Pragmatism in the initial history of occupational therapy

Abstract

As a philosophical movement and epistemological base of occupational therapy, pragmatism is cited in few texts at the beginning of the profession. For this reason, this article seeks to describe the influences of pragmatist philosophy at the beginning of occupational therapy in the United States of America. To do this, it focuses on two aspects: 1. the relationships of the pragmatists and the first generation of occupational therapists; and 2. the theoretical development of occupational therapy and pragmatism, where three aspects stand out: i) holism in the profession, ii) the significance of people's subjectivity and iii) Meyer's pragmatism. It is concluded how pragmatism, despite not being a widely disseminated philosophy in the profession, presents a strong background regarding its importance in its beginnings. Finally, there are some challenges and possibilities related to the contributions that pragmatism could have for the discipline today.

Keywords:
Philosophy/Knowledge; History/Occupational Therapy; Epistemology

Resumen

Cómo movimiento filosófico y fundamento epistemológico de la terapia ocupacional, el pragmatismo es citado en escasos textos al inicio de la profesión. Es por lo anterior, que en este artículo se busca describir las influencias de la filosofía pragmatista en los comienzos de la terapia ocupacional en Estados Unidos de América. Para ello, se centra en dos aspectos: 1. las relaciones de los/as pragmatistas y la primera generación de terapeutas ocupacionales; y 2. el desarrollo teórico de la terapia ocupacional y el pragmatismo, donde se destacan tres aspectos: i) el holismo en la profesión, ii) la significación de la subjetividad de las personas y iii) el pragmatismo de Meyer. Se concluye cómo el pragmatismo, a pesar de no ser una filosofía ampliamente divulgada en la profesión, presenta antecedentes contundentes respecto a su importancia en sus inicios. Finalmente, se plantean algunos desafíos y posibilidades relacionadas con los aportes que el pragmatismo podría tener para la disciplina hoy en día.

Palabras-clave:
Filosofía/Conocimiento; Historia/Terapia Ocupacional; Epistemología

Resumo

Como movimento filosófico e fundamento epistemológico da terapia ocupacional, o pragmatismo é citado em poucos textos no início da profissão. Por esse motivo, este artigo busca descrever as influências da filosofia pragmatista para o início da terapia ocupacional nos Estados Unidos de América. Para isso, concentra-se em dois aspetos: 1. as relações dos/as pragmatistas e a primeira geração de terapeutas ocupacionais; e 2. o desenvolvimento teórico da terapia ocupacional e do pragmatismo, destacando-se três aspetos: i) o holismo na profissão, ii) o significado da subjetividade das pessoas e iii) o pragmatismo de Meyer. Conclui-se como o pragmatismo, apesar de não ser uma filosofia amplamente disseminada na terapia ocupacional, apresenta fortes antecedentes no que se refere à importância para o início da profissão. Finalmente, se consideram alguns desafios e possibilidades relacionados às contribuições que o pragmatismo poderia ter para a disciplina atualmente.

Palavras-chave:
Filosofia/Conhecimento; História/Terapia Ocupacional; Epistemologia

Introduction

One way of understanding pragmatism is as an American philosophical current that proposes the impossibility of separating theory from practice. Also, it proposes a way for the analysis, understanding, and questioning of “the truth”. It understands the truth as a construct in permanent transformation and that affects our reality through its practical repercussions in our lives. Also, it proposes that thought provides unique opportunities to transform reality and that its direction should always be towards the improvement of situations, theories, research, social conditions, among others that we live, that is, the thought must guide action through a critical process of reflection-action (Morrison, 2017).

This philosophy is considered a structural pillar of occupational therapy, although little-recognized (Breines, 1986; Hooper & Wood, 2002; Ikiugu, 2001; Morrison, 2017; Reed, 2017, 2018). The absence of pragmatism in the profession for many years has nothing to do only with a contemporary issue. Not all the founders of occupational therapy explicitly cited pragmatism in their documents (Breines, 1986; Slagle, 1936; Tracy, 1910) Two references cited pragmatists in their publications. In particular, they referred to Jane Addams, William James, and John Dewey.

On the other hand, the main influences and theoretical and political contexts documented in the beginnings of the discipline in the United States of America are the well-known moral treatment and arts and crafts movements (Gordon, 2009; Kielhofner, 2009; Levine, 1987); the mental hygiene movement (Breines, 1986); the movement of social settlements, in which we highlight the founding of the Hull House by Jane Addams (Quiroga, 1995); the political-democratic-liberal climate that provoked major political reforms in Chicago (Addams, 1935/2004); and, to a lesser extent, the Emmanuel movement, of a religious-Christian aspect whose development was accentuated in Baltimore, especially at the Heppard-Pratt Hospital where William R. Dunton worked (and which would also have had an impact on Herbert J. Hall) (Gordon, 2002). All these, added to the First and Second World Wars (Kielhofner, 2009), plus the second wave of feminism (Morrison, 2014, 2016a) would have facilitated the constitution of the profession and the extension of its theoretical development.

These elements above allowed the founders to come together under the central idea that the occupation constitutes a preventive, curative, and restorative potential of functions and abilities and, above all, the well-being and health of people (Morrison, 2014).

This was shared by both pragmatists such as Addams, James, or Dewey, and occupational therapists such as Slagle, Tracy, and Johnson (Morrison, 2017). This would have been developed in this way since the constant exchanges between the first generation of occupational therapists and the classical pragmatists were constant.

Because of the above, this article aims to describe the influences of the pragmatist philosophy in the beginnings of occupational therapy in the United States of America, through two moments. The first is about the links between pragmatists and occupational therapists; and the second, on the integration of some pragmatist ideas in different aspects of the theoretical development of the discipline.

Pragmatists and the First Generation of Occupational Therapists

Emil Gustave Hirsch was a rabbi who integrated his ethical and religious perspective with the principles of pragmatism and occupational therapy (Breines, 1992), he worked with Jane Addams and Julia Lathrop collaborating in the founding of the Chicago Arts and Crafts Society. Also, he participated in other important social transformations, such as the Jewish reform of the United States of America and is a rabbi of the Chicago Sinai Congregation, shared the pulpit with Jane Addams supporting her to be the first woman to speak in that instance (Breines, 1986). Hirsch fervently believed in the healing power of occupations, so he used them in his work; he primarily targeted disadvantaged youth who were delinquent and lacked social opportunities. Many of his beliefs were consistent with Addams' Quaker principles (Breines, 1992).

Hirsch played an important role in the development of occupational therapy by organizing the course of the therapeutic occupation together with Julia Lathrop, for people with disabilities at the Hull House (Morrison, 2016a). In this way, Hirsch was the professor of Eleanor Clarke Slagle and Mary Potter Brooks Meyer (Breines, 1986), and together with Addams, Lathrop, and Graham Tylor, he founded the School of Civics and Philanthropy and was part of the Chicago Charities Commission and the State Board of Charities together with Lathrop (Addams, 1935/2004). Hirsch exemplifies one of the links between pragmatism and young occupational therapy as does a fairly unknown figure, Mary Potter Brooks Meyer.

Brooks worked in Baltimore and at the Pathological Institute of the New York State Hospitals making home visits to psychiatric patients and reporting her findings to the medical team (John Hopkins Medicine, 2020). She was convinced that social factors affected people's mental health. But she mainly excelled at the Worcester Massachusetts State Hospital, developing a program of therapeutic occupations. This program included aspects of the psychobiology of Adolf Meyer (her husband) and the arts and crafts for therapeutic purposes. She carried out a similar systematization to Slagle's from a pragmatist approach and was one of the first social workers to offer systematic interventions to help patients, their families, and medical staff (Levine, 1987; Mansfield, 2013).

The Hull House offered innovative programs that had great collaborators like Dewey or Mead and trained many influential people in society like Brooks and Meyer. This couple was in direct contact with Lathrop, who invited Meyer to join the Hull House. For this, Meyer was very fond of Lathrop, and both discussed issues of interest in mental health and reforms in the treatment of psychiatric patients (Addams, 1935/2004).

In Chicago, the collaboration between Meyer and Lathrop resulted in the application of a program using the arts and crafts on chronic patients. Lathrop had studied bookbinding at Kelmscott Press with William Morris and wanted to improve people's lives by using arts and crafts. She achieved this goal by influencing the Illinois State Board of Charities and Correction. Together with Hircsh, in 1906, she organized a training program in therapeutic occupations for nurses (Levine, 1987).

Meyer's link to occupational therapy stems from his association with Slagle, Dunton, Lathrop, and Addams (Addams, 1935/2004). Although Dunton did not fully share Meyer's theoretical development, which is expressed when rarely collaborated in meetings although they worked in the same hospital for years, they belonged to several societies in common and had a mutual appreciation for their professional work (Breines, 1986).

When Meyer was attending Clark University and Worcester Insane Hospital in Massachusetts, he met William James who was then a professor at Harvard University. He also met George Herbert Mead since both belonged to almost the same associations in Chicago. When Dewey and Mead were at the University of Chicago, Meyer was in Kankakke, (Illinois), so he visited the University (Breines, 1986).

The Hull House was the meeting point for great thinkers and social reformers, who combined pragmatism with social activism. But it was not only there that contacts were established with the main exponents. For example, Dewey left Chicago in 1904 and Slagle joined in 1908 and, although there is no information to indicate that she was in Chicago before, she still took classes with him at Columbia University (Morrison, 2014).

On the other hand, Susan Tracy was a follower of Dewey and used many of his ideas in her occupational treatment. At the same time, she kept in touch with Dunton and they would influence each other. In 1921, Tracy would adopt the term "occupation therapy", originally conceived by Dunton, and he would design training programs based on Tracy's writings (Bing, 1981). Also, Tracy referred to Dewey in her 1910 text. Barton was the one who gave the definitive name to the discipline as occupational therapy from the initial ideas of Tracy and Dunton (Breines, 1986). On the other hand, Slagle took several of James's writings as a reference to her training in his habits (Slagle, 1936).

Theoretical Development of Occupational Therapy and Pragmatism

Susan Tracy, Susan Cox Johnson, Eleanor Clarke Slagle, and other founders were in direct contact with pragmatism and put its main ideas into practice, expressed in their writings and treatments towards their patients, and also implicitly in their training programs (Morrison, 2014).

Although here we considered that pragmatism is one of the philosophical bases of occupational therapy, the same has not happened in various writings in the disciplinary literature, nor in training programs for occupational therapists, as we observed in different publications (Breines, 1986; Gordon, 2002; Hooper & Wood, 2002; Ikiugu, 2001; Ikiugu & Schultz, 2006; Morrison, 2014, 2016b, 2017).

One of the explanations for the absence of pragmatism in the occupational therapy training curriculum is that, due to androcentrism, many writings of the founding women were not considered at the same level as those of the men (Morrison, 2014). The clearest example of this is that the first formal document of the discipline is from Dunton (1919) or even Meyer (1976) in 1922, and not by Tracy (1910).

It is curious that despite Tracy's explicit mention of Dewey (Tracy, 1910), and the allusion to the theory of habits of pragmatists like James and Peirce, to which Slagle referred (Slagle, 1922, 1936, 1944), many occupational therapists have not considered pragmatism as a constituent epistemology of the profession. Even though it has been reflected in central elements such as holism.

Holism in occupational therapy

Since its inception, the holistic perspective of occupational therapy sought to understand how diseases that affected a part of the body had an impact on both the performance of occupations and the health and well-being of people (Morrison, 2017). Also, holism alludes to how “physical” problems generate problems in the mind (Gordon, 2002), which is why the psyche-soma, the mind-body relationship is established in an integrated whole, and which is also within a particular context. This was also described by pragmatists such as Dewey (1922) when they referred to habits and occupations.

Under the previous premise, from the beginning of the profession, it was evidenced how patients managed to improve their mental and physical conditions when they were engaged, for example, in arts and crafts (Slagle, 1922). This was a justification for the occupational therapy of the early 20^th century, where the holistic perspective of health was fundamental for the understanding of the human being (Bing, 1981). Thus, occupational treatments and interventions were built trying to abolish the dichotomies that divided the body from the mind and sought to become more complex, showing its benefits both in the recovery processes and in the restoration of physical functionality and mental attitude (Quiroga, 1995).

The holistic view is typical of occupational therapists and has a basis in pragmatism (Wish-Baratz, 1989). Many times, this particular look has generated some confusion in the discipline. Because the doing of the profession is observed, but from a perspective based on dichotomies, it tends to be confused with other disciplines such as psychology or physiotherapy, when similar performances are “observed” in practice.

This difficulty in understanding the discipline due to its pragmatist holism is a problem that comes from the perspective of neo-positivist science (Olivares et al., 2015). Science as a procedure that allows, through observation, to identify positive results in a certain phenomenon was a prevailing idea during the development of neo-positivism (Olivares et al., 2015). This would help to understand occupational therapy, understood as “[...] a treatment, which was originally considered a part of psychotherapy” (Gordon, 2009, p. 205), from an objective and quantifiable way.

Theoretically endorsing the concept of occupation brought with it some difficulties for the first occupational therapists, specifically to build a clear and coherent body of knowledge in the scientific world (Kielhofner, 2009; Quiroga, 1995). Although during the first third of the 20^th century in the United States of America, occupational therapy had clear scientific bases¹ (Morrison, 2014), neo-positivism in medicine expressed in the biomedical model, began to question the epistemological foundations of the occupational therapy, which were not fully consolidated, causing the discipline to be under the wing of medicine for many decades (Kielhofner, 2009). This was one of the causes but we also need to consider the role of the war in this process.

The neo-positivist biomedical model focused on the quantifiable results of the patients, while occupational therapy in the recovery process had a more qualitative and humanistic orientation (Quiroga, 1995). This dilemma between the neo-positivist scientist and the humanist would persist for much of the development of the discipline, even influencing its development in Latin America (Monzeli et al., 2019; Morrison et al., 2016). Holism is a pragmatist heritage that is increasingly being understood better in the world of medicine (Gaitán et al., 2019; Mezzich, 2007; Palma, 2004) and in certain aspects, occupational therapy has been a pioneer in it.

The significance of people’s subjectivity

From pragmatism, occupational therapy includes human beings fully and permanently involved in occupations, in which each performance is individual, and is perceived by people in a unique, transitory way and considering cultural meanings (Slagle, 1934b). Also, it establishes that occupations occur in a complex network of transactional relationships in the environment (Mead, 1934).

In this way, the first generation of occupational therapists built a humanistic view, in addition to a holistic view, in which the person is the center. Therefore, it gives importance to the particular characteristics, and the specific abilities, values, problems, needs, and cultural heritage of each person (Finlay, 2001).

We need to deepen into how pragmatism discussed these issues to understand the apparent simplicity of the above.

What we understand by reality is an individual perception, as well as collective, and unique (Putnam, 1999). This means that when faced with the question: how do we know the world, pragmatism will propose that reality is a social, transitory, partial consensus and whose usefulness must be permanently evaluated (Addams, 1902/2002; Dewey, 1922; Mead, 1934).

This perception of reality is built on ideas. The ideas represent a central aspect in the pragmatist philosophy since they allow to establish social consensus and maintain or transform the same reality. Thus, ideas depend on a specific context and are changeable depending on the interactions they develop in those contexts (including interaction with other people). An idea "happens the truth", means that it does not have a priori veracity, its assessment and consideration as true will depend on the conditions where it is found. Thus, its future is a probability (James, 1892, 1909 1974).

Thus, the ideas in people constituted by their experiences, judgments, and perceptions, give an account of their life stories and desires. This represents one of the foundational ideas in the training of occupational therapists: that a person's situation is a reality, it is their reality, therefore, it forms an independent value of medical or professional opinions, although the latter are “scientific truths”. This could translate into different situations, for example, that the opinion of a patient is crucial in the decision regarding a medical or therapeutic treatment that concerns them.

Although the reality is a consensus and can be transformed as we agree on our ideas, it is relevant to mention that, unfortunately, not all people participate in equal conditions to live and think about that reality (Addams, 1902/2002; Dewey, 1916/2004). For Addams and Dewey, education was a way of balancing for the development of a critical reflection to rethink reality, which the first generation of occupational therapists would take within the professional intervention processes.

Mutilated people, inside psychiatric hospitals, living on the street, etc. do not participate in that consensus of reality, much less in the processes that managed to reverse the social conditions that reproduced social inequalities. Thus, people learned that their reality cannot be modified. For this reason, the early occupational therapy interventions tried, through occupation, to generate enriched environments for these excluded people to provide stimuli that would develop their skills and improve their health situations, at the same time that they sought to generate changes in some of the structures that perpetuated the processes of exclusion.

In this way, understanding a person's subjectivity and place in the world would allow us to rethink both elements and question what is given as reality, at the same time facilitating inclusion processes. This is rooted in the belief that it is possible to transform a given reality.

Another expression of the significance of each person's subjectivity is related to the type and design of the treatments used in occupational therapy. Understanding that the truth is transitory, and all its expressions such as medical, psychiatric treatments, etc., for early occupational therapy, the standardization of therapeutic means was not an objective. On the other hand, as different intervening women proposed (Addams, 1935/2004; Johnson, 1919; Slagle, 1922, 1931; Tracy, 1910), it is not the people who must adapt to the treatments or means of intervention but the opposite.

In the previous process, it was necessary to become aware of their abilities and forms of relationship and guide them towards a dignified and friendly treatment, since the role of the occupational therapist was fundamental in the successful process of treatment and the improvement of the state of health and well-being of people (Slagle, 1922, 1934a). Reinforced under the idea of pragmatism, people are constituted through interaction with the context and in the relationship with other people (Mead, 1934, 1936). Thus, it was sought to resolve the deprivations of the environment in the intervention processes.

Significance through subjectivity and the holistic view are just two of the different heritages of pragmatism in occupational therapy. As part of the diversity of influences, we will notice one more aspect related to the theoretical development of Adolf Meyer in the medical world.

Meyer’s pragmatism and occupational therapy

Meyer was not just an important figure for occupational therapy. He has been recognized as one of those who contributed to changing the concept of psychiatry in the United States of America by working on the socialization and personal life aspects of his patients (Marx, 1993). However, in the opinion of historians of occupational therapy such as Gordon (2002), considering him as “the great theoretical leader” of the time is exaggerated since many of his postulates are reconstructions of pragmatism. He used terms such as adaptation, action, evolution, integrated systems, temporality, the reality through the transaction, social welfare, health through education, among others (Meyer, 1976). He influenced medical pathology, neurology, psychiatry, administration, medical education, and mental hygiene (Breines, 1986), and contributed to social work, medicine, and nursing (Addams, 1935/2004).

Regarding his pragmatist bases, Meyer agreed with Peirce (1904/2004) in attacking Cartesian dichotomies to explain the world and in understanding that human beings are part of nature and that they are constantly in interaction with the environment. At the same time, the sensory organs of people develop according to the adaptation vital for survival. He considered that the mind is not an abstract entity, nor separate from the body, and, like Peirce, he did not conceive that thought was separated from circumstances, the mind creates solutions to problems of experience. For this reason, Meyer concluded that the way to eradicate the old dispute between physiological and psychological terms about the human being was to stop thinking in dichotomies (Lidz, 1985).

Another example is what James and Peirce pointed out about habits and health. Many doctors of the time considered that the lifestyles generated by industrialization were one of the main causes of typical diseases such as neurasthenia (Addams, 1935/2004; Gordon, 2002).

In particular, James proposed explanations for mental illness. He pointed out that they had an important social aspect and that it was not only caused by biological agents (James, 1892 1985). Meyer also pointed out that it was necessary to review the life histories of his patients since they were not beings isolated from the world (Lidz, 1985; Marx, 1993). This last aspect was one of his main contributions to psychiatry: focusing on the lives of his patients, on their experiences and previous decisions, observing their circumstances, and evaluating how they were inputs for mental illness.

These approaches were consolidated in his stay at the Hull House when observing the work of Addams and Lathrop. They considered that social conditions have an important role in mental health (Addams, 2002, 1912), so exploring these aspects could give some idea of how to carry out a more accurate treatment.

People's lives and “common sense” was something that Meyer would return to psychiatry, which had begun to “[...] look for causes in brain cells, in physiology or biochemistry” (Lidz, 1985, p. 43). In this way, in addition to the ideas of Peirce, James, Addams, and Lathrop, he considered the concepts of the temporality of Mead (1934, 1936), who conceived the human being as a temporary person and constructed from subjective influences of himself and others.

Thus, Meyer thought that a mental illness cannot be explained if the life history of people is not considered (Lidz, 1985), for which he pointed out that in doing, action and experience, the human being is constituted as a social being (Breines, 1986).

For all the above, doing is where there were greater opportunities to improve patients. Balance in lifestyles, the importance of habits, and the development of health through activities were central elements of the pragmatist theories that Meyer shared with early occupational therapy (Gordon, 2002). These elements were developed by this first generation of professionals under the idea of occupation. For Meyer: “[...] occupation is, with a good direction, the most essential side of hygienic treatment for the sickest of patients”² (as cited in Bing (1981, p. 511) due to the whole body in action is integrated into the occupation, and under a therapeutic direction, it is possible to develop the “dormant” aspects of the health of the patients.

Meyer stated that occupational therapy conceives the mind-body unity as a whole with the environment. Thus, the problem of people with mental illness is a problem of adaptation to their context and occupation is the best treatment for these problems (Meyer, 1976).

The ideas of habits and transactions with the environment allow us to consider activities as instruments of interaction that have allowed survival and progress (James, 1892 1985). Like pragmatism posits, Meyer was convinced that human beings can transform themselves. Our actions depend on our decisions and decisions are made using critical judgment (Lidz, 1985). These ideas were integrated into the development of his psychobiology, and his holistic perspective on the health-disease process.

Finally, some of the elements that he developed in occupational therapy were that human behavior is integrated into the mind and what a person thinks affects their vital functions, from a cellular level to their symbolization, affecting their social relationships. The physical, chemical, cellular, psychological levels are tremendously relevant to helping a person, but independently, separately, they do not account for what the person is (Lidz, 1985).

Final Considerations

This article has sought to show the relationships between pragmatism and early occupational therapy in the United States of America. A relationship of influence is observed in the ideals, theories, and practices of the profession, with the approaches of classical pragmatists such as William James, Charles Peirce, George Mead, John Dewey, and Jane Addams. Understanding pragmatism is getting closer to understanding our occupational therapy.

As challenges, we could discuss what aspects of pragmatism are consistent with the ways of doing occupational therapy and occupational science in Latin America. Is it an epistemology that helps us think about the occupation today? Is it a contribution to occupational therapy practices? Is it possible to integrate pragmatist perspectives into Latin American approaches to the profession? These questions remain are part of the open debate and, certainly, it would be a contribution that different colleagues in Latin America could discuss.

• 1
  For example, Slagle’s publications on training in habits, in the process of social reintegration of people with chronic diseases, was recognized in much of psychiatry as a novel and highly effective method with a scientific foundation. Meyer's proposals on occupational balance from the perspective of psycho-biology were also considered as an important basis for the processes of understanding the disease of the time, where the context took a leading role, not the reductionist elements that later, during the second third of the 20th century, they would take on a greater role (Morrison, 2014).
• 2
  Our Translation.
• How to cite: Morrison, R. (2021). Pragmatism in the initial history of occupational therapy. Cadernos Brasileiros de Terapia Ocupacional, 29, e2147. https://doi.org/10.1590/2526-8910.ctoARF2147

• Funding Source

  Departamento de Terapia Ocupacional y Ciencia de la Ocupación de la Universidad de Chile, Chile.

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Edited by

Section editor

Prof. Dr. Daniela Tavares Gontijo

Publication Dates

• Publication in this collection
  21 May 2021
• Date of issue
  2021

History

• Received
  29 Aug 2020
• Reviewed
  06 Nov 2020
• Accepted
  23 Nov 2020