and the people you serve.

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Your membership allows us to be a powerful voice for the profession. We protect your needs and create new opportunities by advocating on your behalf with the public, at state legislatures, and all the way to Capitol Hill. Our wins impact your everyday practice, from billing and compensation to the scope and reach of occupational therapy.

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2020s: Social Polarization and Injustice

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2020s: Social Polarization and Injustice

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National pandemic, telehealth therapy, and changes to ACA resulted in increased attention to social injustices. Therapists focus shifted to health, wellbeing, and community-based programs.

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OT practitioners provide services through participation in programs and services that address prevention and promotion of healthy occupations in the community.