Chapter 2: A Contextual History of Occupational Therapy — Comprehensive Notes

1960-1979

• After World War II, OT practice was heavily influenced by a medical rehabilitation model emphasizing neuromotor and musculoskeletal systems and their impact on function (Kielhofner, 2009).
• The 1960s brought organizational and scholarly shifts in OT:
  • During the AOTA reorganization in $1964$ under President Wilma West, there was renewed emphasis on supporting scientific endeavors in OT (Yerxa, 1967b).
  • In $1965$, the American Occupational Therapy Foundation (AOTF) was established to advance the science of OT and improve public recognition (AOTA, 1969).
  • Emphasis on science and theory development led to increased graduate education and a proliferation of models, theories, and frames of reference for practice.
  • Regulational push: the U.S. government began capping outpatient therapy payments in $1972$ as concerns about costs grew; state licensure became more emphasized.
  • In $1971$, Puerto Rico became the first US state/territory to initiate licensure (AOTA, 2021a).
  • Globally, WFOT was recognized as an NGO by the United Nations in $1963**$ (WFOT, 2022a).
• The practice of OT during this period remained strongly influenced by medical rehabilitation and the mechanistic paradigm, but neuroscience advances also started to shape practice:
  • A. Jean Ayres applied neuroscience to practice, studying perceptual-motor issues in children and developing the theory of sensory integration (Ayres, $1966$, $1972$).
  • Ayres’ approach reflected a bottom-up focus on underlying sensory and motor functions, often emphasizing reflex integration and motor function rather than holistic mind–body occupation-based approaches.
• Social policy and legislation expanded OT practice and working domains:
  • Great Society programs and the Education for All Handicapped Children Act (EAHCA, $1975$) broadened OT practice areas and populations served.
  • Medicare and Medicaid laid groundwork for expanding services to older adults, people with disabilities, and the poor; EAHCA mandated access to education for all children, including those with disabilities.
  • In $1965$, guidelines for accredited OT programs were developed in the United States, and in $1967$ AOTA celebrated the 50th anniversary of OT (Andersen & Reed, 2017).
• International context and models:
  • OT globally remained guided by theory-driven clinical models but was still heavily shaped by medical and social healthcare institutions, which served as major OT employers (Clouston & Whitcombe, 2008).
  • ADL tools and adaptations were developed to accommodate dysfunctions (Hocking, 2008).
  • There was an increase in OT educational programs worldwide, supported in part by WFOT participants (Cockburn, 2001).
• People and ideas influencing OT (1960-1979):
  • Mary Reilly: Clinician in the U.S. Army Medical Corps; contributed the occupational behavior framework emphasizing work skills and productive occupations; highlighted the link between occupation and health (Reilly, 1962).
  • A. Jean Ayres: neuroscience-informed practice; sensory integration theory; developed assessment tools and later, the Ayres Clinic (Ayres, 1989).
  • Gail Fidler: promoted occupation as emotional expression; author of Introduction to Psychiatric Occupational Therapy (Fidler & Fidler, 1954); contributed 13 books and served on the AOTA executive board (Peters, 2011a; Gillette, 2005).
  • Ann Mosey: advanced object relations/psychodynamic frame of reference for using activities and groups in therapy (Mosey, 1973).
  • Lorna Jean King (1974): applied sensory integrative theories to schizophrenia.
  • Claudia Allen: contributed theories of cognition to guide therapy for chronic mental illness (AOTA, 2019).
  • Kielhofner & Burke (1977): advocated a focus on human adaptation and occupation; foundational to the Model of Human Occupation (MOHO) (Kielhofner & Burke, 1980).
  • Wilma L. West: former executive director of AOTA (1947–1952); led AOTF in formative years (1972–1982); promoted research and recruited Gary Kielhofner as foundational editor for OTJR; honored by an extensive AOTF library (Foto, 1997).
  • Elizabeth Yerxa: emphasized advancing theory to support practice; promoted professionalism, research, and the development of occupational science (Yerxa, 1966; Yerxa, 1967a; Yerxa, 1989).
  • Lela A. Llorens: first person of color to deliver the Eleanor Clarke Slagle lecture in 1970; emphasized occupation across lifespan (AOTA, 2017a).

1980-1999

• Global and political shifts shaped the 1980s and 1990s:
  • End of the Cold War, collapse of the Soviet Union, and the fall of the Berlin Wall; Maastricht Treaty and EU development; rise of global digital technology (Thomas Friedman’s framing in the 2000s is later contextualized here).
  • The US political landscape under Ronald Reagan and the early digital age with the Space Shuttle and widespread computerization (Time Magazine naming the home computer the “Machine of the Year” in 1982/1983).
  • By the late 1990s, computers and the Web integrated into all sectors (business, education, healthcare).
• Healthcare and policy shifts:
  • Healthcare costs and reimbursements became a central concern; telemedicine began to emerge; privacy concerns led to HIPAA (1996).
  • The recovery model in mental health gained prominence, influenced by Anthony (1993), emphasizing consumer empowerment, self-determination, and community involvement in psychiatric rehabilitation (Tilsen & Nylund, 2008; Gagne et al., 2007).
  • Education and disability policy evolved: the Education for All Handicapped Children Act evolved into IDEA (1997 amendments); the Americans with Disabilities Act (ADA) was signed in 1990 to prohibit discrimination and improve access.
  • The Balanced Budget Act (BBA) of $1997$ aimed to control Medicare subacute care costs, which reduced rehabilitation positions and affected OT program enrollments (Qaseem et al., 2007).
• OT practice and research maturation:
  • Emphasis on research, efficacy, and defining scope of practice; debates about use of physical agent modalities by OTs (West, 1991).
  • AOTF initiatives to advance OT research included founding The Occupational Therapy Journal of Research (OTJR) in $1980$ and the Academy of Research in $1983$ (Classen, 2017; AOTF, 2012).
  • Certification governance: in $1986$, the AOTA board determined certification and membership activities were not independent enough to shield from antitrust liability, leading to the creation of the American Occupational Therapy Certification Board (NBCOT), which later became NBCOT; this shift reduced AOTA membership in some cases (Low, 1997).
• Emergence of occupational science and new practice models:
  • The field began proposing occupational science as an underlying foundation for OT (Yerxa, 1990).
  • The first occupational science PhD program was established at USC in $1989$ (Gordon, 2009).
  • MOHO matured and expanded, with related work in other occupation-based models: PEOP (Baum, Christiansen, & Bass, 2015; Christiansen & Baum, 1997); the Ecology of Human Performance (Dunn et al., 1994); the Occupational Performance Process Model (Fearing et al., 1997); and the Canadian Model of Occupational Performance (CAOT, 1997; Townsend, 2002).
  • Occupational justice concept emerged, linking occupation to health and democracy in Wilcock’s work (Wilcock, 1988; Stadnyk, Townsend, & Wilcock, 2010).
• Canada and international development:
  • Canada initiated aging and health-promotion projects; the CAOT promoted Enabling Occupation (1997) and health-promotion initiatives (CAOT, 1993).
  • An international movement toward occupational science gained momentum with academic units rebranding and global collaboration (Ireland/Australia/USA contexts).
• Notable people influencing OT (1980-1999):
  • Elizabeth Yerxa, Ruth Zemke, Ann Wilcock, and Gary Kielhofner advanced occupational science and MOHO.
  • Florence Clark contributed to OT science through lifestyle-oriented programs and leadership (Clark et al., 1997, 2012); served as AOTA president (2012-2015).
  • Gary Kielhofner, building on Reilly’s work, proposed MOHO; his global influence included research and practice guidance until his death in 2010.
  • Mary Law (Canada) co-founded the CanChild Centre and developed COPM and the Person-Environment-Occupation (PEO) model (Law et al., 1990; Law et al., 1996); recognized with Officer of the Order of Canada (2017).

2000-2019

• The 21st century ushered global economic integration and digital connectivity:
  • The world became more connected economically due to digital tech and the Internet; emerging economies (e.g., China, India) expanded participation in global markets (Friedman, 2006).
  • The US experienced significant political and economic events: contested presidential election (2000), 9/11/2001 attacks, Patriot Act, Department of Homeland Security, and efforts to reform healthcare policy (Birn et al., 2003).
  • Medicare Part D (Prescription Drug Benefit) was signed in 2003; Obama’s administration pursued healthcare reform, including the Affordable Care Act (2010) and the Patient-Centered Outcomes Research Institute (2017);
  • These reforms expanded coverage and emphasized patient-centered care.
• Healthcare delivery and policy changes shape OT:
  • ICF framework adopted by WHO in $2001$, reframing disability and health to emphasize functioning, environmental factors, and participation.
  • NIH Roadmap (2004) guided rehabilitation research; NIH strategic planning supported OT research and training through biomedical funding programs (Frontera et al., 2017).
  • CMS and AHRQ linked evidence-based practice to reimbursement, influencing OT service delivery toward discharge-focused inpatient care and increased outpatient/home-based therapy (Slutsky et al., 2010).
• International and methodological expansion:
  • OT conceptual models were tested and challenged through global practice and education; the Kawa Model (Iwama, 2006) introduced culturally responsive OT perspectives aligned with Asian Pacific collectivist cultures (Iwama, 2006; Iwama et al., 2009).
  • The international community formed societies and networks (SSO: USA; Asia Pacific; Canada; Europe) to advance occupational science globally.
• Centennial Vision and research infrastructure:
  • In 2004, the AOTA board, led by Carolyn Baum and with Charles Christiansen, launched a strategic planning initiative to establish a Centennial Vision (to extend beyond 2017) emphasizing visibility, influence, research, evidence-based practice, diversity, global connectivity, and client-centered needs (AOTA, 2006a).
  • In $2007$, AOTA and AOTF published the Research Agenda for Occupational Therapy to build infrastructure supporting research demonstrating efficacy (AOTA/AOTF Research Advisory Panel, 2011).
  • In $2013$, AOTF and AOTA launched a joint research grant program to fund OT interventions and support training of OT scientists (AOTF, 2014; 2015).
• Military and clinical education:
  • Ongoing wars abroad led to significant injuries among veterans, prompting innovations in military OT and reintegration services for polytrauma including brain injuries, burns, and amputations (Howard & Doukas, 2006).
  • OT education shifted toward clinical doctorates; online/hybrid formats expanded; digital learning technologies and social media broadened access to education.
• Interprofessional practice and technology:
  • 3D printing facilitated innovations in assistive devices, orthotics, and prosthetics; OT curricula incorporated interdisciplinary collaboration (Iwama & colleagues; Wagner et al., 2018).
  • Interprofessional education gained emphasis across OT education standards (ACOTE and others) and in practice (Alotabi et al., 2019).
• People and ideas influencing OT (2000-2019):
  • Ann Wilcock (Australia) proposed OT’s role in population health; Elizabeth Townsend helped develop occupational justice (Townsend & Wilcock, 2004).
  • M. Carolyn Baum served as AOTA president (2004-2007); emphasized links among practice, education, and research, and co-developed the PEOP model with Christiansen (Baum; Christiansen & Baum, 1997).
  • The PEOP model (Christiansen & Baum, 1997; Baum et al., 2015) and related models (e.g., Canadian Model of Occupational Performance) solidified occupation-centered practice.
  • 2016: Hawaii became the 50th state to license OT practitioners; 2017: Vision 2025 and strategic planning led by Amy Lamb to articulate goals beyond the centennial year (AOTA, 2017b, 2017c).
  • August 2017: Accreditation Council for Occupational Therapy Education mandated entry-level OT and OTAs to be at Doctorate of Occupational Therapy (OTD) and Bachelor of Science (BS) respectively by $2027$ (AOTA, 2017d).
• Centennial celebration and global integration:
  • In $2017$, the AOTA hosted a centennial celebration in Philadelphia, with global events and a dedicated history website (otcentennial.org).
• Technological and societal trends shaping OT:
  • Telehealth and online education grew alongside increasing broadband access; pandemics and global events accelerated adoption of telehealth in OT practice (Gustafsson, 2020; Hoel et al., 2021).
  • Societal movements toward diversity, equity, and inclusion led to organizational commitments (e.g., COTAD) and ongoing advocacy for occupational justice in practice (WFOT, 2022b).

2020 to Present

• COVID-19 pandemic and rapid changes in OT:
  • The pandemic accelerated changes in education and healthcare delivery; OT education used simulation, web-based, and hybrid formats; online platforms expanded, but some regions faced digital divides and disparities in access to technology (Gustafsson, 2020; Hoel et al., 2021).
  • Remote/telehealth OT services expanded where broadband/technology allowed (Garfinkel & Minard, 2021; Gitlow, 2021; Lunsford et al., 2016).
  • Expanded insurance coverage for telehealth created new opportunities and resources, but disparities persisted in access to technology and other barriers (AOTA, 2021b; Hoel et al., 2021).
• Occupational justice and global response:
  • The pandemic highlighted occupational injustice; WFOT conducted surveys of 100 country member organizations to identify priorities: (a) collaborative information/education; (b) quality service standards; (c) advocacy to promote OT access and occupational justice (WFOT, 2022b).
  • WFOT provided pandemic-related information to support efforts globally.
• Technological innovations and interprofessional collaboration:
  • 3D printing continued to enable rapid fabrication of assistive devices, orthotics, and prosthetics; OT education increasingly integrated 3D printing into curricula (Wagner et al., 2018).
  • Interprofessional education remained a focus in OT curricula and accreditation standards (ACOTE; OT schools worldwide).
• Global and regional development:
  • The internet, global virtual conferences, and WFOT-enabled collaborations enhanced international exchange and practice innovations.
• People and ideas influencing OT (2020 to present):
  • Ann Wilcock and Elizabeth Townsend continued to advocate for population health and occupational justice; the concept of occupational justice informed responses to pandemic-related access issues.
  • The profession’s ongoing emphasis on science-based practice, while maintaining a focus on occupation as a therapeutic medium, remained central to practice.
• Ethical, philosophical, and practical implications:
  • Privacy and data security remained central (HIPAA-era concerns in digital health).
  • Access to technology influenced equity of OT services; telehealth offered benefits but also created disparities for underserved populations.
  • The profession faced ongoing questions about how to balance technology-enabled care with the human, meaning-centered aspects of occupation (Engelhardt, 1983).
• Figures referenced in this era:
  • Figure 2.8 illustrates military OT support in life skills/occupational training for amputees in a rehabilitation setting (US Air Force photo/Steve White).
  • Figure 2.9 shows an OT treating a COVID-positive patient in a level 1 trauma setting.

Theoretical and Practical Concepts Across Periods

• Model of Human Occupation (MOHO):
  • Emerged from Kielhofner and Burke’s work (1980, 1980) and developed by Kielhofner and colleagues (1980a, 1980b; 1980; 2008; 2009).
  • Emphasizes motivation, performance, and patterns/routines; informs practice by focusing on the interplay between person, environment, and occupation.
• Person-Environment-Occupation (PEO/PEOP) models:
  • PEO model refined in the 1990s (Law et al., 1990; Law et al., 1996).
  • PEOP model (Christiansen & Baum, 1997; Baum et al., 2015) emphasizes transactional relationships among person, environment, and occupation to support performance and participation.
• Sensory integration and sensation-focused approaches:
  • Sensory integration theory advanced by Ayres (1966, 1972, 1989) and applied to practice, particularly in pediatric contexts; emphasized the role of sensory processing in learning and behavior.
• Occupational justice and client-centered practice:
  • Wilcock (1988) introduced the concept of occupational justice, arguing that meaningful engagement in occupation is necessary for health and that a just world must enable opportunities for engagement (Stadnyk et al., 2010).
  • Townsend & Wilcock (2004) linked occupational justice to client-centered practice (occupational science and practice integration).
• CanChild COPM and Canadian practice models:
  • COPM (Law et al., 1990) and COPM-based practice framework promoted outcome-focused OT practice; CANADIAN occupation-focused models emphasized person-centered approaches (Law et al., 1996).
• 3D printing and interprofessional education:
  • 3D printing emerged as a tool for rapid prototyping of devices; collaboration across OT, engineering, and librarianship enhanced educational and clinical innovation (Wagner et al., 2018).
• Kawa Model (Iwama):
  • Introduced as a culturally relevant OT model for Asian Pacific and collectivist cultures, offering an alternative lens to conventional Western models (Iwama, 2006; Iwama et al., 2009).

Connections to Foundational Principles and Real-World Relevance

• OT’s evolution shows a tension between mechanistic models and occupation-centered approaches, with the MOHO and occupation-based models providing a bridge between theory and meaningful daily activity.
• Legislation and policy consistently shaped OT practice domains (schools, hospitals, rehabilitation, community settings) and influenced the distribution of OT employment across settings.
• The shift toward evidence-based practice and investment in OT research (Centennial Vision, Research Agenda, NIH/NIH-funded training) strengthened the profession’s legitimacy and ability to justify interventions.
• The emergence of occupational science as an academic discipline created foundational knowledge to inform practice and to legitimize occupation as a core therapeutic medium.
• Global health and equity considerations (occupational justice, access to care, telehealth disparities) reflect OT’s commitment to social relevance and ethics in professional practice.
• The integration of technology (telehealth, 3D printing, digital records) requires balancing efficiency and data security with the humanistic, meaning-centered aspects of occupation.

Key Acts, Models, and Concepts (selected, with identifiers)

• Education and accessibility:
  • Education for All Handicapped Children Act (EAHCA) → Individuals with Disabilities Education Act (IDEA) amendments; $1975$ and $1997$ amendments (Education policy and school-based OT practice).
  • Americans with Disabilities Act (ADA), $1990$; amended in $2008$.
  • Balanced Budget Act (1997) to control Medicare costs.
• Practice models and theories:
  • Model of Human Occupation (MOHO): Kielhofner & Burke; multiple iterations (1980; 2008; 2009).
  • Person-Environment-Occupation (PEO) model and PEOP model (Baum, Christiansen & Bass, 2015; Christiansen & Baum, 1997).
  • Ecology of Human Performance (Dunn et al., 1994).
  • Occupational Performance Process Model (Fearing et al., 1997).
  • Canadian Model of Occupational Performance (CAOT, 1997; Townsend, 2002).
  • Kawa model (Iwama, 2006; Iwama et al., 2009).
• Measurement and outcomes:
  • Canadian Occupational Performance Measure (COPM) (Law et al., 1990).
• Occupational justice and global health:
  • Wilcock (1988); Stadnyk, Townsend & Wilcock (2010); Townsend & Wilcock (2004).
• Key legal and regulatory milestones (selected):
  • HIPAA (1996).
  • IDEA amendments (1997).
  • ADA (1990; amended 2008).
  • NBCOT formation (1986) as an independent certification body (Low, 1997).
• International organizations and events:
  • WFOT’s NGO status (1963);
  • SSO: USA formation in 2002; international expansion (AOTA, 2006a; 2011).

Notable Figures and Their Legacies (brief references)

• Mary Reilly: Grounded occupational behavior; advocated reclaiming roots in occupation; influence on MOHO and occupational science foundations.
• A. Jean Ayres: Sensory integration theory; sensory processing assessments and clinical practice foundations.
• Gail Fidler: Ego psychology and therapeutic use of self; contributed to early psychiatric OT literature; co-authored early textbooks.
• Ann Mosey: Object relations/psychodynamic frame for group-based and activity-based therapy.
• Lorna Jean King: Sensory integrative approach to schizophrenia in OT.
• Claudia Allen: Cognition-focused theories guiding mental health OT.
• Kielhofner: MOHO development; global influence on OT theory and practice.
• Mary Law: COPM and PEOP models; CanChild Centre for Childhood Disability Research; many contributions to client-centered practice.
• Elizabeth Yerxa: Emphasized theory development, professionalism, and occupational science as the foundation for modern OT.
• Lela A. Llorens: Emphasized occupation’s role across the life span; first color speaker for Slagle lecture; diversity in OT leadership.
• Wilma West: Leadership in AOTA and AOTF; advocacy for research; key in founding OTJR; supported institutional memory and resources.
• Gary Kielhofner: MOHO theorist; global influence on occupation-centered practice until his passing in 2010.

Summary of Shifts in Practice and Focus Over Time

• 1960-1979: Professionalization through science; shift toward regulation and licensure; growth of theory-driven practice; early adoption of mechanistic rehabilitation frameworks; expansion of OT roles in education and public health policy.
• 1980-1999: Transition to evidence-based practice; rise of occupational science; development of MOHO and other models; increased OT in schools; growth of research infrastructure; policy shifts increasing access (ADA, IDEA) but cost containment limited funding; introduction of new assessment tools and professional governance.
• 2000-2019: Globalization and digital health; renewed emphasis on research funding and infrastructure; NIH Roadmap; ICF integration; Centennial Vision guiding long-term goals; 3D printing and telehealth shaping practice; ongoing professionalization with Doctoral-level education emphasis.
• 2020-present: Pandemic-driven changes; rapid expansion of telehealth; online education; focus on occupational justice during global health crisis; emphasis on DEI and global collaboration; ongoing innovation through technology and international networks.

References (selected within the notes above)

• Anthony, W. A. (1993). Recovery from mental illness: The guiding vision of the mental health system in the 1990's. Psychosocial Rehabilitation Journal, 16(4), 11-23.
• Ayres, A. J. (1966). Interrelationships among perceptual-motor functions in children. American Journal of Occupational Therapy, 20(2), 68-71.
• Kielhofner, G. (1980a). A model of human occupation, part 2. Ontogenesis from the perspective of temporal adaptation. American Journal of Occupational Therapy, 34(10), 657-663.
• Kielhofner, G., & Burke, J. P. (1980). A model of human occupation, part 1. Conceptual framework and content. American Journal of Occupational Therapy, 34(9), 572-581.
• Law, M., Baptiste, S., McColl, M., Opzoomer, A., Polatajko, H., & Pollock, N. (1990). The Canadian occupational performance measure: An outcome measure for occupational therapy. Canadian Journal of Occupational Therapy, 57(2), 82-87.
• Townsend, E. (Ed.). (2002). Enabling occupation: An occupational therapy perspective. Canadian Association of Occupational Therapists.
• Wilcock, A. A. (1988). An occupational perspective on health. SLACK.
• World Federation of Occupational Therapists. (2022a). History. https://www.wfot.org/about/history
• World Health Organization. (2001). International classification of functioning, disability and health (ICF).