Tuesday, September 09, 2014

Basic vs. applied science: The ongoing OT and OS debate


 Over the course of the last several years an important professional debate about social justice has been occurring in the occupational therapy profession.

That actual debate started innocently by a student who posted a question in the Public Forums on OT Connections who was interested in conversation about an RA motion to remove Social Justice from the AOTA Code of Ethics.  That student disagreed, stating that she did not think that Social Justice represented a single political philosophy and that it should not be removed.

Some leaders in the occupational therapy community voiced their support of the student's position, stating that social justice is not reflective of a singular political ideology and should not be re-framed as such.  There was near immediate disagreement, with other AOTA members expressing that it does represent a single political ideology.

The basis of the eventual RA vote that supported inclusion of Social Justice was made on the questionable premise that Social Justice does not represent a single political ideology.  In the ensuing years of debate a lot of evidence has been provided to counter that premise.  The new draft of the AOTA Code of Ethics removes the term 'social justice' but many of the constructs remain embedded within the document.  That document remains in revision and feedback is still being collected.

I am prompted to write this reflective summary because I believe that a new level of evidence about the nature of Social Justice has been revealed, although it is unfortunate that this evidence is not in the public OT Connections forum where the debate has continued for several years.  The evidence about the political nature of Social Justice as it relates to occupational therapy is evident in a discussion thread of the International Society of Occupational Science.

The ISOS group is an essentially open membership organization that is virtually organized and focused on enabling international communication between people who are interested in occupational science.  Many of the members and leaders within the ISOS organization are occupational therapists, but certainly not all of them are.  Many of the members and leaders of the ISOS organization are also members of the Society for the Study of Occupation: USA.  As such, many of the ISOS participants are leading academics for American-based occupational therapy.

Unfortunately, while the debate about Social Justice occurred on the open OT Connections forum, there was not broad participation by the OT Academic community or the membership itself, for that matter.  Underlying the OT Connections debate there have been several themes.  Some who opposed Social Justice did so more from a basis of political opposition to the concept.  Some did so more from a basis of concern about applicability of the Social Justice and other occupational science concepts to the applied field.   Some had a combination of concerns.

The challenge in the debate has been a lack of participation and most certainly not a lack of substance.

In August 2014, the ISOS group started a discussion thread entitled "Developing occupational science as a critical and socially responsive discipline: challenges and opportunities." The following information is available on their website and is quoted directly:



"Occupational science appears in a crucial moment of its development, characterized by an increasing awareness of issues of inequity and injustice, and calls to further embrace diversity, situatedness and critical reflexivity. Overall, there appears to be a call for occupational science to become a more critical and socially responsive discipline, and increased attention has been focused on topics such as: how certain occupations are promoted by social policy discourses that reinforce structures of domination, how ideologies underlying certain occupations create and perpetuate occupational injustices, and whether occupational science has a responsibility to address social justice, humanitarism and human rights."


Certainly, occupational science is NOT occupational therapy, but one of the expressed purposes of the science was to inform the occupational therapy profession.   However, we now have a basic science that is interested in "expand[ing] the understanding of occupation and enhance the social relevance of the discipline, particularly as issues of occupational inequity and injustice are increasingly fore- fronted in local to global socio- political contexts."

The content of the discussion is based on the a priori assumption of "how can occupational science move forward in its development as a socially and politically engaged discipline?"  Responses from forum participants in the ISOS context are entirely political, including open embrace of Marxism, promotion of Nussbaum's Capabilities Approach, and a strong interest in interpretation of occupation through the lens of socialistic political interpretations of economies and power distribution.  In short, the ISOS discussions represent a unidimensional political agenda.

It is unfortunate that the proponents of occupational science were not willing to commit to a public and open conversation about this on the OT Connections website.  A lot of discussion about the political aims of Social Justice could have been avoided if we had more participation from those Academics who were proponents of this politicization.

So the facts are very clear, and those facts are that Social Justice does reflect a particular political ideology and represents a unidimensional world view on the political nature of occupations.

This leaves some members who stated that Social Justice is apolitical in a position where they need to explain their statements.  It may be very possible that some of those members were simply unaware of the political nature of the Social Justice construct.  Even a cursory review of the ISOS discussion will provide evidence to refute those claims.

As a final point, the occupational therapy profession needs to move forward.  There are several important issues that are on the table:

1. Will we re-affirm our Core Values or will we follow a handful of international Academics into a New Model of justice-based and rights-based ethics?

2. Will we take steps to revise our Code of Ethics to reflect pragmatic concerns of practice?

3. Will we expend occupational therapy resources on a basic occupational science that is not responsive to actual practice concerns and seems focused on promoting a political philosophy?

4. Will we create, nurture, and promote conversations where we have HONEST DIALOGUE about the very nature of these concerns?

The OT Connections forum and the ISOS forum should serve as a reflection point for those who wish to identify as 'occupational scientists' and those who wish to identify as 'occupational therapists.'  It is evident in these conversations that the concern about basic vs. applied science is far from over.

I would like to close this with a quote from Dr. Gary Kielhofner, who I believe presciently identified our current problem and explained his concerns when discussing the purpose of some of his final work:


This current volume was inspired by my increasing concern  that the pendulum has swung too far in the opposite direction.  It was greatly influenced by a concern that the field, in its eagerness to develop a science of occupation, may be leaving behind or forgetting the "therapy" in occupational therapy.



References:

(direct links above)

Kielhofner, G. (2009). Conceptual Foundations of Occupational Therapy Practice, 4th ed.  F.A. Davis: Philadephia.



Background reading:

 The 2011 Social Justice Debates in Occupational Therapy
Social Justice Follow Up: Brass Tacks for the Occupational Therapy Profession
Social Justice: What Would Dr. Kielhofner Say?
Emmanuelism Provided the Core Values to the Developing Occupational Therapy Profession
Patient vs. Client - What Could Go Wrong?  Look Around and See...



Friday, August 29, 2014

Patient vs. Client - What could go wrong? Look around and see...

Thirty years ago there was an important philosophical debate in the occupational therapy profession.  That debate had to do with whether or not use of the term 'patient' or 'client' was more appropriate for occupational therapy.

Reilly argued that a move away from the term 'patient' would equate to abandoning the moral base of the profession and in fact changes the entire purpose of the profession.  She considered the change as abandonment of our ethics around patient care, and without those ethics we would no longer be in a position to help people because we would instead have to focus on contractually serving the needs of our patron clients.

Yerxa and Sharrott were also deeply concerned about abandoning patient-based ethics.  They outlined several problems with client-based ethics (my numbering for organization purposes):

1. A legalistic or rights-based medical ethic is untenable for several reasons. First, it would require that requests for medical care be allotted on a preemptory basis...

2. Second, the patient-health professional relationship would forfeit its compassion and trust for the adversarial relationship of legal ethics.

3. Third, a right holder (in this case the client) must be a competent adult capable of self-directed choice, with adequate understanding of the provider's knowledge.  However, the recipient of health care often is not capable of an equal relationship.

Their prescience is actually quite incredible in consideration of where we currently stand in our health care context.  Yerxa and Sharrott warned about client-based ethics:

This could result in a normative, restrictive view of health, which robs patients of their liberty. The patient's role in developing goals pertinent to his or her concerns- and not necessarily consistent with those generated by health practitioners - could be adversely affected.

We are now living out the warnings that were given to us thirty years ago.  Here is evidence of our philosophical drift where we no longer have an ethical rudder:

1. Social justice, also termed distributive justice, was inserted into the Code of Ethics and occupational therapists were told it is a MUST FOLLOW rule (Slater, 2011).  We have been told that we must advocate for the highest principles of social justice, which relegates professionals into the role of determining who has 'more' or 'less' in order to guide advocacy and decision making.

2. Some within the occupational therapy Academy take it a step further, and actually promote radical change to rights-based ethics based on a new morality of resource distribution.  Autonomy is simply lost in this new ethic, a fact pointed out by Durocher (2014).

3. As a practical example, in pediatric practice occupational therapists now provide services to SCHOOL SYSTEMS instead of CHILDREN and the professional association promulgates resource allocation and staffing based on WORKLOAD instead of a CASELOAD (AOTA, APTA, ASHA, 2014).  There is no patient morality here and in fact this is the deepest example of how we have lost our professional souls in service to the municipal patrons that govern the educational system.

There is a beginning of an awakening to this as a problem.

Some therapists are championing a debate about the appropriateness of social justice as a guiding ethic.

Some therapists are questioning whether or not occupational science as a discipline has any authority to dictate a new morality that shatters the social contract that occupational therapy has with the public.

Thirty years ago Mary Reilly stated

In the history of our discipline there is probably no more important policy decision than this one, which changes the focus of service from patient to client. The astounding aspect of the decision is not that it was made, but that it was made outside the awareness of most of the membership.  Because this policy forces a radical transformation of the nature of occupational therapy, it threatens the survival of the discipline.  A greater danger, however, lies in the disinterest or lack of attention the membership has paid to the issue... It is both an individual and national association shame that occupational therapists do not seem to know how and when to engage in a public debate on an issue so critical to the membership and the society in which the service is embedded.

Many people missed the opportunity to engage the debate thirty years ago.  The new debate on our Code of Ethics and on promoting a rights-based service ethic is dragging us further off the path that represents our social contract based on our founding moral philosophy.

Don't miss the chance to participate this time.  Join these debates.  Read, discuss, and engage the issue.  The future of the profession depends upon it.


References:

AOTA, APTA, ASHA (2014). Workload approach: A paradigm shift for positive impact on student outcomes.  Downloaded 8/29/14 from http://www.aota.org/-/media/Corporate/Files/Practice/Children/APTA-ASHA-AOTA-Joint-Doc-Workload-Approach-Schools-2014.pdf

Durocher, E. (2014). Occupational Justice: Future Directions.  Journal of Occupational Science, 21:4, 431-442.

Reilly, M. (1984). The importance of the client vs. patient issue for occupational therapy. American Journal of Occupational Therapy, 38(6), 404-406.

Slater, D.Y. (Ed.). (2011) Reference guide to the occupational therapy code of ethics and ethics standards. Bethesda: AOTA Press.

Yerxa, E.J. & Sharrott,G.W. (1985). Promises to Keep: Implications of the referent "patient" versus "client" for those served by occupational therapy.  American Journal of Occupational Therapy, 39(6), 401-405.

Monday, August 04, 2014

Comments re: recent RCT on sensory integration


I received several emails asking me about the dialogue that was recently published in the Journal of Autism and Developmental Disorders regarding the Schaaf, et. al (2013) study.  A kind colleague forwarded the comments to me and I had the chance to review them.

Ashburner, Rodger, Ziviani, and Hinder (2014) made some comments about the original research.  They basically outlined concerns with the parent report measures, lack of blinding, and confounding impact of invested time for the parents.  They also expressed concerns with dosage and non-equivalent treatment conditions between groups. 

The original authors (Schaaf et al, 2014) thanked them for their comments and expressed that a treatment manual would be published later this year that might help others replicate the interventions.  They also expressed that they are following a step-wise method of progression from case study to feasability study to RCT.  They state that future studies will address some of the concerns raised.  The authors defended the non-blinded and non-equivalent design, stating that using blinded evaluators was enough to address concerns and that treatment effects were large.

The concerns raised by Ashburner, Rodger, Ziviani, and Hinder are very similar to what was posted in this blog in December, right after the original study was published.  There really are not any new concerns.  Now they are just formally published concerns.

As I indicated in December, if there are true differences to be measured because of sensory integration treatment we will find them after we design studies that are not so vulnerable to criticism.  I blogged about the design as soon as I read it because the problems seemed rather obvious.  The fact that a group of academics and researchers bothered to write formal comments to the journal would seem to validate the concerns.

References:


Ashburner, J.K., Rodger, S.A., Ziviani, J.M., Hinder, E.A. (2014). Comment on "An intervention for sensory difficulties in children with autism: A randomized trial by Schaaf et al. (2013)." Journal of Autism and Developmental Disorders, 44, 1486-1488.

Schaaf, R. et al (2013). An intervention for sensory difficulties in children with autism: A randomized trial. Journal of Autism and Developmental Disabilities, published online at http://link.springer.com/article/10.1007%2Fs10803-013-1983-8/fulltext.html

Schaaf, R. et al (2014).  Response from authors to comments on "An intervention for sensory difficulties in children with autism: A randomized trial."  Journal of Autism and Developmental Disorders, 44, 1489-1491.

Wednesday, July 30, 2014

Do we need more schooling, or just re-tooling?

In a conversation on the OT Connections Forum Dr. Pam Toto stated "These other professions - PT, Pharmacy, Nursing - whether you think they are comparable or not, have evolved to a point where they feel a need for that additional training for competent entry-level practice."

I think these comments are interesting.  Dr. Toto is not the first to make these kinds of observations.  Others have stated that we need to prepare practitioners for the complexity and demands of the future.'  I have been wondering what that really means.

First of all, I would like to acknowledge that in some instances our practice tools have gotten more complex.  I can think of a few examples.  It would not surprise me if pediatric standardized tests were more complex than they were when our profession was founded.  I am actually wondering if any even existed!  I think that you could make a strong argument that splinting and prosthetics have also gotten more complex.  Of course we can say that our health care delivery systems are also more complex, although those are not practice tools.  There are other examples, but I think those are good ones where we can say that some things have gotten more complex over time.

The question to me is whether or not the practice tools and systems that have gotten more complex have hit some critical level of complexity that we can justify a need for more training or schooling.

Even if they are non-parallel examples, lets look at nursing and medicine.  Let's compare professions at the time of our founding (~1917) to today.

In the early 1900s here are 5 things that were in use that illustrate the sophistication of medicine at that time:
1. Mrs. Winslow's Soothing Syrup - a heroin concoction used for teething babies for over 50 years, finally denounced as a "baby killer" by the AMA in 1911.
2. Doctors began experimenting with lobotomies at this time, and they became increasingly common and it was as recent as 1949 Nobel Prize in Medicine was given to the originator of the procedure.  Amazing.
3. "Female Hysteria" was a very common condition and the some of the recommended "treatments" are not suitable for discussion on this board.  Trust me.
4. Mercury as a cure-all!  Mercury was used for everything.  People realize how insane the use of mercury was now, but even I remember Mom's bottle of Mercurochrome that was pulled out and used as an antiseptic every time we got a cut or scrape.  Maybe that is what is wrong with me?
5. No antibiotics!  Lots of people had tuberculosis.  Effective TB antibiotics didn't appear until 1949 with Streptomycin.

Even based on these simple examples we can see how much change has occurred in medicine in the last century.  The few things I listed don't even come close to more recent scientific advances like understanding blood chemistry, development of imaging diagnostics, and the explosion of genetic knowledge and how that has accelerated our understanding of diseases and pharmacology.  There is no question that medicine as a field has lots of reason to state that higher levels of training are needed in order to keep pace with needs of the future, whatever those are.



But what about occupational therapy?  Has it also changed?

++

As comparison, I would like to quote from Elwood Worcester's recounting of his first "treatment" session with George Barton.  As we now know, Barton was so astounded by his recovery that this sparked the creation of our profession when he invited other leaders to form a society for occupational therapy.  Here are Worcester's comments:

"While engaged in erecting a great sanatorium for consumptives in the mountains of Colorado, he was suddenly affected in a strange manner... When he awoke the next morning his right arm was paralyzed... his right knee was ankylosed... In consequence of his constrained and unnatural position the right foot had begun to mortify and Dr. Mumford had amputated two of his toes.  When I first saw George he was in the spiritual condition of a mad dog... He said "What is the use of talking to me?  My life is utterly ruined, my health, my power of movement, my beautiful profession, my wife and child, my home, my capacity for earning money are taken from me.  All that is left for me is to sit in this chair, a beggar, a pauper and to suffer like hell..."

Using a combination of spiritual counseling, relaxation techniques, and suggestion, Worcester "treated" Barton.

"If this were all, the story would hardly be worth telling.  The next time I saw George he was in Boston.  He ran up my stairs two steps at a time and seized my hand with his once paralyzed hand in such a blacksmith's grip that I was obliged to remind him that I had no fingers to spare.  He was perfectly able to return to his architecture, but by this time he had discovered a new form of architecture which he greatly preferred to the old - building up again the broken lives of men and women who were suffering as he had suffered, under the eye of Dr. Mumford and the physicians of Clifton Springs.  With the help of a few rich friends he built his "Consolation House" and equipped it with splendid workshops where, through the sweetness of his new personality, and his knowledge of crafts and arts, he did a wonderful work for years."

++

What impresses me about this early accounting of OT is that it even though it happened in 1914, it could have happened in 2014.

This makes me pause whenever I hear people saying that the occupational needs of people have changed and are changing so radically.  I don't know if that is really true.  Although some tools and systems change, the fundamental nature of occupational therapy does not.  In this sense it is nothing at all like medicine.  Medicine has changed.  Has occupational therapy?  In many ways we understand occupational needs the same way that Worcester did and the same way that Barton did.

So do we need more schooling, or just re-tooling?


References:

Worcester, E. (1932). Life's Adventure: The Story of a Varied Career.  New York: Charles Scribner's Sons.

Wednesday, July 09, 2014

Witness

I sat on the witness stand, about 20 feet away from the parents that I had known and worked with for the last five years, and did my best to answer the Judge's questions as accurately as possible.  I think that I was more uncomfortable than the parents were and they did not seem to have any ill will and did not seem to be upset about my testimony.  They knew that I was just telling the truth, I think.

I told the Family Court Judge that I knew the family for several years because several of their children had been assigned to me for early intervention occupational therapy.  I was asked about one of my therapy sessions on a specific date and I told the Judge that as I sat and played with the child the fleas were jumping out of the carpet and onto little Jenna's legs.  And onto my socks and pants.  Jenna's legs were covered with bites and streaked blood from all the scratching.  The week prior to that session I taught the parents how to use commercially available 'flea bomb' products safely in order to address the problem.  It seemed to work for a day or two, but they had difficulty getting all the fleas and eggs vacuumed up.  I spent part of one of my therapy sessions repairing their vacuum cleaner that was clogged and had a broken belt so they could vacuum, but I think that was part of the reason why the flea problem persisted.  The fleas were just everywhere, and the problem probably needed to be solved with a professional exterminator.  I know it was not my job to fix a vacuum but I was trying my best to help.  I had some small fear that I would be criticized for stepping outside of my role in taking that action.  They don't often talk about this kind of stuff in OT school, which is a shame, because it is a reality.

The family sat there, unphased by my testimony.  It was all true, and I tried to help them.

I explained that at one point in time a municipal social worker determined that the children needed to be removed from the home, so the children were sent to another family except for the baby, who the County allowed the parents to keep.  I worked with little Jenna and she thrived in her new home and with her new family.  The fleas were really just a tipping point that activated a system.  Although I believe that the parents loved their children they did not have the resources to care for them.  They did not have the knowledge, capacity, understanding, or money.  In some bizarre bargaining session between County officials and the parent's appointed lawyers and the children's Law Guardians, the children were traded back and forth like poker chips, and the parents decided to relinquish custody of the older children if they were able to keep the baby.

After the Court decision and the change of custody it was a challenging situation to navigate.  I knew the family for several years, and then I was subpoenaed to participate in the County's efforts to remove the children, and then I was the therapist when the children moved to their 'new' family.  Throughout all of this the County adoption workers discouraged care providers from sharing information about the 'old' family with the 'new' family because of privacy concerns.  Then it got even more complicated when the baby was approved for early intervention and the 'old' family requested me.  It was all clearly an example of having Too Much Information.

Society has an interest in the well being of its members, and actually takes on some rather aggressive stances when there is documented threat to the well being of children in particular.  This is legally known as the parens patriae functions of the State.  A lot of people who work in child welfare contexts bemoan the slowness of this system to respond, and people on the receiving end of State intervention bemoan the powerlessness that they perceive when these systems are activated.  I think both of those perspectives are correct at the same time.

The 'new' family wanted little Jenna to continue receiving therapy, based on history and perceived needs and objective data.  They were surprised when the child's case came up for discussion regarding EI to CPSE transition because the County and the School District decided that the child did not require special education supports.

This was interesting to me as a person who had Too Much Information, because I knew the 'old' family and the intellectual disabilities of the parents.  I knew the intellectual and developmental disabilities of the older siblings.  I also knew about the intellectual and developmental disabilities of little Jenna.  Now it is true that once she wasn't raking her skin raw in an attempt to alleviate the itching from flea bites that she was able to direct more energy into development.  It was simply true that she made a lot of progress after she was removed from her 'old' family and placed with her 'new' family.

Society believed that there was such a threat to little Jenna's well being and development that they removed her from her family, but that same Society also believed that maybe it wasn't so bad after all and that she didn't need special education.  These are relatively incompatible beliefs, but as they are two totally distinct County agencies with separate bureaucracies that there will be no accountability for the discrepancy.

I tried to talk to the Education bureaucracy within the boundaries of what I am entitled to discuss, but it was evident that there was an intransigence there based on a different and competing set of realities.  On one hand you have the reality that Society is very interested in doing what is in the best interest of children, to the point where people have started to cynically identify that whenever a politician wants to accomplish something they will use the catch phrase 'for the children.'  On the other hand is the reality that people who are comprised into larger units that we call 'Society' are beginning to decide that they do not have endless resources and that there have to be limits to what they want their governments to do.  So although they are emotionally tied to doing things 'for the children' they have taken pragmatic steps by implementing property tax caps that then cause Education bureaucracies to limit things like special education services.

The bureaucracies, functionally ignorant of what drives broad policy and competing emotional sentiment at the level of the family and individual child, just looks kind of stupid as it takes such dramatic action to 'save' children from danger and then does little to nothing to actually promote a more functional outcome once they are removed from the 'danger.'

From a current day news context, this is why people line up in Murietta, California and block busloads of children who are illegal immigrants.  They care about those kids, but not when the caring means that they have to open their wallets and accept higher property taxes.  People legitimately have some outrage, because the apparent answer is to use Federal tax money to make more detention centers and to hire more bureaucrats to process paperwork, but the localities would be stuck with the real cost in health and human services costs over time. Local people can't afford it, or don't want to afford it.  That causes some people to say that the people blocking buses hate children, and it causes the people blocking buses to be in a ridiculous situation of having to explain that they do not hate children. 

Meanwhile, kids sit on buses.  Or perhaps closer to home you might notice that they are yanked out of their families to save them, but not always provided services that they probably need to really save them.  The families who take these children into their homes often don't realize this.  Sometimes the children are lucky and the mere change in environmental context and the structure and support of a resource-privileged foster family makes up the difference.  Sometimes it doesn't.

In the Early Intervention to CPSE transition meeting where I had to shut my mouth and not talk about everything I know the County agency who did not talk to the other County agency told the partially informed foster family that they could come back to the Committee in case there are concerns in the future but that they didn't want to "burden" the child with too many services all at once.

They actually said "burden" as if providing help to a child was somehow a burden.

There have been a lot of impactful verdicts in little Jenna's life.  The 'old' family had no power over the last verdict.  The 'new' family turned to me and I suggested that they advantage a loophole in early intervention eligibility that would allow her to receive special education supports through the EI system until the end of the year and delay her transition into the preschool system.

So little Jenna will get her services, because her OT knows the loopholes and tricks.  It kicks the can down the road another six months, when there will have to be another meeting and another determination made in a room by a bunch of people who know the truth and can't speak it and others who don't know the truth and are not incentivized to seek it out. There will be another verdict, and I will mash up the details with other situations and probably report on the typical outcome of such situations.

Between then and now, if people are inspired to do so, I hope things like this get read so there can be some improved understanding of our very confused priorities and policies around the needs of children.

Thursday, June 19, 2014

Crisis of confidence in AOTA governance


A crisis of confidence is defined as a situation in which people have stopped believing that something is good.  Such a point has been reached with the American Occupational Therapy Association's Representative Assembly.

Here is some data for those interested in understanding our current Representative Assembly and the meeting that is happening that is precipitating a crisis of confidence.

FIRST OF ALL, it is clear that there are many dedicated people who are attending the meeting, voting, and representing you as is their responsibility.  It takes time, energy, and commitment to volunteer.

However, here are some statistics to consider:

1. At the time for discussion on an item that was pulled from the consent agenda, only approximately 61% of those eligible to vote had even responded to a roll call.  Only two representatives discussed the item, which is only 4% of the members.  Both of them were from NY, which does not bode well for the rest of the country.

2. At the time that voting closed on an agenda item, 80% of those eligible to vote responded to roll call.  However, only 54% bothered to cast a vote.

3. 17% of those eligible to participate and vote in the RA meeting didn't even bother to respond to a roll call at all.  3% showed up after the original meeting was supposed to already be over.

Numbers are as close to accurate as possible.  It took a lot of time and energy to compile all of the data and all attempts were made to be as accurate in compiling as possible.  Unfortunately, the time and date stamp on these forums does not correspond to the correct time and date, so there might be small percentage changes in any direction, depending on when votes stopped and started.  I used gross date data and did not analyze it down to the actual hours of voting.  If anyone would like to see my Excel spreadsheet where I have entered all of the data gleaned from the Online Meeting please email me and I will happily share it.

I am deeply appreciative of those who responded to roll call and those who voted.  I am particularly deeply appreciative of my NY reps who have been very engaged and active.

What is happening now is that there is a motion to 'reconsider' voting on the item that only 54% of the people even bothered to vote for the first time.  I strongly suggest that the motions on the table be withdrawn/postponed, the meeting adjourned, and our leadership to address the serious problem that is obvious re: inadequate participation from the elected body.  Important matters come up to our Representative Assembly and we need to have confidence that this is a functional body.

Representative Margaret Frye (NY) summarized the current issue particularly well:

A quorum was established, time for questions and deliberation scheduled and provided, a rationale for the elimination of the ASD vote requested and provided.

Abridged Guidelines for Parliamentary Procedure (p. 9), “It (reconsideration) is used to reconsider a decision made under a misapprehension or with inadequate information.”

I disagree that the RA’s decision was made under these circumstances. It is obvious that the COE SOPs generated very little discussion among the members of the assembly but this lack of deliberation should not be interpreted to meet the criteria for reconsideration.

Some members have had difficulty posting. We had obvious difficulty with the election site. My concern is that if the discussion were to continue these problems will still exist, limiting participation.

The lack of discussion, for technical or other reasons, should be addressed, but in my opinion this is a separate, larger issue than the decision made on the COE SOPs. We met the criteria for a quorum, our process was followed, decision was made. Ultimately we must stay true to our process in order to serve members fairly and effectively.

The current RA meeting should be of significant interest to the occupational therapy community and all of its stakeholders because it is evident that there is very low participation and debate on matters that are coming in front of the Representative Assembly.  Ultimately, the entry level doctoral issue will come before the Representative Assembly.

The problems that are evident in the current meeting are a concern because although the COE SOPs are an important issue for our Association, moving to an entry level doctorate as a single point of entry is an even larger issue.  The SOPs are just an internal matter - the entry level doctorate will set a policy in place that will impact the entire country, including who will and will not enter the field and what our future workforce will look like in composition and in numbers.

If the BoD wishes to have any legitimacy to its process it is imperative that significant and noticeable efforts are made to publicly address the problems with the low participation in the RA.  I have several suggestions to improve the process:

1. Consider more robust quorum rules, particularly since this doctoral issue has national public implications.

2. Consider the educational and orientation process for incoming RA members so that we can achieve greater vote rates than 54%

3. Consider the timeline that will be offered if such a large issue ever comes in front of the RA.  People in the RA have complained about the timeline and scheduling, indicating that it has impacted their ability to participate.  Some, including President Stoffel herself, have stated that attending a conference has limited her participation.  She stated:

I speak in favor of this motion.

I apologize for my voice not being more present as an RA member as I have been at the WFOT Council meetings and now the WFOT Congress having left home on the early morning of June 7th. Although I have attempted to be involved in  listening and following the discussions on each of the parts of the meeting forums, I have also had difficulty with the time differences and trying to juggle that with fully participating in the international forum here in Japan.

I shared my concerns about the level of participation in the discussion that occurred in the US on Saturday with VP Amy Lamb and Speaker Francie Baxter asking about what steps could be taken to allow for greater participation without a time lag of several months before action could be taken. I am used to an RA that offers amendments if they feel their concerns would shape the policy along the lines they feel would strengthen the document being considered. I appreciate that Vice President Lamb initiated this motion, as I believe it reflects a sincere effort to gain greater clarity on what aspects of the original proposed COE SOP.

As others have stated, I hope that more time to discuss the 2 proposed changes in the document separately, 1) the student vote on COE and 2) the membership of the ALC- OT and OTA could occur to better inform our future decisions. I also hope that when questions are raised, that resource people be invited to offer their perspectives and input so that we can all benefit.

Whatever the outcome of this motion, I look forward to our work together on behalf of our Association and our profession!
 
That she was allowed to exceed the 200 word limit is something I brought up to my representative and indicates additional problems with inconsistency in applying Rules.

4. Consider eliminating the 200 word limit during debate, as it is nearly impossible to present a complete argument for such a complex issue as entry level doctoral education in 200 words.

5. Consider if the online format is even adequate for such complex issues.  If there are problems handling internal matters like SOPs in an online format then how can there be confidence in that format for larger issues?

These are beginning suggestions. 

AOTA is VERY FORTUNATE to have these kinds of issue come up as concerns PRIOR to votes on even larger issues like the entry level doctorate, because this creates a context for understanding  how to improve the process and to be sure that there is legitimacy and confidence in the governance of the Association.

A crisis in confidence is not a good thing - but it presents an opportunity.  I am very hopeful that this will be used as a springboard for improvement.

Wednesday, May 07, 2014

Emmanuelism provided the Core Values to the developing occupational therapy profession

As part of a multi-year research effort into the nature of Social Justice I have been participating in an lengthy conversation about this topic on the OT Connections forum, which is an official message board for the American Occupational Therapy Association.

From the beginning of the discussion some have claimed that Social Justice is a Core Value in occupational therapy.  This has been a difficult claim to validate, because there does not seem to be a a standard definition of 'Core Value' just as there does not seem to be agreement on the definition of Social Justice itself.
"In 2003, members of the AOTA Representative Assembly Coordinating Committee recognized that the philosophical and historical roots of occupational therapy were not known to all occupational therapy professionals. In response, the 2003 RA adopted a motion to form the Ad Hoc Committee on Historical Foundations, which was chaired by Kathlyn Reed and included Suzanne Peloquin and Christine Peters. The subsequent series of articles, published in OT Practice magazine, illustrate how events and societal values of a given time period influenced the role and practice of occupational therapy."  http://www.aota.org/en/Publications-News/OTP/Values.aspx

 Unfortunately, Social Justice is not mentioned in Dr. Reed's 'Values and Beliefs' series, and Justice itself is barely mentioned in these documents.  I believe that the reason Dr. Reed did not find a focus on justice is because there was no focus on justice.  Simply stated, this was not a driving philosophical point for the profession.

A bioethicist on the AOTA Ethics Commission has stated "My recollection of our discussions during my tenure on the Ethics Commission, is that the concept of social justice was incorporated secondary to the vast literature within our profession and articulating healthcare discussions which identify social justice as central to the profession’s core values."

The obvious question is that if Social Justice is not a Core Value as identified in the AOTA Values and Belief Series, then how did the Ethics Commission believe that there was a "vast literature" that said social justice was a Core Value?  This is very curious.

Social justice is a newer term that was just added to the 2010 AOTA Code of Ethics:

Social justice, also called distributive justice, refers to the fair, equitable, and appropriate distribution of resources. The principle of social justice refers broadly to the distribution of all rights and responsibilities in society (Beauchamp and Childress, 2009).  In general, the principle of social justice supports the concept of achieving justice in every aspect of society rather than merely the administration of law. The general idea is that individuals and groups should receive fair treatment and an impartial share of the benefits of society. Occupational therapy personnel have a vested interest in addressing unjust inequities that limit opportunities for participation insociety (Braveman and Bass-Haugen, 2009). While opinions differ regarding the most ethical approach to addressing distribution of health care resources and reduction of health disparities, the issue of social justice continues to focus on limiting the impact of social inequality on health outcomes.

Many of the principles previously identified as 'Beneficence' in the 2005 code were simply re-labeled and placed under Social Justice in the 2010 code.  What was removed from the definition of Social Justice was the obvious reference to political rights, as identified by Beauchamp and Childress. Additionally, there is a failure to identify that Social Justice is chiefly a political term, and has been identified repeatedly as an expression of liberal entitlement along with a morality that requires some people to pay for those things that other people think they should have.

As is eloquently expressed in the video linked here Social Justice becomes a mixed sense of entitlement based on a variety of factors - right to just about anything, as long as it is desirable.  Given that living conditions at the time of the OT founding were so challenged (poverty, chronic illness, rise of industrialism, World War I, loss of agrarian life, and so on) there was a lot of understandable desire for improvement.

There were many 'social movements' occurring at this time to counteract the changes people were experiencing during this 'Gilded Age.'  Most of these movements were taken up by the social elites and were based on charity, philanthropy, and Christian Ethics (as expressed philosophically via Pope Leo's Rerum Novarum and popularized through specific religious efforts like the Emmanuel Movement and the lay efforts of the Arts and Crafts Movement).

A lot of change was desired.  A lot of effort was undertaken to effect those changes.  However, these efforts were not undertaken in a Rawlsian definition of Distributive Social Justice.  They were undertaken in a Christian Ethic that guided charitable deeds.

So when Jane Addams started her settlement house work it was not based off of governmental largesse and re-distribution of resources.  It happened because of philanthropic efforts.  It was not until her program became DEPENDENT on governmental distribution that Hull House ultimately was destroyed.

When Elwood Worcester set up treatment programs for people who had tuberculosis in the slums of Boston, it was not based off of governmental largesse and re-distribution of resources.  It happened because of philanthropic efforts.

When Jessie Luther made the long trip North to Newfoundland it was not based off of governmental largesse and re-distribution of resources.  It happened because of philanthropic efforts.

When Phillip King Brown traveled to San Francisco and did his work in the Arequipa Sanitorium and helped to rebuild the city after the Great Earthquake it was not based off of governmental largesse and re-distribution of resources.  It happened because of philanthropic efforts.

Why is it that occupational therapists have come to believe that social (distributive) justice is a correct way of understanding the philosophy and ethic behind these efforts?  They make this mistake because they MISLABEL ANYTHING THAT IS DESIRABLE AND GOOD AS SOCIAL JUSTICE.

As an exemplar, I encourage everyone to go read Harley and Schwartz (2013) Philip King Brown and Arequipa Sanatorium: Early Occupational Therapy as Medical and Social Experiment.  American Journal of Occupational Therapy, 67, e11-e17.

The premise of this article is that Philip King Brown established social justice as a core value in occupational therapy when he founded a tuberculosis sanitarium in 1911.  The authors claim " It is noteworthy that he was a pioneer in advocating for occupational justice 100 years before the term was introduced into the occupational therapy lexicon."

Just at face value, isn't it a little odd that someone can pioneer something 100 years before there is even a word to describe it?

Although it is true that men and women had very divergent 'cure pathways' for tuberculosis in the early 1900s, this had more to do with social status, expectations regarding role behavior, and perceptions on what was respectful of different gender roles at that time.  These differences between men and women's cure pathways is explored in great depth in Sheila Rothman's (1994) book: Shadow of Death: Tuberculosis and the Social Experience of Illness in American History. New York: Basic Books.

That Philip King Brown founded a tuberculosis hospital for women in California in 1911 had more to do with exigent realities of women's health following the Great California Earthquake then it did in trying to resolve some fundamentally unjust context where 'chasing the cure' was biased in favor of men.  Here we see the bending of history to suit a current Social Justice narrative - where the premise of those favoring Social Justice models believing that building a sanitarium for women MUST OF COURSE be due to the need to correct some Social Injustice against women.

Of course, "occupation work" as it was called back then was not even codified into the discrete profession of occupational therapy, Philip Brown King was a medical doctor and not even a direct 'Occupation Worker," and the founding of the profession did not even occur until 6 years after the sanitarium was built.  It seems to be a stretch to say that the generic "occupation work" within this particular institution had anything at all to do with specific occupational therapy much less some newborn concept of Social Justice that we wouldn't even know how to label until Rawls came up with his definition 60 years later.

I am NOT criticizing the significant efforts and humanitarian work of Dr. Philip King Brown.  I am just questioning that it was all done to serve a Social Justice narrative that didn't yet exist and for a profession that was not yet even named.  The reality is that the methods used at Arequipa were no different than those used at any other progressive Sanitarium of that day that had adopted a 'work cure.'

The authors of this article also state, "To our knowledge, Brown is the only one of the founding generation of occupational therapists to explicitly champion the cause of social justice by creating a program specifically for the underserved."  There are several logical flaws with this statement.  First of all, Brown was not an occupational therapist or even an occupation worker.  He was a doctor who was in charge of the sanitarium.  Second, it is unfortunate that the authors did not find any of the dozens of sanitariums that were set up and established specifically for the 'underserved.'  A prime example of one such sanitarium was The Pickford Sanitarium which was founded much earlier than Arequipa and was devoted to the care of African American people who had tuberculosis. docsouth.unc.edu/.../summary.html  Of course there is also Jessie Luther's efforts, mentioned above.

And of course there was also the work of Elwood Worcester and the Emmanuelists in Boston, also mentioned above.  And there was Dr. Henry Foster who founded Clifton Springs Sanitarium and Dr. James Mumford and his efforts to bring Emmanuelist philosophy to the Clifton Springs Sanitarium - and I hope that most people know what that led to! (Adams, 1985).

There were many others.


The development of these tuberculosis sanitariums and the spread of 'occupation work' was not because of an unjust distribution of care resources.  They were developed based on the humanitarian desire of people to help other people.  Attempting to frame the humanitarian motivations into some re-configured social justice narrative is factually incorrect.

The Social Justice philosophy does not fit the reality of what caused these Sanitariums to be founded.  They were not founded because of some sense of unjust distribution of care.  They were founded because of the severe problems that tuberculosis caused to society, the threat that the disease posed to every single person, the need to redirect the energies of a disabled and "invalid" generation back into productivity, and of course (perhaps most importantly) the humanitarian desire to help other people.

The analysis in the Arequipa article is an example of how history is bent to serve the political narrative of the Social Justice Experiment.

What is left out of the analysis is that Dr. Philip King Brown was visited by Elwood Worcester in January and February  of 1909 (Worcester, 1932).  Dr. Brown and Worcester both hailed from Boston and were good friends, and in fact the work cure that was promoted by Brown was a direct copy of the Emmanuelists.  This is further documented in the subsequent San Francisco visits of Dr. Richard Cabot in 1912 (Quiroga, 1995) who was also a proponent of the work cure.  

It is not mere coincidence that Dr. Brown was visited by Worcester himself who founded the Emmanuel Movement and Dr. Cabot who was among the first MDs in Worcester's circle who was promoting this method.

The Emmanuel method was not based on any conception of Social Justice.  There is so much rich documentation of what it DID stand for that to make any claim other than that Dr. Brown was an Emmanuelist is simply a matter of historical distortion to fit a political narrative.

In order to understand the VERY DIRECT impact that the Emmanuelists had on occupational therapy we do not need to create a fictional social justice narrative.  Why don't we just read the words of George Barton, one of the actual founders of the OT profession?  He was 'cured' by Worcester himself, assisted by James Mumford (Worcester, 1932).  Let's look at what Barton wrote in his often conveniently ignored treatise "Re-education: An analysis of the institutional system of the United States" (Barton, 1917).  Here is a choice quotation from Barton - an occupational therapy founder, and Emmanuel practitioner:
"And if it seems cruel to the charitably disposed mind to let a man go hungry under any circumstances, it should be borne in mind that St. Paul said, "And if any would not work, neither should he eat";  that Adam was told that by the sweat of his face he should earn his bread; and that, according to the Commandment, it is six times more important to work than to keep the Sabbath. The vagabond would no longer find it necessary to attract the roundsman's attention by throwing a brick through the window of some respectable taxpayer; for, by declaring himself dependent at any police station, he could be sent to that shop where he was best fitted to work, and where, by his own efforts, he could be fed and lodged until his little earnings had amounted to enough to give him a fresh start."

I am curious as to why we ignore the Emmanuel Movement as much as we do - it is sometimes named but few will dare to discuss its roots - which are deeply religious and based on the idea that medicine did not have the answer to these vexing problems and that a NEW MODEL was needed that combined medical and social and spiritual components.  Rather than being an argument for social justice and distribution to correct inequity, it seems that this is a very different kind of philosophy regarding responsibility and self reliance - and surrounded by Christian values of charity.  That might be too painful for some people to tolerate, and I am curious if this is why we have to re-create a fictional Social Justice narrative.

Here is another Barton quote:
"There is necessarily a limit to the amount which the normal man can do for his unfortunate brother. There is necessarily a limit to the number of members of a community who can remain in idleness, no matter how distressing their condition. More than that — to support in idleness, even though in distress or pain, if not the worst, is not the best means of assisting the unfortunate. "

Again, that hardly seems to support the notion of distribution based on inequity.  Rather, this is a philosophy of responsibility and self reliance.

Here is another Barton quote:
"Indeed, so thoroughly have our so-called charitable impulses undermined the self-respect of the people that a new medical term has been introduced in Europe to cover those cases who, through fear of not being supported for nothing, refuse to endeavor to return to work. This condition is known as "pension hysteria."

I don't even know how you can bend a social justice framework around that!

And finally, we have George Barton stating what drove all of his efforts:
"Or even the author who, during the ten or twelve years of hospital and convalescent life necessary for the overcoming of four attacks of tuberculosis, four surgical operations, including an exploratory laparotomy and an amputation, morphinism, hysteria, gangrene, and paralysis, has studied the relation of the sick man to society, and who now offers this little book as one of the results of his disability."

The Core Values of occupational therapy are based in Emmanuelism.  They are NOT based in Social Justice, or anything that anyone wants to try to bend in order to fit a Social Justice model.


Today Social Justice is a predominantly leftist term and is a political philosophy used to promote liberal policies.  Attempting to claim the charitable efforts of philanthropists in the Gilded Age as evidence of 'Social Justice Pioneers' is incorrect.

Occupational therapists should not be ashamed of the philanthropic notions that were present as the humanitarian spark for our profession, and they most certainly should not attempt to revise history to make it sound like OTs have always been for redistributing resources because of inequity.  These founders voluntarily 'redistributed' because of their Christian Ethics and philanthropy - not because the government made them and because everyone was supposed to be 'equal.'


References:

Adams, R.A. (1985). The Emmanuel Movement: An antecedent to occupational therapy.  (Unpublished Masters Thesis), Rush University, Chicago.

Barton, G.E. (1917).  Re-education: An analysis of the institutional system of the United States.  Boston: Houghton Mifflin Co.

Beauchamp, T. L., and Childress, J. F. (2009). Principles of biomedical ethics(6th ed.). New York: Oxford University Press.

Harley and Schwartz (2013) Philip King Brown and Arequipa Sanatorium: Early Occupational Therapy as Medical and Social Experiment.  American Journal of Occupational Therapy, 67, e11-e17.

Quiroga, V. (1995). Occupational therapy: The first 30 years.  Bethesda, MD: AOTA Press.

Rompkey, R. (2001).  Jessie Luther at the Grenfell Mission.  Montreal: McGill Queen's. 

Rawls, J. (1971). A Theory of Justice. The Belknap Press of Harvard University Press

Rothman, S. (1994). Shadow of Death: Tuberculosis and the Social Experience of Illness in American History. New York: Basic Books.

Worcester, E. (1932). Life's adventures: The story of a varied career.  New York: Scribner's Sons.