Meanings of creativity within occupational therapy practice

Australian Occupational Therapy Journal (2004) 51, 80 88 Blackwell Publishing, Ltd. Research Article Creativity within occupational therapy practice Meanings of creativity within occupational therapy practice Therese Schmid Discipline of Occupational Therapy, The University of Newcastle, Newcastle, New South Wales, Australia Since the early days of the occupational therapy profession, creativity has been intrinsic to the beliefs and practice of occupational therapists. However, notions of creativity have been rarely explicated in occupational therapy research. The aim of this exploratory research was to study the phenomenon of creativity through the subjective perceptions of three occupational therapy clinicians. This qualitative research used a methodology in the spirit of phenomenology and took a descriptive, critical approach. Five themes of meaning were derived from the data: creativity is part of everyday practice; the use of creativity as a conscious approach; creativity involves risk-taking; creativity needs a supportive environment; and creativity is the use of expressive arts in therapy. This study illustrated that creativity, as a phenomenon, has a multifaceted structure and appears to manifest in practice in a much richer way than is being revealed by occupational therapy literature. KEY WORDS creativity, meaning, occupational therapy, qualitative research. INTRODUCTION Literature in other fields There is a wealth of literature on the meanings of creativity and creative behaviour, mostly published during the last 50 years in the fields of psychology, education and the arts (see for example: Maslow, 1974; Sternberg, 1988; De Bono, 1992; Wijers, 1996; Runco, 1997). Discussion has been broad ranging including: creative thinking and problem solving, the creative process, psychometric approaches, personality, the role of the environment, creative systems, social psychology, training in creativity, creativity in women, in families, in motivation, and in neurological and socio-biological antecedents. The research methods are also broad, with extensive quantitative research from psychology and education. Overall, the arts and philosophy literature is descriptive and theory focused. However, there has been little discussion about the meaning of creativity within the occupational therapy context. Occupational therapy literature Arts and crafts activities constituted the main tools of occupational therapy practice from the beginning of the profession until about the 1960s (Bissell & Mailloux, 1981; Dickerson & Kaplan, 1991; Wilcock, 2001). Since the 1960s, the use of arts and crafts as therapeutic activities has diminished in practice and professional education (Eliason & Gohl-Giese, 1979; Barris, Cordero & Christiaansen, 1986; Gohl-Giese & Eliason, 1986; Taylor & Manguno, 1991; Thompson & Blair, 1998). Dickerson and Kaplan pointed out that the profession as a whole has Therese Schmid MHlthScOT, AATR, Dip OTNSW; Lecturer. The research was conducted in the Hunter Valley and New South Wales. It was prepared as a part of the requirements for completion of Master of Health Science (Occupational Therapy) at the University of South Australia, Adelaide. Correspondence: Therese Schmid, 33 King Street, Lorn, NSW 2320, Australia. Email: therese.schmid@newcastle.edu.au Accepted for publication November 2003. 2004 Australian Association of Occupational Therapists

Creativity within occupational therapy practice 81 been divided on the use of crafts as a therapeutic tool. Nevertheless, the use of creative activities as therapeutic tools (Denshire, 1996; Thompson & Blair) continues to the present mostly in mental health settings. The use of creative activities within occupational therapy practice raises the question: What meanings do occupational therapists give to creativity? Maybe therapists have avoided dealing with creative aspects of therapy because it was too hard to deal with creative concepts. This study aims to assist in overcoming the mystique of creativity and perhaps clarifying ways to approach it. Throughout this paper the term creative activities will include art and craft activities and the modern practice of the expressive arts. The occupational therapy literature refers to the profession as being creative (Reilly, 1962; Mattingly & Fleming, 1994; Kielhofner, 2002). However, this belief remains mostly obscure, with few exceptions (Graham, 1983; Du Toit, 1991; Hagedorn, 1995; Creek, 1997; Lewin & Reed, 1998; Atkinson & Wells, 2000). Atkinson and Wells published a monograph on creative therapies using a psychodynamic approach within occupational therapy. Graham discussed the value of creative problem-solving within an occupational therapy curriculum. Du Toit devised a theory of Creative Ability as a model for psychiatric occupational therapy practice. Hagedorn described creativity as a part of clinical reasoning. Lewin and Reed have written a monograph on creative problem solving in occupational therapy. Finally, Creek provided an overview of creativity for occupational therapists working in mental health. While the aim of this research is the study of the phenomenon of creativity, the participants whose perceptions and meanings are explored are occupational therapists. This choice is for four reasons: (i) because there is an historical link between arts and crafts and occupational therapy practice; (ii) the use of creative activities as a therapeutic intervention is a controversial issue; (iii) occupational therapists are generally regarded, informally, by other health professions as being particularly creative; and (iv) there is a lack of occupational therapy research on what creativity means. The focus of this research therefore was the question: What meanings do occupational therapists give to creativity within their practice? RESEARCH DESIGN This small exploratory study was designed in the spirit of phenomenology (Crotty, 1996; Finlay, 1999). The data gathering and analysis was guided by van Manen s (1990) description of hermeneutic phenomenology, which includes attention to both terms of its methodology: it is descriptive (phenomenological) methodology because it wants to be attentive to how things appear, it wants to let things speak for themselves; it is interpretative (hermeneutic) methodology because it claims that there are no such things as un-interpreted phenomena (p. 180). In this study the result and discussion section of the paper details quotes from the participants and thus demonstrates that the participants speak for themselves. In addition, van Manen s method of thematic analysis was chosen in order to investigate recurrent themes within the descriptions of the meanings of the phenomenon of creativity. As well, the phenomenological research question of this study sought to understand the essential nature of the lived human experience (Hasselkus, 1995), the major characteristic of phenomenological methodology. The purpose of this research was to investigate the meaning of creativity with the possibility that a pattern and meaning would reveal various dimensions, meanings, forms and functions that have not yet been elucidated in occupational therapy. Sampling Purposeful intensity sampling (Patton, 1990) consisting of selecting information rich cases that manifest the phenomenon of interest was used. Van Kaam s (1966) method of selecting participants for the application of phenomenological method guided the sampling method in two ways. The first was by choosing subjects for the sake of phenomenon, not phenomenon for the sake of subjects (p. 328). Second, this study was guided by the view that the participants needed to have extensive experiences with creativity in practice. The use of phenomenology allows an in-depth exploration of a small number of participants (Sandelowski, 1995). Three participants were chosen whose reputations preceded them as being particularly creative in practice and who currently practise arts and creative activities. Their lived experiences in practice would best enable them to respond to the essential phenomenological question (van Manen, 1990; Crotty, 1996). An ethics proposal and application was submitted to the University of Newcastle s Ethics Committee and approved. Access to participants was made through the researcher s knowledge and contacts with practising occupational therapists in the local geographical area. A list of potential occupational therapists was generated and written invitations were sent to the first three. Those occupational therapists accepted the invitation. They were female, Australian, of Anglo-Saxon origin, and had an average of 18 years employment as practising occupational therapists. Demographic data of the participants is summarised in Table 1.

82 T. Schmid Table 1. Demographic data on participants Participants Age Gender Data gathering No. of years working as an OT Work setting Participant A 45 Female 18 Private rehabilitation Participant B 48 Female 26 Mental health Participant C 31 Female 10 Hospice The phenomenological orientation utilised a collaborative process involving interpretation through conversation (van Manen, 1990, p. 97). The conversations involved questions, answers and views about the phenomenon, with the conversation orientated to making sense of and giving meaning to creativity as it was experienced by the participants (van Kaam, 1966; van Manen). The final interview question ( Table 2) was included because while describing what was not creative, participants were able to give a more in-depth description of what was creative. Streubert and Carpenter (1995) and van Kaam (1966) suggested that soliciting negative descriptions of a topic is helpful in establishing authenticity and trustworthiness of the data. In addition, the intent of the critical component of the methodology (as discussed previously) was understood by the participants. While the topic and methodology was a new experience for them, they embraced the notion of questioning their meanings of creativity in the light of striving towards new meanings (Crotty, 1996). It was anticipated that the participants would be interviewed about three times. As suggested by Streubert and Carpenter (1995), van Kaam (1966) and van Manen (1990), the participants were given prolonged engagement with the subject matter. The interviews were approximately one hour and spread over a 7-week period. This Table 2. Sample interview questions What meaning do you give to creativity in your practice? What comes to mind when you think about creativity? Think over your practice today/this week as an occupational therapist and identify one or more experiences which involved creativity. It could be that you felt you instigated a new idea or approach. Describe that experience, including what you did, how you did it, what the outcome was and how you felt about it. Share all your thoughts, perceptions and feelings until you have no more to say about the experience. Can you describe a situation where you would feel that you were not creative in your work practice? allowed for dynamic and flexible processes of researcher, colleague and participant reflection, and dialogue with the participant for checking and rechecking the accuracy of the meanings ( Krefting, 1991). Each participant was involved in the study until the analysis arrived at a point where no further information was forthcoming (van Manen). One participant completed the descriptions in two interviews; two participants finished in three interviews. A field journal was kept throughout the study in order to detail the daily schedule and logistics of the study, log the research methods and procedures used, help the data reduction process, and reflect thoughts, feelings, ideas and hypotheses generated by contact with participants (Koch, 1994). The journal aided the recognition and subsequent bracketing of biases and preconceived assumptions, essential in the phenomenological method (Streubert & Carpenter, 1995). Handwritten notes made in the journal, tape recording and verbatim transcription aided the accuracy of the data (Jasper, 1994). The journal provided material and a description of method that could be audited by others (Krefting, 1991; Koch; Streubert & Carpenter) as a check of rigour within the research. Data analysis An important aspect of the data analysis was engaging in thematic analysis (van Manen, 1990) by viewing the transcript data. Every description which revealed a meaning of creativity (van Kaam, 1966) was highlighted and separated. To determine the universal or essential quality of a theme, the researcher isolated thematic statements from the transcript data by asking the following questions: What statement(s) or phrase(s) seem particularly essential or revealing about the meaning of creativity being described? Are there any phrases that stand out? There were 33 initial meanings of creativity identified ( Table 3). These were reduced and coded in consultation with a colleague and through checking with the participants. After completing executive summaries, consultation with a colleague, member checking and conducting the second interviews with the participants, the list was collapsed to five themes. These five themes were checked through discussions with a colleague and by referring back to analysis. FINDINGS AND DISCUSSION One of the five themes that emerged, Creativity needs a supportive environment, was not a meaning of creativity. Nevertheless, it was frequently raised and expressed as a

Creativity within occupational therapy practice 83 Table 3. Five themes derived from the initial meanings of creativity Initial meanings Goes by a different name; Rests on fundamental notions of OT; No formula; Personal beliefs; Problem solving; Aiming for new solutions/discoveries; Begins with the identification of something missing; Facilitating client s creative processes; Facilitating staff s creative processes; Used when baffled by what to do; Has a doing process; Need for a supportive environment for clients and staff; Risk-taking; Decisions on instigating a creative intervention depends on assessing the environment for safe risk taking. Within expressive arts, problem solving; Part of a process; Cannot take place without a supportive environment; Staff and clients both take risks. Trust, safety, support needs to be in the environment for risks to take place Immediate environment and wider context; Systems can stifle creativity; Effective creativity cannot take place without a supportive environment. Derived five themes Part of everyday practice Use of a conscious approach Risk-taking Creativity needs a supportive environment Use of expressive arts, Use of expressive arts as domain of OT; Clear aims for intervention; Exploring feelings and issues through creative media; Use of art as a prompt; Has a power/force; Has client self-discoveries; Has a doing process, going with the flow; Need for a supportive environment for staff; Involves risks for participants and risks for clients vital prerequisite for effective creativity. It is recommended that this area needs further research. The meanings of creativity for the participants are reflected in the descriptions of the other four themes which will be discussed in detail. Recommendations are included at the end of each theme. The following presentation of the findings is written with meaning being the key focus of analysis and is amplified by the participants quotes. Creativity is part of everyday practice All participants related that in their everyday practice they often used other words to describe creativity and that creativity was fundamental to occupational therapy philosophies in regard to the client therapist relationship. Another word is used The participants stated that although creativity had meaning in their everyday practice, they rarely use the word. Instead they tended to use the words adaptation, readaptation, innovation, problem solving and change. This critical reflection on the word creativity led the participants to explore new meanings and understandings of creativity in practice. However, the participants did not have a standard definition of what creativity means in practice; two participants did not feel that they had sufficient grounding in theory to discuss the word with confidence. For example, participant A: We wouldn t call creativity our basic philosophy but in fact, the process of problem solving and adapting and looking at new ways of doing things is creative by nature, isn t it? There is substantial occupational therapy literature on adaptation, a key concept in occupational therapy practice (Bruce & Borg, 1993; Finlay, 1993; Hagedorn, 1995, 1997; Miller, Sieg, Ludwig, Shortridge & Van Deusen, 1988; Kielhofner, 2002). However, while adaptation does seem to be linked with creativity (Rogers & Dodson, 1988), occupational therapy literature has not made this connection. Although Hasselkus and Dickie (1990, pp. 199 200) have used the words sense of inventiveness, and the sense of initiative to describe creative behaviour in occupational therapy practice, further identification of the meanings attributed to creative behaviour would seem to be warranted. Creativity is linked to occupational therapy assumptions All participants attributed creativity to fundamental humanistic occupational therapy philosophies (Hagedorn, 1997) (e.g. assisting clients to reach their full potential;

84 T. Schmid every client is unique, therefore within different environments, at different times a different solution needs to be found) which they applied daily in their practice. For example, Participant B: there s so many other parameters we have to consider to come up with a solution for an individual that it s very difficult to just embrace a whole lot of descriptive procedures that tell you what to do. You ve got to create things every time, because this time, with this individual it is going to be different from another individual. These meanings appear to be connected to notions of what makes an expert occupational therapist, and the artistic dimension of practice (Mattingly & Fleming, 1994; Rogers, 1983, p. 614). This raises the possibilities that creativity could be explored further in relation to these notions and the philosophies of practice embedded within them. The use of creativity as a conscious approach In searching for meanings of creativity, all participants discovered that they consciously chose a creative approach in their everyday practice which was reflected in their behaviour, their clinical reasoning, and their selection of an occupational therapy intervention. Creative behaviours All participants meanings associated with creativity in practice revealed an intentional application of a special way of thinking or problem-solving. Problem solving was described in the context of clinical reasoning, with the aim to come up with new solutions to a problem or issue, or to set goals that had not been set before. In addition, the designing of equipment, the development of new programs and being engaged in creative approaches with interdisciplinary team members were identified as creative behaviours. Creative thinking The meaning of creativity as a conscious approach in problem-solving has been explicated substantially in other fields of study and is commonly called creative thinking or lateral thinking (Stein, 1974; Glover, Ronning & Reynolds, 1989; Mayer, 1989; De Bono, 1992; Weisberg, 1992; Smith, Ward & Finke, 1995; Jay & Perkins, 1997). Over the last 20 years occupational therapy literature on problem solving has slowly emerged. It is identified as fundamental to occupational therapy practice, and links have been made to the process of creative reasoning (Graham, 1983; Mattingly & Fleming, 1994; Hagedorn, 1995; Lewin & Reed, 1998). Graham presented a model for creative problem solving and creative analysis skills in undergraduate occupational therapy programs. Hagedorn (1995, p. 162) perceived a particular form of clinical reasoning used in occupational therapy which she termed intuitive-creative-qualitative-phenomenological thinking. Likewise, Mattingly and Fleming (1994) described at length conditional reasoning as a particular form of occupational therapy clinical reasoning using terminology, which current researchers in the field of creativity would regard as a description of creative behaviour and thinking. Lewin and Reed (1998) have more recently published a monograph on creative problem solving in occupational therapy. The creative process The participants illustrated that they undertook a creative process in working with their clients in therapy. For example, Participant A: It involved a process, it was the process I adopt because I really thought, What am I going to do with this woman? So I thought, We ll just take the creative approach and see where things go and take a few risks if we need to All participants described the initial stages of a creative process in therapy by identifying the sense that something was missing. For example, Participant C in her description of choosing expressive art in therapy as an intervention said: it was like they [the clients] were screaming at you, I ve got this stuff in here [C points to her mid-chest], but our program was saying, Keep it there, thanks, we re not here to look at that, or We re not interested, and I didn t feel it was equal So I saw it as a tool that could get people in touch with other sorts of feelings or feelings that they can t express any other way. This identification of something missing could be explained as being the first insight stage of the creative process (Edwards, 1986). The description above resembles the meaning identified by Hasselkus and Dickie (1990, p. 199) as a sense of initiative. Participant A described her creative approach as involving: going with the flow, empowering people to think by saying to clients well, I think you ve got some ideas of your own of how you can get over that problem and I see that as a creative process. The use of expressive art (drawing and painting) in therapy as a tool was described as often being used to facilitate creative thinking in clients. This portrayed the notion that the clients also underwent a creative process. For example, Participant A: But I think the creative part in her was looking at some aspects of things that she hadn t explored before or hadn t set the goals.

Creativity within occupational therapy practice 85 Psychology literature explicates creativity in therapy. The work of Zinker (1977), a psychotherapist, linked the creative process to personal change and hence to therapy, for therapy is a process of changing awareness and behaviour (p. 5). The work of Maslow (1974) and Zinker strongly argues that creativity and therapy are interconnected at the fundamental levels of transformation, metamorphosis and change. As yet there is little specific occupational therapy literature (Finlay, 1993; Breines, 1995; Denshire, 1996 being the exceptions) on the use of choosing a creative approach to facilitate a client s creative process nor on the concurrent experience of therapists and clients undergoing a creative process. All of the above sub-themes of creativity as the use of a conscious approach (Borg & Bruce, 1997, p. 7) appear to have connections to the concepts the therapeutic relationship (Bruce & Borg, 1993, p. 17), notions of the art of occupational therapy practice (Rogers, 1983) and Therapy is very much a process of creating an experience (Mattingly & Fleming, 1994, p. 132). It is recommended that these connections demand further research, which may explicate the notion that occupational therapists function creatively. Creativity involves risk-taking All participants described risk-taking as a fundamental element of the therapeutic relationship for themselves and the client. Risk-taking was seen to be intrinsic to new ideas and solutions, and required the provision of a trusting, safe, and supportive environment for their clients. They implied that without this, risk-taking would not take place. For example, going with the flow threw open the possibilities of risk because the process and direction of the intervention were unclear. Participant A: That s the whole thing about creativity you don t necessarily know where it s going to lead you. But that s how the process works so it s creative for me, too, because I m always learning something else taking risk with your own experience in general. Risk-taking is mentioned in literature and is often tied to notions of the therapeutic relationship (Bruce & Borg, 1993, p. 13; Borg & Bruce, 1997, p. 7). It has been suggested that risk-taking is a notion that also seems to be implicit within occupational therapy practice and referred to as client adaptation, or client making changes. In this process new skills and behaviours are learned. Research into the current use of occupational therapy terminology and its various meanings could be worthwhile in making explicit the role of a supportive environment in risk taking in order that the client can make changes. Creativity is the use of expressive arts in therapy The three participants discussed various aspects of the therapeutic use of creative activities. The use of creative activities in therapy were viewed as legitimate tools of practice. The doing aspect of the activities was regarded as therapeutic. The creative activity itself was viewed as having a life of its own (which was therapeutic in its own right). The clients made important self-discoveries as a result of being involved in creative activities. The domain of occupational therapy Creativity as the use of expressive arts held an influential place in all participants narratives. For example, Participant B related: I think as occupational therapists certainly we ve got some claim to utilising creative media, and in that context I m talking about the arts and exploring things in ways that aren t just based on verbal expression utilising those other creative media that give meaning to our lives and extend vision and different ways of viewing our lives. All participants strongly identified expressive arts as part of occupational therapy practice in psychiatric settings, a position which they attributed to their undergraduate training. The most illuminating and detailed meanings of creativity came from the direct experience of two participants (Participants A and C) who use expressive arts, drawing and painting in a hospice setting and in a pain management program in a general rehabilitation setting. Throughout conversations about this theme, all participants revealed a critical reflection upon the meanings of creativity they received within their occupational therapy undergraduate training. For example, Participant C wondered about the struggles she had in instigating expressive art in therapy outside a psychiatric setting: I wonder if a lot of it comes back to the old fight we had as OT students I trained in the transition period where in my training we did no craft work, not a bit. The crafts and art were chucked out and they threw the baby out with the bath water and there has been a bit of a struggle to say that craft is valid. The doing of the expressive arts was meaningful Two participants indicated that the most significant meaning of creativity lay in the actual doing of the expressive art. The doing seemed to be associated with the words creative process, and a go with the flow approach. There was a strong emphasis on risk-taking being a vital part of the process for the therapist and client.

86 T. Schmid Participant A: this is really scary. I have no idea how this is going to work, but let us see what happens It s sort of exciting, that you re not quite sure where it s going to you don t know how people would respond felt comfortable with using art and I felt comfortable with the people but I hadn t explored this issue specifically. Even though we d talked about it before, I hadn t set out to say, let s have a group looking at the issue of hope and inner strength The activity has a life of its own Two participants claimed they did little to direct the clients in the actual doing of the expressive arts. For example, Participant A: and that was with no prompting from anyone, just people coming to their own realisation in this situation it was just discovering a new way of viewing themselves in these circumstances they hadn t before. This lack of prompting implied that the therapist let go of their control of the process and allowed the efficacy of the expressive arts media to take over. Client self-discoveries Two participants attributed potency to the use of expressive arts and related that at the end of an intervention, clients were often surprised with their self-discoveries. To the participants, this signified the effectiveness of the intervention. Participant A: I ve seen its power You just get the vibes, I can t explain it people [clients] then wanted to follow it on at the end of the group Participant C: It was like opening a door to me it just blew me away the force of it took me by surprise people [clients] just blossomed in a one-hour session and I guarantee you I [got to] know more about those people in that one-hour session than any of us do in the other two weeks and it still blows me away after two years. it pours out, it pours out it s their energy it s their thoughts, it s their emotions it s all the stuff that they can t just talk out. Participant C: generally what they [the clients] say about their painting and their pain and what it s like now for them is pretty spot on. Participant A (relating client conversation): this is really good. Yeah, this is interesting, that it can change, you know, help me look at things differently. While some occupational therapists are deeply involved in creative processes, occupational therapy research into the theories of creativity has fallen behind the research of therapists in the professional fields of music, art and recreation (Price, 1993). It is recommended that the occupational therapy profession investigate a theoretical framework for creative activities and processes. In addition, it is recommended that research be undertaken to re-establish the links of knowledge and research between occupational therapy and the expressive arts speciality therapies. Limitations More meanings for creativity within the context of occupational therapy may have been disclosed by a larger number of participants with a wider age range. That does not negate the usefulness of the research outcomes. CONCLUSION In this study the participants have removed some of the mystique from the word creativity. The existence of the phenomenon of creativity in occupational therapy was found to be multifaceted. The participants related that creativity was a difficult concept to define, and other words were used to describe creativity. However, new meanings of creativity were identified by the participants, revealing various components of the phenomenon of creativity: adaptation; innovation, change, first insight; going with the flow; risk-taking; creativity has a life of its own (in other words, creativity generates more creativity). These words and ideas can be employed in practice and teaching. They could be used to assist students and therapists in ways in which they could take creative action. The more light we shed on creativity, the more therapists will use it, the more success they will have with it and the more they will enjoy it. The participants described creativity as being part of everyday life, and under a variety of guises, a conscious part of problem-solving and risk-taking. All three said that in order for creativity to flourish there needed to be a supportive environment; they identified aspects of using creative activities in therapy. This study revealed many interpretations of creativity in practice that are not displayed in the occupational therapy literature. In conclusion, creativity was a difficult subject to research, with little occupational therapy literature on one hand and on the other hand, a wealth of literature from other fields. There was a sense that the dearth of literature on creativity in the occupational therapy profession is a

Creativity within occupational therapy practice 87 denial of its own history. It would be significant to adopt a more substantial perspective and language for creativity within occupational therapy practice. Further research is recommended to make the outcomes useful in practice. ACKNOWLEDGEMENTS I would like to thank the three participants who willingly reflected on their practice, Christine Boerema who supervised this study, and Sue Hunt and Trish McLaine from the School of Occupational Therapy at the University of South Australia for their comments on an earlier draft of this paper. REFERENCES Atkinson, K. & Wells, C. (2000). Creative therapies: A Psychodynamic approach within occupational therapy. Cheltenham, UK: Stanley Thornes. Barris, R., Cordero, J. & Christiaansen, R. (1986). Occupational therapists use of media. American Journal of Occupational Therapy, 40, 679 684. Bissell, J. C. & Mailloux, Z. (1981). The use of crafts in occupational therapy for the physically disabled. American Journal of Occupational Therapy, 35, 369 374. Borg, B. & Bruce, M. A. (1997). Occupational therapy stories: Psychosocial interaction in practice. Thorofare, NJ: Slack. Breines, E. B. (1995). Occupational therapy activities from clay to computers: Theory and practice. Philadelphia: FA Davis Co. Bruce, M. A. & Borg, B. (1993). Psychosocial occupational therapy: Frames of reference for intervention. Thorofare, NJ: Slack. Creek, J. (1997). Occupational therapy and mental health (2nd ed.). New York: Churchill Livingstone. Crotty, M. (1996). Phenomenology and nursing research. Melbourne: Churchill Livingstone. De Bono, E. (1992). Serious creativity. New York: Harper Collins. Denshire, S. (1996). A decade of creative occupation: The production of a youth arts archive in a hospital site. Journal of Occupational Science: Australia, 3, 93 98. Dickerson, A. & Kaplan, S. H. (1991). A comparison of craft use and academic preparation in craft modalities. American Journal of Occupational Therapy, 45, 11 17. Du Toit, V. (1991). Patient volition and action in occupational therapy. Hillbrow, South Africa: Vona & Marie du Toit Foundation. Edwards, B. (1986). Drawing on the artist within. London: Harper and Collins. Eliason, M. L. & Gohl-Giese, A. (1979). A question of professional boundaries: Implications for educational programs. American Journal of Occupational Therapy, 33, 175 179. Finlay, L. (1993). Groupwork in occupational therapy. London: Chapman & Hall. Finlay, L. (1999). Applying phenomenology in research: Problems, principles and practice. British Journal of Occupational Therapy, 62, 299 306. Glover, J. A., Ronning, R. R. & Reynolds, C. R. (1989). Handbook of creativity. New York: Plenum Press. Gohl-Giese, A. & Eliason, M. L. (1986). Changes in the frequency of use of occupational therapy modalities from 1978 to 1985: Educational implications. In: The American Occupational Therapy Association s occupational therapy education: Target 2000 proceedings (p. 149). Rockville, MD: American Occupational. Therapy Association. Graham, J. (1983). Occupational therapy: Is it the creative problem solving process which the profession claims? Australian Occupational Therapy Journal, 30, 89 102. Hagedorn, R. (1995). Occupational therapy: Perspectives and processes. Edinburgh: Churchill Livingstone. Hagedorn, R. (1997). Foundations for practice in occupational therapy. (2nd ed.). London: Churchill Livingstone. Hasselkus, B. R. (1995). Beyond ethnography: Expanding our understanding and criteria for qualitative research. Occupational Therapy Journal of Research, 15, 75 84. Hasselkus, B. R. & Dickie, V. A. (1990). Themes of meaning: Occupational therapists perspectives on practice. Occupational Therapy Journal of Research, 10, 195 207. Jasper, M. A. (1994). Issues in phenomenology for researchers of nursing. Journal of Advanced Nursing, 19, 309 314. Jay, E. S. & Perkins, D. N. (1997). Problem finding: The search for mechanism. In: M. A. Runco (Ed.). The creativity research handbook (Vol. 1, pp. 257 293). Cresskill, NJ: Hampton Press. Kielhofner, G. (2002). A model of human occupation. London: Williams & Wilkins. Koch, T. (1994). Establishing rigour in qualitative research: The decision trail. Journal of Advanced Nursing, 19, 976 986. Krefting, L. (1991). Rigor of qualitative research: The assessment of trustworthiness. American Journal of Occupational Therapy, 45, 214 222. Lewin, J. E. & Reed, C. A. (1998). Creative problem solving in occupational therapy: With stories about children. Philadelphia: Lippincott. Maslow, A. H. (1974). The farther reaches of human nature. New York: The Viking Press. Mattingly, C. & Fleming, M. H. (1994). Clinical reasoning: Forms of inquiry in a therapeutic practice. Philadelphia: FA Davis. Mayer, R. E. (1989). Cognitive views of creativity: Creative teaching for creative learning. Contemporary Educational Psychology, 14, 203 211. Miller, B. R. J., Sieg, K. W., Ludwig, F. M., Shortridge, S. D. & Van Deusen, J. V. (1988). Six perspectives on theory for the practice of occupational therapy. Rockville, Maryland: Aspen. Patton, M. (1990). Qualitative evaluation and research methods (2nd ed.). Newbury Park: Sage. Price, S. (1993). New pathways for psychosocial occupational therapists. American Journal of Occupational Therapy, 47, 557 559. Reilly, M. (1962). Occupational therapy can be one of the great ideas of the 20th century medicine. American Journal of Occupational Therapy, 16, 1 9. Rogers, J. C. (1983). Clinical reasoning: The ethics, science, and art. American Journal of Occupational Therapy, 37, 601 616. Rogers, J. C. & Dodson, S. C. (1988). Burnout in occupational therapists. American Journal of Occupational Therapy, 42, 787 792. Runco, M. A. (1997). The creativity research handbook (Vol. 1). Cresskill, New Jersey: Hampton Roads Publishing Co.

88 T. Schmid Sandelowski, M. (1995). Focus on qualitative methods. Sample size in qualitative research. Research in Nursing and Health, 18, 179 183. Smith, M., Ward, T. B. & Finke, R. A. (1995). The creative cognition approach. Cambridge: Bradford. Stein, M. I. (1974). Stimulating creativity (Vol. 1 and 2). New York: Academic Press. Sternberg, R. J. (1988). The nature of creativity. Contemporary psychological perspectives. Cambridge: Cambridge University Press. Streubert, H. J. & Carpenter, D. R. (1995). Qualitative research in nursing. Philadelphia: J. B. Lippincott Co. Taylor, E. & Manguno, J. (1991). Use of treatment activities in occupational therapy. American Journal of Occupational Therapy, 45, 317 322. Thompson, M. & Blair, S. E. E. (1998). Creative arts in occupational therapy: Ancient history or contemporary practice? Occupational Therapy International, 5, 49 65. van Kaam, A. (1966). Existential foundations of psychology. Garden City, NY: Image Books. van Manen, M. (1990). Researching lived experience. New York: State University of New York Press. Weisberg, R. W. (1992). Creativity. Beyond the myth of genius. New York: W. H. Freeman. Wijers, L. (1996). Art meets science and spirituality in a changing economy: From competition to compassion. London: Academy Editions. Wilcock, A. A. (2001). Occupation for health, 1: A journey from self help to prescription. London: British Association and College of Occupational Therapists. Zinker, J. (1977). Creative process in gestalt therapy. New York: Brunner/Mazel, Inc.