Tuesday, September 22, 2015

Editing the American influence out of the history of occupational therapy

During the very long social justice debate that preceded the revised AOTA Code of Ethics there were repeated claims that social justice represented a Core Value of the occupational therapy profession.  Those claims have been thoroughly addressed here and here.  In these entries and several other previous entries information was presented to support the claim that American influences are germane to understanding the driving forces behind the formation of the profession.

In my ongoing readings related to this topic I was comparing textbooks and am developing some new questions.  I am very curious about information that was recently edited out of the new edition of the Occupational Perspective of Health, 3rd ed (Wilcock and Hocking, 2015).

In An Occupational Perspective of Health, 2nd ed., Wilcock (2006) discusses the driving forces leading up to the formation of the occupational therapy profession.  She explains that changes occurred as Ruskin and Morris' ideas (via the Arts and Crafts movement) were brought to the United States.  She writes

However, because the Puritan work ethic was so central to American culture, Ruskin's and Morris' conception of a preindustrial, creatively absorbed craftperson became reinterpreted so that eventually no distinction was made between modern and pre-industrial work habits.  American Arts and Crafts leaders, along with their progressive contemporaries, drew back from fundamental social change for social justice, favoring instead "a new kind of reform" aimed at "manipulating psychic well being" and fitting individuals into emerging hierarchies.  This notion of "mental and moral growth" was compatible with 19th century American ideas about individualism, which was central to capitalism, its liberal democracy ideology, and values focusing on human rights... Similarly at Hull House, where Ruskin's and Morris' photographs had pride of place, the Arts and Crafts ideology was reinterpreted from a socialist to an individualistic focus.

This analysis is in line with my previous essays on this topic and in my estimation this is an accurate representation that dismisses the fallacious 'Social Justice as Core Value' argument.  Unfortunately, this entire section has been edited out of the 3rd edition of the same text.  Instead, Wilcock and Hocking (2015) offers this:

Neither the antimodern socialist revolution focus, nor the capitalist, individualist growth focus, nor the establishment of occupational therapy was successful in creating global awareness of the need to consider people's inner being and occupational nature in future social or health planning, although all went some way in that direction.  Later, the dominance of reductionistic medicine led to public health practitioners being tied to a practice geared to civic sanitary conditions and control of epidemics of infectious diseases, and the diminution of broadly based, population-focused occupational approaches to health, delaying a collective consciousness of their importance.

So an accurate analysis of the American forces that shaped the unique focus of the profession is now removed and we are left with an accusation that those influences were detrimental to what I will label as Wilcock's and Hocking's Occupational Therapy New World Order, which is all based on a new justice paradigm.  This is consistent with other academic efforts to bend history in order to fit a social justice narrative.

I am wondering if Wilcock's original analysis is edited out of the 3rd edition discussion because its presence undercuts the arguments of social and occupational justice proponents. It is unfortunate that she did not EXPAND on this line of analysis and include information on the influence of the Transcendentalists, the Boston Society of Arts and Crafts, the Emmanuel Movement, and George Barton. This all becomes immensely important as it relates to our theory development because it helps us to answer questions about whether or not that American influence is important.  I argue that it is, and that is why I spend so much of my research time attempting to reconstruct the neglected Barton thread of the occupational therapy story.

These topics are important for uncovering the full truth about our historical roots and Core Values.  When we omit important historical facts and analysis we have incomplete information to form proper opinions.  This kind of cherry picking has led some scholars to misinterpret history and to oddly focus only on justice models or feminist interpretations of Hull House influences.  A proper historical analysis will balance all of these factors together and will not selectively edit anything out.

History should be history.  It should not be selectively edited and it should not be revised to suit current political and justice agendas.


Wilcock, A.A. (2006). An Occupational Perspective of Health, 2nd ed. Thorofare, NJ: Slack, Inc.

Wilcock, A.A. and Hocking, C.H. (2015). An Occupational Perspective of Health, 3rd ed.  Thorofare, NJ: Slack, Inc.

Monday, September 21, 2015

I vaant to TELL you zomething!

I want to share a message about authenticity in therapeutic relationships.

Jim was a 40 year old man who participated in  a day treatment program in a rural community.  The program itself was conceived and nurtured by Jim's parents along with other parents who were desperately trying to find non-institutional program options for their children.  Jim had cerebral palsy and an intellectual disability.  He attended that community program as a school child and eventually 'graduated' into the adult day treatment program.  The program grew from providing services to just a few children to several hundred people with developmental disabilities of all ages.  The program was an act of love, gifted by parents to their children.  That is the best way I can think to describe programs that developed this way.

I am not sure how aware Jim was of all that.  He was mostly focused on relationships with people and he had no disability in that social arena.

I had no special relationship with Jim, except that he treated all of the people that he interacted with in a special way.  Because of that I loved spending time with him.  Who doesn't love spending time with someone who treats them like they are special?

You could always hear Jim before you could see him; he had an uncanny ability to know where you were before he could see you.  Perhaps because his vision was poor and his motor abilities were limited he compensated with hearing or something else.  He would slowly wheel himself from around a corner, propelling his wheelchair mostly with small wrist movements, and you would hear a characteristic voice with his 'fake' accent that sounded like something out of a Dracula movie: "Chreeeeeestopherrrr.... I vaant to TELL you zomething!"

I have no idea where he got that 'voice' from.  Just remembering his voice cracks me up as I think about it.

Five years after I left that facility I was working in a children's hospital in a nearby city.  I was working in the orthopedic clinic and I heard that voice from behind one of the closed curtains in an evaluation room, just as if those five years had not even passed.  The voice said clearly, "Chreeeeeestopherrrr.... Eeez Zat YOU????  I vaant to TELL you zomething!"  Of course it was Jim - who despite his age was still being followed in the developmental disabilities clinics of that pediatric hospital.  I couldn't believe that he knew I was there even though he couldn't see me from the other side of that curtain!  It was a wonderful reunion, like seeing an old friend again.

There is a special authenticity about those kinds of interactions that is very difficult to explain in words in some blog post.

I got to thinking about this because I was recently reminded about this kind of authenticity in my work at the college.  The college has a transitional program for young adults who have developmental disabilities.  Those students attend educational classes, some of which are college courses.  They are not graded on their efforts but the idea is to promote inclusion and participation.  I was fortunate enough to have some of those students in a Freshman level 'Intro to OT' course, and even though I think that the program needs more OTs working in it in a general sense, the participation of those students in the class was positive in just about every way I might think to measure.

What struck me most though was that as the next semester began I would pass by some students from my Intro to OT course as I walked around campus.  The students were always polite and friendly, perhaps verbalizing a quick 'hi' or giving a quick head nod along with a fleeting moment of eye contact as they rushed around campus.

That is not how the 'Intro to OT' students from that transitional program acted though.  The first response that I got when I saw them was quite different.  They ran to greet me, excited to tell me about their summer experiences.  One asked for a hug.  And it wasn't just that first time, because now they stop by my office or stop me to talk when I am walking around the halls.  One of them still wanted to talk about the book I had them read last semester, Tuesdays with Morrie.  I think that even though the writing skills are imperfect, one of those students really understood the message in the book.  That student wrote:
Morrie said that “This  is  a  part  of  what  a  family  is  about,  not  just  love.  It’s  knowing  that  your family  will  be  there  watching  out  for  you.  Nothing  else  will  give  you  that.  Not  money.  Not  fame.  Not  work.”  So What  does  this  mean to me?  To  me,  it  means  that  yours  or  my family--mothers,  fathers,  brothers,  sisters,  aunts,  uncles,  cousins,  grandparents,  friends, teachers etc. will be  by  our  sides  no  matter  what.  It  doesn’t  mean  who’s  just  in  our  blood,  it  also  means who  our  friends  are  who  take  us  in  as  their  sister  or  brother.  You  could  be  famous  person  and  still  need  your  mom  or  dad  to  support  you.  You  could  have  a  job  that  has  a  bunch  of hours  and  pays  at  minimum  wage  while  still  being  happy  with  what  you  have. Families are  important  in  our  lives, no matter who we are calling family.  And we should probably dance with them if we love to dance.

So, I vaant to TELL zomething to OT students who I hope will also have the opportunity to work with people who have developmental disabilities during their careers.  It is pretty important that we learn to strip away and look beyond the labels that are placed on people.  Sometimes we find ourselves working within systems that apply those labels for what are supposed to be good reasons but sometimes they distract us from understanding that people of all abilities have some important observations to offer and some important contributions to make. 

I am not trolling for hugs next semester from my Freshmen students, but I think it is correct to observe that we have a lot to learn from each other, even when our abilities and skills are very different.  In particular, I think that we all have more to learn about how we are supposed to care about each other and how we can interact with each other in more authentic ways.

The whole idea of inclusion is that it opens us up to opportunities to interact.  It is never going to be enough to just interact though.  We have to open our hearts to each other and learn to listen closely to the messages that people have and that we can learn from.

Sometimes they come hidden in fake Transylvanian accents.  Sometimes it will come in an essay.  Sometimes it will come in the happiness that people experience when you stop long enough to treat them like they are important. 

You just never know, and that is why you always have to watch closely for those lessons when they come your way.

Tuesday, September 08, 2015

Narrative summary of the ACOTE Occupational Therapy Entry Level Survey

*This represents MY Summary and opinions on this report:

As part of the process of gathering data to inform decision making regarding the entry level degree required for occupational therapy practice, the Accreditation Council on Occupational Therapy Education conducted a survey.

In summarizing these statistics, categories of respondents were combined to simplify analysis.  Also, in summarizing agreement or disagreement, categories of 'strongly agree' and 'agree' were combined as were 'strongly disagree' and 'disagree.'

That survey was open between March 13, 2015 and closed May 15, 2015.  There were 2,829 respondents.  The generalized categories of respondents were OT practitioners (50%), OT students (19%), OT academicians (29%),and employers (3%).

The overwhelming majority of respondents (71%) agreed that the OT profession should embrace a single entry level.  This opinion was similar across all categories of respondents.

When asked if the body of OT evidence would benefit if the entry level degree moved to the doctorate, 61% of respondents disagreed.

When asked if if a doctoral entry level degree would allow for an increased impact on healthcare reform, 61% of respondents disagreed.  Practitioners in particular disagreed with this statement (70%).

When asked if moving to an entry level doctorate would positively impact practice on the respondent's particular region, 69% disagreed.  Practitioners in particular disagreed with this statement (78%).

When asked if such a change would positively impact students, 70% disagreed.

67% of respondents did not think that a doctoral entry level degree offered more opportunity for promotion.    Only 23% of practitioners thought it could offer such opportunity as opposed to 43% of educators who thought it could offer such opportunity.

 Securing fieldwork placements was a concern of the majority of respondents (66%).  Most respondents (57%) did not believe that academic institutions are positioned to meet the changing needs of OT programs.  70% of respondents believed that there was a lack of qualified faculty, 40% believed that there was a lack of State support, and 42% believed that there was a lack of institutional support.  72% believe that an entry level OTD will decrease the number of applicants to OT programs, and 64% believe that it will decrease the diversity of applicants.  Only 12% of respondents believed that no challenges were anticipated.

Cost was a significant concern; 74% of respondents believed that the cost of a higher entry level degree would not be worth any benefits that it might bring.

Employers responded in an overwhelming fashion (82%) that they are not more likely to hire OTs with a higher entry level degree.

Most respondents overwhelmingly felt that the current degree requirements were sufficient: 92% believed that basic tenets were sufficient,  90% believed that theoretical perspectives were sufficient, 87% believed education on evaluation was sufficient,  85% believed that education on intervention was sufficient, 89% felt that education on service delivery context was sufficient, and 94% believed that education on ethics and professional responsibilities was sufficient.   Beliefs on sufficiency of education on scholarship (79%) and management (82%) were lower, but still rather high.



The ACOTE decision to support dual entry into the profession is in opposition to the AOTA Board of Director's opinion on the doctoral degree as a single point of entry.  The recommendation is certainly not based on survey results alone.  However, the largest concern for the OT community should be the overwhelming and consistent difference of opinion between this survey and the responses and recommendations of the AOTA Ad Hoc Committee on the Future of Occupational Therapy Education and the AOTA Board of Directors.

The future of this doctoral issue remains uncertain, but the OT community should study the results of this survey and attempt to understand why the OT leadership would come to a conclusion that is so apparently out of step with its membership and other stakeholders.

Based on previous analysis, there was a concerning lack of diversity on the Ad Hoc committee.  That committee was composed almost entirely of academics.  I reported on the concern 18 months ago when the recommendation for the OTD was made:

The AOTA Board informed their decision on two workgroups: one an Ad Hoc Board Committee on the Future of OT Education chaired by Dr. Thomas Fisher and the other an internal subcommittee of the Board itself that reviewed the Ad Hoc Committee's findings.

The Ad Hoc Committee was comprised of occupational therapists who also served as Deans, Provosts, or other high ranking University officials as well as the AOTA Director of Accreditation and Academic Affairs.  Task groups were developed to address specific questions.  Specifically, one task group called the "Maturing of the Profession" task group made the specific recommendation for mandatory doctoral level education.  This group consisted of a physical therapy educator/Dean and four occupational therapy academics who all held high ranking University positions.

It is not known who comprised the sub group of the AOTA Board of Directors that looked at the Ad Hoc groups findings.  However, the AOTA Board of Directors is known to be heavily weighted with those who work in academic settings.  Among those who are not currently in academia, most either hold dual academic appointments, have held academic appointments in the past,  or are in senior administrative positions in their work settings.

The fundamental problem with the composition of these committees and task groups is that they are making recommendations that stretch outside the confines of academia.  The recommendation for mandatory doctoral level training is not an academic recommendation.  It is a practice recommendation.

The ACOTE survey provides a rich data set that reflects the position of a more diverse group of stakeholders.  Perhaps even more importantly, the survey represents an opportunity for the AOTA Board of Directors to reflect on how they constitute Ad Hoc committees and how they might promote more diverse engagement from the entire occupational therapy community in the future.

Saturday, August 29, 2015

Investigating the status of "The Pledge and Creed for Occupational Therapists"

A little over a year ago I presented an argument that the Emmanuel Movement provided important core values for the occupational therapy profession.  This argument was constructed in context of a debate on whether or not Social Justice was a historical value of the profession.

I was curious as to why we neglected to include the Emmanuel Movement when we discussed our values and beliefs.  In the beginnings of the 20th century the Emmanuel Movement was based on the notion that a new method was required to address the social problems of disability and illness.  That new method was a philosophy regarding responsibility and self reliance - and surrounded by Christian values of charity.

Furthermore, that method was most certainly not based on a governmental model of redistribution or in a new age construct of oppression and liberation.  That fact is what made some of the recent social justice debates so curious.

Shannon (1977) warned that "a discipline that forgets its founders may be lost."

I have been studying these Values and Beliefs articles for a couple years and I recently noticed something that seemed to be missing.  In the initial article for the series covering the dates from 1904-1929 there is no mention of the  Occupational Therapy Pledge and Creed.  Certainly a Pledge and Creed would be an important document that would reflect both values and beliefs. 

The Occupational Therapy Pledge and Creed was submitted by the Boston School of Occupational Therapy and adopted by AOTA in 1926.  What is noteworthy is that the Pledge and Creed is mentioned in the book of one of the authors of the Values and Belief series (Reed and Sanderson, 1999, p. 408).  The Pledge and Creed states:

REVERENTLY AND EARNESTLY do I pledge my whole-hearted service in aiding those crippled in mind and body.

TO THIS END that my work for the sick may be successful, I will ever strive for greater knowledge, skill and understanding in the discharge of my duties in whatsoever position I may find myself.

I SOLEMNLY DECLARE that I will hold and keep inviolate whatever I may learn of the lives of the sick.

I ACKNOWLEDGE the dignity of the cure of disease and the safeguarding of health in which no act is menial or inglorious.

I WILL WALK in upright faithfulness and obedience to those under whose guidance I am to work, and I pray for patience, kindliness, and strength in the holy ministry to broken minds and bodies.

Most interestingly, Reed and Sanderson document that this Pledge and Creed "remains official today" when their book was published in 1999.  Since Reed wrote about the Pledge and Creed in 1999 certainly she was aware of it when she wrote the Values and Beliefs series.  I am not sure why it would not be mentioned in the series.

I have not been able to locate any documentation or announcement that this Pledge and Creed has ever been rescinded but this is an area that I am continuing to investigate.

Aside from the curious omission from the values and beliefs series it is important to note that such a Pledge and Creed incorporates a view of occupational therapy that is at severe odds with the changes that have been espoused by some therapists in the last twenty years.  Values of social justice, political redistribution of resources, client-based ethics, and redefinition of who we provide services to (whole communities, agencies, non-human entities, etc) are all severely out of step with the Pledge and Creed.  

The words 'pray' and 'holy ministry' are certainly interesting and I wonder if that is why the Pledge and Creed are not mentioned by those who espouse a secular interpretation of occupational therapy history.

I am not advocating the position that OT has to be explained in Christian terms but perhaps the inability to advance and explain the spiritual dimension of practice is why we have become so lost with our definitions. The existence of the Pledge and Creed presents itself as a philosophic conundrum for the profession.  

The Pledge and Creed is not on the AOTA website.  Has it been rescinded?

Does it 'remain official today?'

Is it the will of the association to rescind the document if it has not already been done?

If not expressed in specific terms of Christian ethics, how does the occupational therapy profession express its interest in spirituality?  We have lost our way on this topic. Howard and Howard (1997) asked "What does spirituality have to do with occupational therapy?"  They mentioned the early influence of the Immanuel (sic) movement, but it is clear that even in attempting to cover the topic that they apparently missed the mark.  Christiansen (1997) stated that "by failing to acknowledge a spiritual dimension, occupational therapy practitioners lose important opportunities for understanding the full potential of occupation to enhance the health and well-being of clients."

Egan and Swedersky (2003) state that "given the diverse definitions and the multiple meaning of spirituality in practice it is perhaps not surprising that studies of American, British, and Canadian occupational therapists are unsure of the role of spirituality in practice."

But even with these acknowledgements of spirituality in practice we have approached the subject as if we are doing so for the first time.  What an unusual position for a profession to be in when its very roots were based in a notion of mind-body-spirit healing!


embedded links, and...

Christiansen, C. (1997).  Acknowledging a spiritual dimension in occupational therapy.  American Journal of Occupational Therapy, 51, 169-172.

Egan, M. and Swedersky, J. (2003). Spirituality as experienced by occupational therapists in practice.  American Journal of Occupational Therapy, 57, 525-533.
Howard, B.S. and Howard, J.R. (1997). Occupation as spiritual activity.  American Journal of Occupational Therapy, 51, 181-185.

Sanderson, S.N. and Reed, K.L. (1999).  Concepts of occupational therapy, 4th ed. Philadelphia: Lippincott, Williams, and Wilkins.

Shannon, P.D. (1977). The derailment of occupational therapy. The American Journal of Occupational Therapy, 31, 229-34.

Friday, August 28, 2015

Ethical occupational therapy practice in nursing home care

I teach ethical decision making to occupational therapy students.  One of the most common concerns that I hear from students each year is the pressure that they experience regarding productivity and 'meeting minutes requirements' in skilled nursing facilities.  Nursing homes receive higher rates of reimbursement based on intensity of rehab services that are provided, so there is an incentive for facilities to provide as much 'high intensity' therapy as possible.

Typically, the students express ethical distress because they often believe that the recipients of these services are receiving marginal or no benefit from their participation.

As a population, OT students feel disempowered about expressing concerns in this area during their fieldwork experiences because

a) they perceive that they are 'just students' and don't want to make waves
b) they feel confused because their clinical preceptors are all engaging in the behavior
c) they have competing pragmatic concerns, like graduating on time, having to find a new fieldwork, etc

Students report that many practitioners 'go along' with the push for more therapy because they become concerned with job security or that they simply accept these practices as 'being the way things are done.'

The Wall Street Journal wrote an excellent investigative article on this issue that I encourage others to read fully and carefully.  The article can be found here: http://www.wsj.com/articles/therapy-is-for-helping-patients-not-the-nursing-homes-1440539579

The article describes massive increases in therapy that advantage Medicare payment rules:

"The ultrahigh-therapy rise stretches from small operators to chains. Genesis HealthCare Corp., among the largest nursing-home providers, cited ultrahigh therapy in 58% of days for which it billed the system in 2013, a Journal analysis of Medicare data shows, up from 8.1% in 2002.

Kindred Healthcare Inc., which runs nursing homes and provides therapy at other facilities through its RehabCare unit, did so 58% of the time in 2013 at its own facilities versus 7.6% in 2002. Kindred and Genesis declined to comment.

HCR billed for ultrahigh services 68% of the time in 2013, versus 8.8% in 2002. In December, the Justice Department joined a whistleblower lawsuit alleging HCR pressured employees to provide unnecessary therapy and overbilled Medicare."

The leaders of the speech, physical, and occupational therapy member associations responded to the article with this letter that can be found here: http://www.wsj.com/articles/therapy-is-for-helping-patients-not-the-nursing-homes-1440539579

The response pays appropriate concern to the problem, but I believe that the member associations need to do more than simply "dialogue with industry to address the issue of volume-based versus value-based care and to improve compliance" and "help clinicians navigate complex regulation and payment systems, emphasize their responsibility to report unethical care provision and promote value-based patient care."

Some therapy groups named in the Wall Street Journal Article declined to comment but they also have direct relationships with the member associations, including sponsorships, clinical affiliation agreements, and other opportunities where they 'partner' with the member associations.

I believe it is reasonable to suspend these kinds of partnership arrangements until there can be a more thorough investigation about the practices of these companies.  Membership associations can't claim to be concerned about possibly unethical or even possibly illegal practices that are discussed in the Wall Street Journal article while they are forming partnerships with these agencies at the same time.

Writing a letter in response to the article only pays lip service concern, particularly when partnership agreements with these agencies remain in force.  Temporarily suspending partnerships pending investigations is prudent and sends a much stronger message about the actual concerns of member associations.  Partnerships can be renewed if there is no wrongdoing.  If there is wrongdoing, the member associations should not be partnering with these groups.

Monday, August 17, 2015

The occupational therapy profession's indecisive step toward its Centennial Anniversary

The Accreditation Council for Occupational Therapy Education released an unexpected set of decisions last week.

In sum, the two decisions promote the concept of dual entry levels for OTA education and dual entry levels for OT education.  The OTA dual entry (associates and baccalaureate) is an entirely new concept while the OT dual entry (masters and doctoral) follows a year-long debate on whether or not the profession should adopt the doctoral level as a single point of entry.

The reason why each of these decisions was surprising is because they contradicted the publicized opinions of the American Occupational Therapy Association, the member group for the profession.

As such the 'problem' with the decisions doesn't rest with ACOTE alone, but rather represents a community of professionals that are at odds with themselves and unsure of how to move toward the future.


Regarding OTA education, an Ad Hoc Committee of AOTA looked at the complex issues surrounding OTA education and came up with three recommendations.  Those recommendations were:

1. Keep OTA education at the associate level
2. Have only one level of degree entry for OTAs
3. Articulate strategies to succeed if the association ever decides to transition to a higher degree level for OTAs.

The reports states that "While there may be some benefits to the two entry-level-degree model, they do not  outweigh the inconsistencies created when  there are  two different degree levels qualifying  graduates for a single set of entry-level competencies."

The full report is available at www.aota.org/.../OT-Entry-Level-Degree-ADHoc-Final.pdf


Regarding OT education, an Ad Hoc Committee of AOTA looked at the complex issues surrounding OT education and came up with nineteen recommendations.  The most relevant regarding entry level was:

"AOTA adopt a mandate that entry-level-degree for practice as an  occupational therapist be a  doctorate by 2017 with a requirement for all academic programs  transition to the doctorate by 2020."

The full reports is available at http://www.aota.org/-/media/Corporate/Files/EducationCareers/Educators/Future-of-Education-Final-Report-2014.pdf


The ACOTE decisions now recommend dual entry for both levels and apparently disregard concerns stated in the above reports in promoting what they are calling 'flexibility.'  ACOTE recognizes inherent difficulties with lack of differences in program outcomes between different levels, difficulties with infrastructure needed to support doctoral programs, and the paucity of fieldwork sites.  These are significant barriers that have been correctly identified.  The full statement is available at http://www.aota.org/Education-Careers/Accreditation/Announcements.aspx

Flexibility is certainly achieved by having dual entry points but also shows a profession that lacks leadership, direction, and ability to make definitive decisions and move toward a consensus.  In the parallel example of multiple entry points for the nursing profession, Smith (2009) states, "The requirements for entry into and completion of these programs vary by state and are controlled by forces within each state’s higher education system and healthcare-related interest groups, and the nursing profession itself."  This is what will also occur within the occupational therapy profession and is already on display in New York State.  A group of academicians, supported explicitly by the State OT board and tacitly by the State member association, is laying the groundwork for an eventual doctoral level entry point.  See here for details.

Not every state has interest groups that will powerfully drive the issue toward a conclusion.  There is a severe maldistribution of occupational therapy educational programs in the United States.  States with few or no programs and weaker State Associations might be among the last to promote a voluntary doctoral level entry point.  This will cause compounding problems with lack of consistency.

Smith (2009) lists several factors that likely contributed to the nursing profession's inability to agree on escalating degree requirements.  Use of a 'top down' decision making strategy was a major impediment that turned many nurses off of the idea of escalating entry level.  Also, the use of 'policy entrepreneurs' who were knowledgeable and well connected backfired on nurses because those people were not viewed as 'one of us' by the average nurse who would be impacted by the decision.  These same factors came into play for occupational therapy.


Several actions are recommended in order to move the occupational therapy community to a consensus decision point.

1. Recognize that "flexibility" is a euphemism for indecision and confusion.  Study the nursing profession example to understand what "flexibility" has accomplished and not accomplished.

2. Place an accreditation moratorium on development of ALL entry level doctoral OT programs and baccalaureate level OTA programs.

3. Outline a process that will encourage a critical analysis of accreditation standards and align their minimal purpose with meeting evidence-based entry level occupational therapy practice competencies.

4. Develop profession-wide consensus on essential educational components based on practice analysis of entry level and advanced level skill sets through research.

5. Listen to and address the relevant concerns of the entire constituency that is impacted by such a decision: academia, clinicians, employers, the public, and other stakeholders.  Most importantly, don't drive this from a top-down perspective.

6. Develop final consensus based on a comprehensive consideration of ALL THE ABOVE.


The current recommendation to promote dual entry levels will allow a condition of indecision to persist.  From a vacuum of indecision we can expect more special interest meddling from within different States.  We can expect a lack of uniformity that can complicate if not jeopardize third party reimbursements.  We can expect continued maldistribution of personnel.  We can expect uneven practice competency.

The occupational therapy profession is about to celebrate its Centennial Anniversary.  Confused and indecisive entry level education standards are not the way to put a best foot forward into a new century.


Smith, T., (October 5, 2009) "A Policy Perspective on the Entry into Practice Issue" OJIN: The Online Journal of Issues in Nursing Vol. 15 No. 1. 

Tuesday, August 04, 2015

OTD 45 day comment period coming to a close next week

This post represents continuing analysis of the process to change the entry level educational requirements for practicing occupational therapy from the masters level to the doctoral level.  The analysis is offered as a public critique of the occupational therapy profession's methodology for enacting such a change.

The 45 day comment period on a new rule that will authorize the conferral in New York State of the degree of Doctor of Occupational Therapy (O.T.D.) will come to a close at the end of next week.

The American Occupational Therapy Association reports:

In June 2015 AOTA staff also surveyed the 152 accredited master’s-degree-level programs, with 131 (86%) responding to the survey. Of the 131 programs that responded, 106 (81%) indicated that they had started working on a transition to the doctorate and planned to have this completed within 10 years (86 within 5 years). 

As I stated recently, "In my opinion the American Occupational Therapy Association Board of Director's 'recommendation' to move to the entry level doctorate is a dog whistle call to academicians to begin readying for a change to an entry level doctorate."  Looks like my analysis was spot on.

The American Occupational Therapy Association also reports:

What is clear from the data collected is that overall, the occupational therapy community is split on this issue, and that the overwhelming majority of participants in the dialogues see both potential threats and opportunities in moving the entry-level degree requirement to the clinical doctorate. 

I note the careful use of the word 'split,' which casually implies equal or near equal parts - but we are living in Orwellian times where words are carefully used this way.  A more accurate representation of this 'split' opinion in OT is probably near 75% in opposition and 25% in support.  Most of the support comes from academicians.

I based this on my own reading of the OT Connections forums and other social media sites and from the expression of opinion in the Town Hall at the AOTA National Conference.

The word-crafting does not end with the word "split."  It is also notable that in the Representative Assembly discussions nearly all the commentary from reps was negative.  On March 31 I posted the following in the RA feedback forums: (link is restricted to AOTA members)

AOTA members should take careful note of the strategies employed in the discussions about the move to an entry level doctorate. In several of the threads discussion was started - and that discussion was almost universally negative or hesitant about the move to an entry level doctorate. Then the Task Group Leaders in a couple threads suggested that Reps use a SWOT analysis in order to express their opinions, because "It will help when gathering and organizing the comments from the four task groups." Use of a SWOT analysis format FORCES reps into making statements that they were not naturally making. Prior to the directive, reps were responding naturally with perceptions of weakness and threats associated with the change. Now their comments are being naturally counterbalanced because they are being asked to include Strengths and Opportunities. Someone made the decision to ask for SWOT, and reps should all wonder where that request came from and why it was made. SWOT does not make data gathering any easier - all it does is balance out the feedback and artificially promote positive comments. That is how the thumb is placed on the scale and influences feedback. It is a detail that does not escape the notice of the membership who is watching this process closely. 

ACOTE will release the results of a survey of 3000 respondents sometime later this month.  It will be interesting to see the results of that poll, and an analysis will be posted here.

One refreshing point of honesty from AOTA was mentioned in their latest statement when they reported "It is likely that student debt will increase, and that continues to be a concern"

The debt issue alone should mobilize some students and parents to write a letter to NY State Department of Education and offer some feedback about the rising cost of higher education and whether or not there is evidence to continue escalating degree requirements and subsequent costs.

I posted a question on the NYSOTA Facebook page two weeks ago asking for their public comment on the OTD proposal.  That question remains unanswered.  According to NYSOTA documents from a couple months ago, there were 1308 student members, which constitutes approximately 65% of their membership.  Perhaps that is why they don't want to answer this question?

This change will probably happen anyway primarily at the whim of academics who have decided the issue for everyone else.  Readers have until next week to register an opinion with the NY State Department of Education.  Write to:

Office of the Professions,
Office of the Deputy Commissioner
State Education Department 
State Education Building 2M
89 Washington Ave.
Albany, NY 12234
(518) 486-1765
email: opdepcom@nysed.gov