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LIildingInclusiveCommunity AChallenge forOccupational Therapy

994 Eleanor Clarke Slagle LectureAnn P. Gradyey Words: adaptation choice behaviordisability

Occupational therapy was founded on values ofchoice relevance nd active participation in mean-ingfuloccupations. To assure choice in daily livinglearning work nd play for persons with disabilitiesor significant health issues occupational therapypractitioners are challenged to g in increased under-standing of the unique culture nd o m m u n ~ v ofeach person nd family with whom they work; createopportunities for these persons to develop their capa-bilities in community settings of their choice promotemore interactive models ofpractice in which the prac-titioner affects the arrangements hetween the personnd society; work with communities to welcome thegifts of diversity nd develop skill in analyzing envi-ronments nd facilitating env ironmental interaction.The environment category of the spatiotemporal adap-tation theO Y is exp nded nd a communic tionmodel for collaboration in bUilding individu l com-munity is proposed as me ns for addressing thechallenges.

Ann P Grady, j\L'\, OTR, fAOTA, is Director of Occupational andPhysical Therapy, The Children's Hospital, Denver, Colorado;Clinical InstructOr in Pediatrics, University of Colorado HealthSciences Center; Training Director, Colorado Univel'sity Affjli-ated Program; and Affiliate Faculty in Occupational Therapy,Colorado State University. (Mailing address: 365 EudoraStreet, Denver, Colorado 80220). This article is based on alecture presented at CAN-AM the Combined Annual Confer-ence of the Canadian Association of Occupational Therapistsand the American Occupational Therapy Association, July1994 Boston, Massachusetts.This arlicte was accepled for publicalion j nu ry 12 1995

Preparation of the Eleanor Clarke Slagle Lecture pro-motes reflection on the values and philosophy ofoccupational therapy. I chose the topic BUildingInclusiue Communily. A Challenge j r OccupationalTherapy because it provided me with an opportunity toexplore my own values and the values of the professionregarding inclusion of all persons into the communitythey choose and into the world community at large. Thetopic particularly led me to review my own work in adap-tation theory developed with Elnora Gilfoyle (Gilfoyle,Grady, & Moore, 1990) in light of changes occurring orbeing promoted in society regarding opportunities forinclusion of all persons in all aspects of living. Ideas aboutinclusion; the meaning of community; the relationshiphetween environment and community; the interactionberween a person's past experience, present situation,and future hopes and dreams and its effect on the rela-tionship thar develops hetween an occupational therapistand a person seeking therary services all hecame focalpoints for exploring our role in building inclusive com-munity. The result has been some expansion of our un-derstanding of the environment category of the spatio-temporal adaptation theory and exploration of therelationship between environment and community. Inaddition, exploring the concepts of the theory led to con-sideration of its relevance for enhanCing our ability toplan with consumers of service who are creating or re-turning to their own community. Focal points for explor-ing the challenges related to building inclusive communi-ty include

An understanding of the meaning of communitybUilding within a person's own environment andaccording to his or her choices.

A review of current ideas about the nature of dis-ability in relation to both philosophy and man-dates for inclusion.

An expansion of ideas about the role of environ-ment in a person s adaptation to communityliving.

A consideration of strategies for promoting choiceClnd inclusion.

For as far back in time as we know, human beings havegathered together to share in daily living and use someform of symbols as means for communicating with eachother, hence the huilding of community (Dance & Larson,1972). To this day, we share meaning in our communitiesthrough symbols composed of pictures, words spoken inour own culturally determined language, and gestures ornonverbal expressions of our thoughts or feelings. NativeAmericans in the southwestern regions of our countrychoose to tell the stories of their community living andbeliefs through petroglyphs, or rock art (Patterson-Rudolph, 1993). One expert in petroglyphs comparedattempts at identifying subject matter and its significanceto cloud watching in that no two people will interpret

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what they see in the same way. Petroglyphs were apparently not intended to represent words of a language as weknow it, but instead were meant to convey more generalconcepts or global ideas about the society, such as ideasabout religion, medicine, governance, art, war, andpeace. An artist's rendition of petroglyphs titled Circle ofFriends (see Figure 1) is chosen to represent ideas aboutcommunity and inclusion that are central to the themes ofthis article. In rock art, spirals, concentric circles, andother geometric shapes are interpreted to be universalsymbols used to convey conceptual ideas (Patterson,1992). There are dozens of possible interpretations connected to each figure in the circle because rock art isinterpreted not only according to the individual symbolspresent, but also by the figures that are combined in apanel, just like words in spoken language. For me, theCircle of Friends represents the encompassing nature of acommunity, whether it is the community that each of usconstructs for ourselves or the larger environment inwhich we discover ourselves. The circle represents thewholeness of a community, and the figures relate to diverSity that can exist within the community. Just as the circleis considered a symbol of inclusion and wholeness, theextension of the circle as a spiral is well known as asymbol of growth and continuity. Spirals frequently appear as symbols of continuity in Native An1erican culture(Patterson, 1992). The spiral r e ~ e t s evolution and renewal with growth emanating from continuous learningand new challt:nges. The spiral and its embedded circleswill be ~ s e d in this article to represent change andcontinuity.

Why is the idea of building inclusive community im-

Figure 1 Circle of Friends petroglyph. Original metalsculpture by Kevin Smith, Golden, Colorado. Appears withpermission of Kevin Smith.

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portant to U as people and as occupational therapists?The idea is both profound and simple. Simply, we believethat people belong together regardless of real or perceived differences. All persons have the right to choosewhere they wish to live, work, learn, and play, and withwhom they wish to spend time. On a deeper level, webelieve that people belong together because of differences. There is a richness that characterizes a communityconstructed with appreciation for both differences andsimilarities among its members. The idea is not new, butas Winston Churchill said, Men [and women I stumbleover the truth from time to time, but most pick themselves up and hurty off as if nothing had happened(McWilliams, 1994, p 413).

The Nature of Community and ChoiceCommunity proVides a context for actualizing individual potential and experiencing oneness with others(McLaughlin & Davidson, 1985). The human conditionyearns for a greater sense of connectedness, expressed asa need to reach out, deeply touch others, and throw offthe pain and loneliness of separation. The term commu-nit) encomrasses communic tion and unity. Yankelovitch said that the community evokes in the individual thefeeling that here is where I belong - these are my people, I care for them, they care for me, I am part of them, Iknow what they expect from me and I from them, theyshare my concerns. I know this place, I am on familiarground, I am at home 1981, p. 224).

There are established communities such as towns,neighborhoods, schools, and workplaces, and there arerersonal communities we create for ourselves, which include family, friends, acquaintances, how and where wespend our time formally or informally, and the relationships we build over time. Our personal communities donot necessarily depend on specific location or specifictime, although they are often embedded in establishedcommunities Building inclusive community refers toboth the larger, more formal community context and thesmaller, informal community that a person identifies as apersonal community. Ideas about diversity and inclusionin community in this article apply to all people, but we asoccupational therapists have particular concerns for as-suring choice in community living for persons with disabilities and chronic health problems, as well as personsfor whom disability and health issues can be prevented

Personal community building begins at the center ofthe circle, where the person is embedded in family andclose relationships (see Figure 2). Networks of informalsuPPOrt develop in the center of a personal community.Relationships grow because persons choose to be connected. The unique culture of personal community iscreated from family exrerience. Values are established;heritage, myths, and traditions are communicated. The

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igure2 Personal community building.

foundation for building personal community is established within the family

We all come from families. Families arc big. small, extended,nuclear, multigenerational, with one parent. two parents, andgrandparents. We live under one roof or man\'. A famih' can be astemporary as a few weeks, as permanent as forever We becomepan of a family by birth, adoption. marriage, or from a desire l i lrmutual support. Families are dynamic ane are cultures untO themselves, with different values and unique ways of realiZing dreams.Our families create neighborhoods, communities, Slates. and nations. (Shelton Stepanek 1994, p. 6)

For both children and adults, family provides a personalculture of embeddedness. Each person creates a commu-nity of family culture in the broadest sense of the conceptof community. Like all cultures, each culture we createwithin our community is based on our values and maydiffer substantially from another s uniquely consummat-ed community. However the family is constituted, wheth-er we judge it adequate or not according to our valuesystem, a person is embedded in his or her family andthat is our starting place for inclusion. A challenge foroccupational therapy practitioners is understandingeach person s unique community including its cultureand the context in which it was formed

The concert of community is broadened to includerelations with acquaintances, coworkers, and schoolmates as well as locations like neighborhoods, workplace,and town. The community circle includes both formal andinformal sources of support. The environment providesthe context in which communities are formed It is composed of persons, objects, and srace - all of which can becombined for personal or formal community building,The environment generally provides formal SUppOf[ topersons in community. Co mmunity is not a static Structure in the environment, but an ongoing process of interaction among persons, objects, and space, Communityprovides familiarity with daily interactions that reducesthe uncertainty experienced in new and challenging situations and creates a sense of belonging,

A sense of belonging in a community proVides thecomfort and security needed to explore and use one sgifts. According t Maslow's hierarchy, belonging is animportant component in the development of self-esteem,Building blocks [ selksteem include a sense of safety inone s immediate community, a sense of self-acceptance,identity, affiliation with others and a sense of competenceand mission. In some instances, we seem to expect children and adults with disabilities to demonstrate a sense ofself-esteem before they can be included in a typical classroom or work or living environment, forgetting that belonging to a typical community is the means by which aperson develops a sense of self (Kunc, 1994) One of thechallenges we olien face is resolution of the conflict wehave over the need/or persons with disabilities t provethemselves capable be/ore thev are included in tvpicalcommunities of their choice rather than creating oppor-

t U l ~ i t i e s for them to deuelop their capaCities in theircommunit . with a ppropriate supports,

Choice is a valued dimension of our community life.Choice means having alternatives from which to make aselection. As occupational therapists, we recognize theimportance of choice in every person's pursuit of selfactualization, pa rticularly as he or she fulfills occupationalroles of daily living, wor-k, school, and play and leisure.Choice in occupational therapy has traditionally meantthat the person seeking services takes an active part inplanning and carrying out a therapy program. Yerxa(1966) maintained that one of the most important rolesan occupational therapist plays is rroviding choice inselection of therapeutic activities. interaction with theactivities and, most important, establishment of objectives for a therapy [1rogram, Exercising choice in a therapeutic environment provides opportunities to eX[1lorecapabilities and options for life outside the therapy setting. Making choices is another way of exploring personalvalues about daily living, relationships, roJes, and thephysical, psychological, social, and spiritual communitiesin which living needs to occur t pursue self-actualization.Making choices in therapy is only a prelude to the choices[1eople need to make regarding their life in the communi-ty. How will I make a living i Where viII I live i Where willmy child go to school What supports will I need t livefully in the community of my choice? A challenge foroccupational therapy practitioners is fostering choicethat reflects their consumer s priorities/01 living and

a c c o m p h ~ - h i l 1 { occupational tasks, even if there are dlfference,, between them regarding ualues or perceptionsofexpertise. Schon (1983) wrote that the interactive practitioner realizes that he or she is not the only one in thesituation to have relevant and important knowledge. Theconsumer interacts by joining with a service provider tmake sense of the situation and, hy doing so, gains asense of increased involvement and action - or choice,

Being part of J community provides opportunitiesfor- lifelong development. Persons with disabilities ancl

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their family members have a right to pursue and panici-pate in all levels of their community, whethcr it is onethey have known well or one they wish to build to accommodate new circumstances and fulfill new or old dreams.Each person creates a community of his or her own culture in the broadest sense of the concern. Like all cultures, each culture we create within our community isbased in our values and may differ substantiallv fromanother's uniquely consummated community. Creatingcommunity opens doors to new cultural vistas with o[J-ponunities to cooperate with each other and panicipatein community activities. Inclusion in a communitv alsomeans an end to loneliness anc helplessness and thebeginning of em[Jowerment to fulfill dreams (Mclaughlin& Davidson, 1985). Building inclusive communities withall rersons provides opportunities For members of thecommunity to experience different relationships. Each ofus has the capacity for creating inclusive communitvthrough our work with individuals as well as our ability toinfluence society and its established institutionsThe Nature of Disabiliry and nclusionA new sociopolitical environment is developing in whichpersons with disabilities are taking or creating social andpolitical actions on their own behalf. Changing perceptions of disability and the histories of the civil rightsmovement in the 1960s and the women's rights movcment in the 1970s resulted in suhstan tiallegislative actionfor disability rights. In his book No Pitv Shapiro (1993)chronicled the course of thc disability rights movement inthe United States. Shapiro stated that persons with disahilities insist simply on common respect and the oppor-tunity to build bonds to their community as fully acceptedparticirants in everyday life. In the past, disability wasusually viewed as a medical problem with the expectationthat, to be accepted, persons with disabilities needed tobe as much like persons without disahilities as possiblewithout regard for their own uniqueness. Now, personswith disabilities are thinking differently about themselves.Many no longer think of their physical or mental differences as a source of shame or something to overcome inorder to be like others or insrire others. In Flving With-out Wings Beisser, who contracted polio as an adult, saidWhen I stopped struggling, working to change, and

found means of accepting what I had already become, Idiscovered that changed me Rather than Feeling disabledand inadequate, I felt whole again" (1989, p. 169). Beisserviews disability as a difFerence among reople. Considering disability as adifference is in itsel f neutral and changesthe way persons with disabilities view themselves and areviewed by others. For examrle, in the village of Chilmarkon Martha's Vineyard Island in Massachusetts, more thanhalf the residents in the 1800s were genetically deaf(Groce, 1985). AJI the peor1e in the village were fluent inc,ign language. It has been reporteel that spoken and sign

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language were used simultaneously or, if a person whowas deaf joined a s[Jeaking group, group members immediately started to use sign as well as speech. Deafness wasnot a clisability in Chilmark. Disability is a dimension ofdiversity not unlike ethnic background, color, religious,or gender differences (Shariro, 1993). Differences do notnecessarily equal limitations, but rather create opportuni-ties for meaningful interaction a Snow, personal com-munication, 1994) as long as peo[Jle are liVing togethernaturally.

Just as perceptions of disabi lity are changing, so arethe reasons that disability was so often seen as a limitation. The difference within the person is no longer viewedas the main problem; instead, the environment that cannot accommodate the person is considered responsibleFor society's failure to include persons with disabilities inthe mainstream Social considerations have led to a shiftfrom the traditional medical view of disability to an interactional model that accounts for the relationship betweenperson and environment. Gill (1987) summarized thisshift in pers[Jective as follows:

According to the medical view, disability is considCl"ed a deficit or abnormality. In an interactional model,disahilltv is a difference.

In the medical view, being disabled is perceived asnegative. [n an interactional model, being disabled is initselF neutral.

Iv edicine views disability as residing in the individual. [n an inter-aetional model, disability is derived Fromproblems encountered during interaction between theindividual and their environment.

In medicine, the remedy for disability-related problems is cure or normalization of the individual. In aninteractional model, the remedy for disability-relatedproblems is a change in the environmental interaction.

Finally, the medical view identiFies the agent of rcmedy as the professional. An international model has pro-posed that the agent of remedy may be the individual, anadvocate, or anyone who aFfects the arrangements between the individual and society.

The last interactional categolY in Gill's summary canhave a significant effect on the roles for occupationaltherarists. The shift from a medical perspective to anenvironmental framework is not difficult for us to under-stand. Occupational therapists have always recognizedthat disability was not an illness that could be cured bymedicine. The challenge(or us is to promote the interac-tive model or practice regardless o the venue o ourpractice. A concurrent challenge is to increase supportor more practice venues in the communit) where en-gagement in real occupation takes place.

Change in perception of disability has Fostered thedisability rights movement and legislative action. The disability rights movement has focused on the rights of persons with disabilities to be included in society accordingto the choices they make for themselves and their fam

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ilies. The rights movement could also be called an inclu-sion movement. Inclusion in communitv means that allrersons regardless of differences r r t i j r ~ l t e in naturalenvironments for living, learning, plaving. working. reSling, and recreating. For per501l5 with disahilities. [1anicipation may be with srecific surrort from others or withadaptations to the environment According to Gill (1987),inclusion means removal of barriers to power. which results in a greater number of alternatives or choices

Shapiro (1993) identified the 1960s as the beginningof the disability indepenclent living movement started byEd Roberts and other students at the Universit)' of California-Berkeley. The movement srread to include action inWashington, DC, that initiated funding for inderendentliving. Grours of rarents of children with disabilities began to form around the country at about the same time.primarily to provide support to other rarents in the samesituations. The groups were often connected to existingorganizations like United Cerebral Palsy or the Easter SealSociety. Later, parent organizations would emerge asinderendent, social change grours

The 1970s saw adoption of Section ')04 of the Rehabilitation Act (Public Law 93-112) rrohibiting discrimination on the basis of disability. But Section ')04 was notimplemented for nearly') years after its adortion and wasimplemented only after a group led by Roberts and othersstaged a sit-in at Department of Health, Education andWelfare office in San Francisco Besides succeeding inobtaining regulations for Section ')04, the event in SanFrancisco created an awareness that linked groups ofadults around the country in a civil r ights movement. Alsoin the 1970s, Public Law 94-142 was adopted as the Education for All Handicarped Children Act (197')), mandatingpublic education in the least restrictive environment forchildren with disabilities who were') years of age andolder.

In the 1980s, suprort was provicled for that aetthrough the establishment of statewide parent information and advocacy center's in every state The legislationwas eX[1anded to include infants and toddlers ,virh passage of the Education of the Handicapred An Amendments of 1986 (Public Law 99-4';7) With this expandedlegislation for education came the components of familycentered care, or respect for a family's central role asdecision maker for a child, or support for an adult, whichis now considered best rractice across the life sran. Public Law 94-142 and Public Law 99-4')7 were combined andexranded in reauthorization as the Individuals With Disabilities Education Act of 1990 (IDEA) (Public Law 10 1476). Meanwhile, the Technology-Related Assistance forIndividuals With Disabilities Act (Public Law 100-407)(191313) began the rrocess of changing policy and availability of assistive technology for persons with disabilities inall states. The legislative decade of the 19130s culminatedwith the Americans With Disahilities Act of 1990 (ADA)(Puhlic Law 101-336) ADA encomrasses ideologv from all

previous legislation by ensuring that the barriel"S to inclusion be eliminated for pCi"sons with disabilities. Althoughfar-reaching disability rights legislation was ufficiallvadoptee in the 19130s, we are still struggling with imrlcmentation of all the laws in the 1990s

The disal,ility rights movement and legislation hasfocused rrimarily on removing rhysical ancllegaJ barriersto inclusion Legislative mandates serve the purpose offorcing inclusion. The sririt of inclusion onlv comes withattitude change supported hy community preramtionand relationship bUilding. In a midwestern city, 9-year-oldAmy, who has cerebral palsy, vbited Santa Claus last yealand had only one wish for Christmas - just one day inschool when the kids did not tease her about her cerebralralsy. Clearly, my was present in school with her typicalreCi S, and being there is a start. But she is not trulyincluded since a community that accepts her for who sheis has not been created. She needed a school communitythat gave her a sense of familiarity, caring, and belonging.She needed relationships thar she could depend upon forsurr0rt ("Disabled Girl Asks Santa," 1993). In anotherCity, 14-vear-old Kevin, who has Down's syndrome. hasbeen with typical peers from the beginning of his schoolcareer. His inclus ion has focused on preparation and relationship building that included Kevin along with theteachers and children in the building. When asked what itwould be like if he \vas not included in typical school, hereplied that he'd feel sad. J like to be in school with myfriends I earn from them and they learn from me (Kevin personal communication. February 1993).

Inclusion is about relationships. Judith Snow, a consumer advocate in Canada, has said that the only realdisability is having no relationships (personal communication, January 1994). Inclusion means participation. Inclusion in school is only the prelude to inclusion in life.Participation may require support not only in the traditional sense of personal assistance and adaptations, butalso in terms of preparing the persons in the communityto welcome differences into their community and helpuevelop natural suppon svstems. challengeforoccupa-tional therapy is development ofprograms that preparepersons and their families for life in tbe comrnunit]while working to prepare the community and persons init to welcome fh gUis of diversity If we esrouse theinteractive model of disability, we can affect the arrangements between the individual and society and makeunique contributions to the interactive model of change.We can assist with remediation of the person's physical orpsychological rroblem to the extent that the manifestations of the problem can be changed. We can participatein modification of the person's environment so that it canaccommodate the needs. We can assist with buildingcommunity with the rerson or family in order to create aplace for belonging that includes both the formal andinformal sources of support. We can continue to promoteinclusion as a value through our sociorolitical systems.

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Celebration Utilization ommitment AppreciationDifferencesPerspective hangeRecognition

Figure 3 Celebrating diversity: Individual and society.Building inclusive community sometimes requires

change in value-based practices. The spiral (see Figure 3)serves


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Figure 4 The person in life span.

recall past behavior [0 respond until environmentalevents can be reorganized to elicit a higher level response. With adaptation as a process for organizing one'sself and environment, interaction between person andenvironment sets up a system of relationships.

Environment as a category in the adaptation theoryis all-inclusive. Environment represents the complete setting or surrounding in which a person lives, including self,other persons, objects, space, and relationships betweenall components in the environment (see Figure 2) Ac-cording to Winnicott, a good enough (1965, p, 67) environment meets and challenges a person's need to growand develop by adapting to stimulation from continuallychanging situations. Yerxa (1994) noted that personsneed just the right challenge to make an adaptive response. Dalol said that

how readily we grow- indeed whe[her we grow a[ al l has agre;l[deal [0 do with the natUl'C' of the wodd in which we transaCi ourlives' husiness. To understand human dev


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to act on his own behalf. A woman recovering from a headinjury may have regained considerable function in a rehabilitation setting, but may be fearful of being back in hercommunity, She will need challenge to regain her independence, but with enough support and facilitation toensure progressively successful adaptation , She may wantto reconstruct the life she led before the accident, or shemay construct a new community and need resources forher new life, An infant may literally require a supportiveenvironment to learn sensorimotor skills or speech or tofocus on learning through play, For all of us, ga ining andmaintaining a balanced interaction between self and environment is a work in progress, We often need to challenge ourselves if we wish to move ahead, Or we seekfacilitation for new situations, or support in difficulttimes, A chaJlenge for occupational therapy practitionersis development of skill in analyzing environments andhelping consumers to identify the type of environmentalmilieu that will facilitate their adaptation process,

Interactive Strategies for Choice and nclusionThe promise of occupational therapy lies in our ability tocontinuously combine the mandates put forth in the earlyteners of our discipline with our constantly changingpractice environments, Occupational therapy emergedfrom both community and medical models of practice,although our philosophy is more related to what weknow as the community-based model because occupations are practiced in community settings, For decadeswe tended to practice more in institutions or specializedsettings, usually trying to simulate real-life settings to prepare persons to live in their community, Some of ourmore visionary colleagues set the course toward a futurethat focused on community consultation models of servi e delivery, The founders and leaders in our professionhave fostered the importance of providing services in aperson's own setting and according [ the person's ownchoices and priorities for gaining or regaining specificskills for living, Our philosophy from the beginning of ourprofession has included the value of choice, relevance,and active participation through engagement in meaningful occupations, Occupation provides a context for organizing one's self and one's environment, thus promotingthe transactional process of adaptation within a community setting (Engelhardt, 1977; Gilfoyle et aI., 1990; Grady,1992; vleyer, 1922; Schwanz, 1992; Yerxa, 1966), Therapyprograms are designed to prevent or remediate the effeers of disability or health issues and promote independent living in the community through occupationssuch as self-care and daily care of Others, ability to playindependently or with other children, ability to learn as achild and engage in lifelong learning as an adult, ability tobe engaged in meaningful work to make a living or forone's own satisfaerion or both, ability to balance work andrecreation, and ability to blend all occupational activity

The merican Journal of Occupational Tberapl

with rest. Although models for community service delivery have been promoted from within the profession, external mandates for change have also influenced expansion of our praCtice environments, The voices heard fromour consumers, our colleagues, legislation at state andnational levels, and rapidly changing payment systemsdirect us toward service delivery that focuses on consumers' priorities for goals and naturally occurring venues foractivities, The new directions in practice allow us to combine our past experience and founders mandates withthe current realities of practice in ways that lead us torealize the future hopes and dreams of our consumers,ourselves as individuals, and the profession as a whole,

To build collaborative models of consumer-driven,community-based practice, we need to focus on a lommunication process that helps us understand other persons' unique culture and priorities for life occupations aswell as meaning associated with past experiences, currenrSituations, and hopes for the future Recent developments in the field support a focus on communication thatenhances a shift from medicaJly focused to interactivemodels of practice in which the therapist serves as anagent of remedy to affeer the arrangements between theindividual and society, The ise of narrative for storytellinghas increased our understanding of a person's past andpresent experience, Reflective practice and clinical reasoning suPPOrt our ability to gain insight into the interactive roles that can unfold between a therapist and arerson seeking se[\/ices. Ethnographic approaches to research have in general heightened our knowledge of persons liVing in their own environments (Clark, 1993: Mattingly Fleming, 1994; Schon, 1983; Yerxa, 1994)

Therapist-consumer collaborative practice modelsmean that communication among the therapist, the person seeking services, the family members, and the closecommunity members is critical. From the beginning, it isthe relationships we build that are critical to our ability tocollaborate effectively, Listening, tal king, reflecting, informing, and demonstrating are all part of the ways weestablish relationships, Human beings are uniquely constituted for giving and receiving information, making andsharing meaning, We have the capacity to use intrapersonal communication skills to explore the meaning of ourown values and experiences, and interpersonal communication skills to link with another person's values and experiences. Intrapersonal cOinmunic llion refers to thecreating, functioning, and evaluating of symbolic processes that operate within us, Such activities as thinking,reflecting, solving some problems, and talking with oneself are part of our unique inrrapersonal communicationsystem (Dance Larson, 1972). Intrapersonal communication is active within us whenever meaning is attached toan internally or externally generated source of stimulation, Meaning associated with past events and currentsituations is deeply embedded in the inrrapersonal sys-tem of both the persons seeking services and the service

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InterpersonalCoMMUN ..... Past ExperienceA ValuesTIoNIntrapersonal

Figure 6 Linking past experiences.

provider. Interrersonal communication serves to link usthrough verbal and nonverbal expression so that we canmore explicitly share information and meaning. Throughinterpersonal communication, we can tell our stories; explore the meaning of relationships, events, and circum-stances; reflect on similarities, differences, strengths, andchallenges; and develop plans for working together toward future goals. Kegan said, If you want to understandanother person in some fundamental way, you mustknow where the person is in his or her evolution. Youneed to understand his or her underlying structure formaking meaning 1982, p. 113). The context in which weas therapists seek and receive the information shared hypersons seeking services can enhance our communica-tion and collaborative rlanning. A communication modelof collaboration can he illustrated by the spiraling modelof rerson in life span (see Figure 4). I f we r1ace sriralsside by side and let one spiral represent the consultanttherapist and the other represent a rerson seeking services, we can visualize the communication sequences thatoccur. Communication moves from intrapersonal r e ~ e c

InterpersonalCo~ Future xpectation

'41 ~ Current Situation~ ~ = = = = = . . . . t Past ExperiencATIoNIntrapersonal

Figure 8 Linking current information.

tion to interrersonallinking through listening and sreak-ing (see Figure 6) A closer look at the circle representingpast experience rrovides details that can be shared aboutthe meaning emhedded in values and culture of childhood, family, and rersonal community (see Figure 7). Wecan discuss rast exreriences in terms of activities andrelationships with family and close friends, with rersonalcommunity, and with the larger environment. Exrloringthe past provides insight into the values that have directed rast choices and the tyres of environments that theperson has exrerienced. Discussing the current situation(see Figures 8 and 9) in the same contexl allows thetherapist to understand the extent and meaning of thechange that has occurred in the rerson's life as well as thepriorities and types of environments that need to be foremost in planning together. The rersons can glean considerahle information about the therarist's perspective onthe current situation on the basis of rast exrerience. Theinterpersonal l inking increases understanding and pro-motes collaborative goal setting between person andtherapist. As much as we have moved toward collabora-

PersonFigure 7 The link of past experience with personal Figure 9 The link of current situation with personalcommunity. community.

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InterpersonalCoMM Future ExpectationsUNIC Past xperiencATIoNIntrapersonal

Figure 10 Exploring future possibilities.

tion in family-centered and person-centered planning, weare stU I sometimes heard to say that we are haVing difFiculty with a person receiving services accepting the goalswe have set for their therary Interactive strategies meanthat persons receiving services set the goals and therapists collaborate to design programs with them that willhelp address the goals. Information shared and the meaning it holds for both consumer and thcrarist rrovide thebasis for collaboratively rlanning the future (see Figures10 and 11). According to Schon 1983), there is gratification and anxiety for the reflective, interactive rractitionerin becoming an active participant in a process of sharedinquiry. For a therapist or consumer who wishes to movefrom traditional to reflective communication, there is thetask of reshaping expectations for the relationship. Bur ifwe are to be agents of remedy in the arrangements between a person and the environment, we need to be ableto share with and receive comrrehensive informationfrom the rersons who are seeking choices for inclusion intheir community.

Figure 11 The link of hopes, dreams, and future expectations with personal community.

ummaryWe have had an opportunity to focus on the challengesand opportunities for building inclusive community withthe persons with whom we work in occupational therapy.We have gained understanding about the meaning ofcommunitv and choice, reviewed current ideas ahout thenature of disahility and mandates for inclusion, expandedideas about environment and adaptation, consideredstrategies for promoting choice and inclusion, and related these concepts to the philosophy of occupational therapy. I had the extraordinary opportunity to explore myown values, past experience, current situation, and hopesfor the future and I am forever changed by the experience. As Emily Bronte reflected, "I've dreamt in my life-dreams that have stayed with me ever after, andchanged my ideas: they've gone through anel throughme, like wine through water, and altered the color of mymind" (cited in The Quotable Woman 1991, p. 185)Leading the development of inclusive community is rightfor occupational therapy and we all have it in us to do it.The challenges before us are as follows:

1. Understanding each rerson's unique community,including its culture and the context in which itwas formed.

2. Resolving the conflict we have over the need forpersons with disabilities to rrove themselves ca-rable before being included in typical communities of choice rather than creating opr0rtunitiesfor developing carabilities in the community withapprorriate supports.

3. Fostering choice [hat reflects a person's prioritiesfor living and accomrJishing occupational tasks,even when there are differences regarding valuesor percertions of expertise.

4. Promoting the interactive model for practice, regardle:is of the venue of practice.

'j Increasing su prort for more practice venues inthe community where engagement in real occuration takes rlace.

6. Developing programs that prepare reople andtheir Families for life in the community whileworking to rrepare the community to welcomethe gifts of diversity.

7 Making a commitment to inclusion in communityfor all persons.

8. Developing skill in analyzing environments anelhelping peor1e identify the type of environmentalmilieu that will facilitate their adartation process.

AcknowledgmentsI thank Ellie Gilfoyle for leading the Eleanor Clarke Slagle nomination process and for a liferime of creative collaboration; mycolleagues who supported rhe nominarion "nd hy doing sooffered focus for rhe ropic; Lou Shannon for ongOing supportand Inspiration; my colleagues at The Children's Hospital for

The American Journal of Oceupal/onal Tberapl 309


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their support; Anita Wagner, Jackie Brand. and all the otherparents \\'ho enlightened me with their perspectives andchanged the course of my professional life; Betty Yerxa, whosephilosophy and writings have influenced my thinking for manyyears; and my family, \\lho are in the center of my personalcommunity. I also [hank Carol Wassell from In:mucrional SeT-vices at Colorado State University for creating beautifu l slides forthe presentation and graphics for this article and Diane Briansfor drawing the Circle of Friends.This lectureship is dedicated to my parents, the late Marionand James Grady, with deep love and appreciation for thestrong focus on family and community that they lived and instilled in their children.

ReferencesAn1ericans With Disabilities Act of 1990 (Public Law 101336) 42 V.S.C 12101.Beissel', A. (1989). Fll ing without wings. New York:Doubleday.Bronte, E. (1991). Cited in The quotaMe woman. Philadelphia: Running Press.Clark, F. (1993) Occupation embedded in a real life: Interweaving occupational science and occupational therapy. 1993

Eleanor Clarke Slagle Lecture. American Journal of Occupa-tional Thempl . 47, 1067-1078.Daloz. L. (1986). Effectil)e mentoring and teaching SanFrancisco: Jossey-Bass.

Dance, F., & Larson, C (1972). Speech communication'Concepts and hehm)ior. New York: Holt, Rhinehart, & Winston.Disabled girl asks Santa to end teasing. (1993, December14). The Denver Post) p. 1.Education fot' All Handicapped Children Act of 1975 (PuhlicLaw 94142)Education of the Handicapped Act Amendments of 1986(Public Law 99-457).Engelhardt, H. (1977). Defining occupational therapy: The

meaning of therapy and the virtues of occupation. AmericanJournal of Occupational Therapv, 31. 666-672.Gilfoyle, E., Grady, A, & Moore, J (1990). Children adapt(2nd ed.). Thorofare, N.J: Slack.Gill, C (1987). A new social perspective on disah ility and itsimplication for rehahilitation. Occupational Thempl' in HealthCare, 7 1.Grady, A. (1992). National] Speaking - Occupation as visian. American Jou.rnal of Occupational Therapv, 46, 10621065Groce, N. (1985). Everyone here spoke s(r;,n language. He-reditary deafness on N1artha s Vinevard Cambridge, \ vIA: Ilarvard University Press.

Individuals With Disabilities Education Act of 1990. (PublicLaw 101-476)Kegan, R. (1982). Tbe euollJing self Cambridge. \ vIA: Harvard University Press.Kunc, N. (1994). TbE other side o{ therapy. Port Alherni,

BC Axis C o n s u l [ ~ l [ i o n Jnd TrJining.Lens, 1.. Law, M., Rigby. P, Cooper. B., Stewart, D., &Strong, S. (1994). Person-environment assessments in occupational therapy. American Journal of Occupational Tberapl ,48, 608-618Mattingly, C, & Fleming, M. (1994). Clinical reasoningForms of inquily in a therapeutic practice. Philadelphia: F. A.Davis.Meyer, A. (1922). The philosophy of occupation therapy.ArchilJes of Occupational Tberapy. 1, 1.McLaughlin, C, & Davidson, G. (1985). Builders of thedawn. Summertown, TN: Book Publishing.McWilliams, P (1994). Do it again. Los Angeles: Prelude.

Patterson, A. (1992). Rock art sJlmhols oftbe grealer Soulbwest. Boulder, CO: Johnson.PattersonRudolph, C (1993). Petroglvphs and Puehlomyths of the Rio Grande (2nd ed). Albuquerque, NM Avanyu.Rehabilitation Act of 1973 (Puhlic Law 93-112),29 US 794. Schein, D. (1983). The reflective pmctilioner New YOI k:Basic.Schwanz, K. (1992). Occupational therapy and education:A shared vision. American journal of Occupational Therapy,46, 12-18

Shapiro, J. (1993). No pity. New York: Times.Shelton, T., & Stepanek, J (1994). Fami/l centered carefor children needing specialized health and delJelopmentalservices. Bethesda, MD: Association for the Care of Children'sHealth.TechnologyRelated Assistance fo r Individuals With Disabilities Act (Puhlic Law 100-407) (1988).

Winnicott, D. (1965). The maturational processes and thefacilitating environmenl. New York: International UniversitiesPress.Yankelovitch, D. (1981). New rules. New YOI k: RandomHouse.Yerxa, E. (1966). Eleanor Clarke Slagle lecture-Authenticoccupational therapy. American journal of OccupationalTberapv, 21, 1-9.Yerxa, E. (1992). Some implications of occupational thetapy's history for its epistemology, values. and relation to medicine. American journal of Occupational Therap I', 46. 79-83.Yerxa, E. (1994). Dreams, dilemmas. and decisions for occupational therapy practice in a new millennium: An Americanperspective. American. oumal of Occupational Therapy, 48,586-589.

The videotape o the Eleanor Clarke Slagle Lecture presented at AOTA's 1994Annual Conference, by Ann Grady, MA, OTR, FAOTA, is currently availablefor purchase ( 25.00 AOTA member, 32.00 nonmember). Approx one hourUse this tape to enhance your OT Month celebration! Also useful for clinical and academicsettings. To order call AOTA Products: I ~ 8 S A Y ~ A O T A (members) or 301-652-2682(nonmembers). TDD customers call 1 8 0 0 3 7 7 ~ 8 5 5 5Shipping and handling additional. The A_rican I I Occupational Therapy_ _ _ _ Associati on, Inc.

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