Thursday, April 23, 2015

When it becomes more important to state 'why' you do something

If you ask 100 occupational therapists what they do you will get 100 different answers, because the nature of the profession is to help people do the things that are important to them.  Every patient has their own priorities, and that makes all the stories different.

Instead of focusing on the 'what' I like to focus on the 'why.'  When I need to be reminded 'why' I do what I do I like to drag this story out.

I knew a young family and they were unable to conceive.  After spending many thousands of dollars they made some arrangement with a young teenage mom so that they could adopt her baby (just about to be born).

So they go to get the baby and sign all the papers and get on the plane.  The baby was only a couple days old. On the way back home the baby goes into cardiac arrest and the new mom (a trained health care professional) gives this new baby rescue breathing and chest compressions. They are admitted directly into the intensive care unit when they get off the plane.

It turns out that the baby had several STDs: syphilis, gonorrhea, chlamydia, plus other bad infections including CMV - any of which could be deadly in a newborn. If that wasn't enough the baby had a poorly developed liver and developed a condition called necrotizing enterocolitis - they had to take out most of her small intestine as it had died inside her. They also put in a feeding tube and a tracheostomy (the baby's lungs were underdeveloped too and she couldn't breathe except with a ventilator). The baby also had a colostomy bag.

So the next eight months were a constant vigil in the ICU for these parents and their family. The feeding tube could never work properly so they had to provide liquid nutrition directly into an artery - a process called hyperalimentation. It is effective for the short term but ultimately will burn out your liver, and that is what happened to the baby. She became so jaundiced and sick that as a last ditch try they flew her to another city that had a great transplant program and prayed for a miracle. Unfortunately, the child's mesenteric artery which supplies the liver was also malformed and so she was not a candidate for any transplant. They sent her back to the hometown hospital.

Now I imagine that everyday these parents faced a fork in the road and could choose to either keep forging ahead or they could throw up their hands and give up. I am not sure if anyone could blame them if they did that - after all, they did not bargain for this situation: months in an ICU with a sick child that is not biologically theirs, and running up hundreds of thousands of dollars in medical bills (of course insurance companies at that time balked at coverage given the adoption and that this was 'pre-existing'). But the parents never quit anyway. They kept with it, every day, every night. Sleeping in chairs in the ICU. The baby had some moments of real quality - she was not neurologically impaired and so with regards to her cognition she was a normal 8 month old baby.

In the end, it was apparent that the baby was in pain, close to death, thrashing inconsolably, and jaundiced the color of yellow-green mustard.  The parents made an unthinkable decision and chose to end her life by withdrawing the ventilator support. The baby was alert and cognizant of her surroundings, which made the decision to withdraw support so much more complex. I can't understand the depth of love it took to do this for their child. Their child - not really theirs. But theirs nonetheless.

The baby died in her real mom's arms one night. After so many months in the ICU and with every day an act of love I think that these parents deserved to be called the baby's "real" parents, regardless of the biology.

This is not a story about heroic doctors.  It is not a story about caring nurses or diligent occupational therapists.  Most of the real stories and the daily events that are out there are about the people we care for.

I provide occupational therapy because every parent has an unbelievable mission to help their own child, and when things go wrong OTs help them do things that matter to them.  It is not so important 'what' you do because those stories will change with every patient and every family.

What matters is 'why' you do it.  I do it because it is all about human need and the value of normal occupation like the dreams and hopes of a family, even in the face of impossible situations.

This is a story that I use for the purpose of focus.

Thursday, April 16, 2015

On persevering in leadership and its relevance to free speech

An interesting quote was attributed today to Amy Lamb, the President-Elect of the American Occupational Therapy Association.  Here is the quote as it appeared on Twitter:

I initially consider that the timing of such a statement that "No means not now" could possibly be related to the recent decision by the US Senate to refuse to support the Cardin-Vitter amendment that would repeal the Medicare outpatient therapy cap.  Therapy leaders have been trying for many years to get the cap repealed and it was a stinging defeat.

I asked for additional context and clarity about the quote and was informed that it was generally stated as an important leadership principle.

The reason why this caught my attention is because of my own experience with the way that the occupational therapy profession deals with divergent opinions.

In 2013 I attempted to reach out to a former Ethics Commission Chair to discuss ongoing concerns with the Social Justice construct.  That Chair was not interested in any conversation, and instead of receiving a note from that person I received a letter from an AOTA attorney that stated, "I understand your perspective on the Social Justice provision of the Ethics Code, and would note that it is settled business at this time."  From the tone of that letter, the philosophy in play was clearly that 'No means no.'  In fairness, that attorney also stated that there might be opportunities to discuss matters when the Code was re-written (in 2015), but that turned out to be a false promise because there was virtually no dialogue allowed with the Ethics Commission members during the current revision period.  In fact, that lack of dialogue and unwillingness to engage the membership contributed to rather serious errors that have been pointed out regarding the Code that was just approved by the RA.

Another example was in conversation with another OT leader about a banal debate in 2014 regarding patient vs. client terminology.  Specifically, I was stating that a lack of philosophic consistency is present in our terminology and ends up getting reflected in our meandering and inconsistent focus on our definition of practice.  In that conversation I was told that "I would describe the “name” issue as essentially resolved in OT and a non-issue."  Again, since the conversation was not of interest to the leader, it was clear that 'No means no.'

These two examples demonstrate clearly that divergent opinions are not always welcome and that sometimes there is a disinterest in even hearing other people's opinions.  When people tell you that something is 'settled' or 'already decided' that is a rhetorical method that cuts off conversation.

In a rather stunning juxtaposition of the 'No means no' methodology there has been evidence of conduct that indicates that 'No means no' only when it is expedient to the beliefs of those in charge.  Specifically,  the OTA Ad Hoc Entry Level group conducted a study that clearly demonstrated the membership's disinterest in moving the OTAs to a bachelor-level degree, but then still advanced a motion to explore how to be successful if a change is ever desired.  There have been several statements by leaders about the entry level OTD issue that show a similar lack of interest in member input - 'The decision has already been made' and 'The entry level OTD is happening like it or not.'  These kinds of statements clearly show that 'No means no' only when applied in certain directions.

So the public statement that acknowledges the value of persevering is something new and I am hopeful that this philosophy will be applied evenly, particularly when members speak out about important matters.  This becomes important because of the new Code of Ethics that states that 'negative online comments' may constitute an ethics breach if someone believes that those comments serve to stifle conversation.  Obviously, persevering and lobbying a position to one person could be considered 'badgering' by someone who holds an opposing view.  This is a very dangerous provision in the new Code of Ethics that could be used to limit the participation of members.  Someone could simply state that another person's opinions are 'badgering' and 'limiting the speech of others.'  Such a provision is a serious threat to free speech.

This is why it was so interesting to see the statement about persevering in leadership.  I am very hopeful that this statement will be universally applied and that this might signal a new day for the way that occupational therapists deal with conflicting professional opinions on the important matters of the profession.

If 'no' actually means 'not now,' and if persevering is a value, then people should be encouraged to persevere in their opinions and lobbying whether or not anything has been 'settled.'  That is the ultimate value of free speech.

Friday, April 03, 2015

Continued evidence of confusing Christian charity with Social Justice

In the Open Journal of Occupational Therapy this month there is an opinion paper written by Barbara Hemphill entitled Social Justice as a Moral Imperative.  The position presented is that Social Justice belongs in the AOTA Code of Ethics, that it is embedded in the tradition of the OT profession, and that it is not a political matter.

There continues to be confusion and conflation between the concepts of Christian charity and Social Justice.  The author states that Social Justice is not political, but this is refuted by literature review.  The originators of this movement in the OT profession have overtly stated that social justice is political (Wilcock, 1998; Townsend, 1993).  This is an inarguable fact.  

I have already written rather extensively on the topic of whether or not Social Justice was a Core Value of the occupational therapy profession.  I don't have too much to add to that original essay and would point to it as my response to the author's assertions on this topic.

One additional point that requires rebuttal is the statement about the parable of the Good Samaritan.  The author states that this parable is an example of Social Justice.  Here we are able to understand the author's characterization, because the statement is attributed to Jim Wallis, who is a very controversial and left wing Christian activist.  Reverend Wallis is editor of Sojourner's magazine, which has received millions of dollars in funding from George Soros' Open Society Institute.  Reverend Wallis regularly espouses an extremely politically liberal viewpoint.  Referencing a politically partisan individual undermines the author's assertion that Social Justice is apolitical.

The specific reference that is used about the Good Samaritan is Jim Wallis' recently published book, "On God's Side: What religion forgets and politics hasn't learned about serving the common good."  With this kind of reference it is difficult to claim that the definition of social justice has nothing to do with politics.

Aside from that, the author seems to misunderstand both the parable and the implications of social justice.  Social justice requires resource (re)distribution in order to assure equity of outcomes.  However, the Good Samaritan did good deeds by his own charity.  When the man was robbed, the Good Samaritan used his own resources based on his own choices.  He did not run to catch up to the priest or Levite that had already passed the man on the road.  He did not make them hand over their wealth to give to the man who was robbed!  If he did, THAT would have been an expression of social justice.

Instead, he took care of the man himself. That is Christian charity.

Social Justice is political and does not belong in the OT Code of Ethics.  It is important to carefully look at the references used by those who are making claims that it is not political.


embedded links above, and

 Hemphill, B. (2015). Social Justice as a moral imperative, The Open Journal of Occupational Therapy, 3(2).  Available at

Townsend, E. (1993).  1993 Muriel Driver Lecture: Occupational therapy's social vision.  Canadian Journal of Occupational Therapy, 60, 174-184.

Wallis, J. (2013).  On God's Side: What religion forgets and politics hasn't learned about serving the common good. Grand Rapid, MI: Brazos Press.

Wilcock, A.A. (1998). An occupational perspective of health.  Thorofare, NJ: Slack, Inc.

Wednesday, March 18, 2015

On 3D printing technologies and The Nature of Gothic

We want one man to be always thinking, and another to be always working, and we call one a gentleman, and the other an operative; whereas the workman ought often to be thinking, and the thinker often to be working, and both should be gentlemen, in the best sense. As it is, we make both ungentle, the one envying, the other despising, his brother; and the mass of society is made up of morbid thinkers and miserable workers. Now it is only by labour that thought can be made healthy, and only by thought that labour can be made happy, and the two cannot be separated with impunity. - John Ruskin, The Stones of Venice.

3D printing technology is a new fad that is capturing the attention of occupational therapists.  The technology is disruptive, primarily because of cost factors, but as is often the case there are important considerations lying underneath the alluring new technology.

During the Industrial Revolution society developed technological solutions that made mass-produced items readily available.  People seem to enjoy showcasing achievement, and I can't help but notice the similarities between our celebrations around 3D technologies and the mid-century celebrations of the Industrial Revolution.  YouTube and Facebook are our new Crystal Palace at The Great Exhibition.  I am not sure that much has changed in the last 150+ years.

Reading Facebook testimonials on the use of 3D technology is a descent into feel-good hashtag exaggeration.  We spend 3 minutes oohing and aahing as an outsider technophile delivers a neon-pink prosthesis to a child whose limb has been blown off by a landmine, but what happens when those cameras stop rolling and the video is over? 

Cost is undoubtedly a disruptive factor - but is all this really as inexpensive as is typically touted?  There are rampant claims about prosthetic hands that can be made for $50 as compared to a standard hook prosthesis that might cost hundreds or thousands of dollars - or as compared to a myolectric prosthesis that can cost tens of thousands of dollars.  Is the new technology really only $50?  Who pays for the printer?  Does the third world country littered with landmines have electric power in remote villages in case a part breaks?  Does the third world country have an outsider technophile at the ready in all the remote villages to print and then assemble and then custom-fit the device?  So is it really just $50?

The allure of the technology causes people to overstate its utility - as has always been the case.  

The mass production of goods in the Industrial Age caused people to yearn for a time when artisans were responsible for the creation of their own products.  Ruskin and then Morris believed that aesthestics were lost in the sea of mass production.  They argued that this was not just a loss of beauty but that it was also a loss of humanity.

So how aesthetic and human is this?

I fully understand that function matters, but functional alone is not enough.  History has taught this lesson rather clearly.

Where is the Nature of Gothic in our new technologies?  We should look at our technologies as a first and faltering step toward improvement.  However, if we fail to address aesthetics, and if we fail to consider that machines will not replace the artisan skills required to deliver help to humans in need, then we will have lost much more than we have gained.

Tuesday, March 17, 2015

Occupational therapy and case management

There is an RA Motion for consideration that charges the RA Speaker to appoint an ad hoc committee beginning the summer of 2015 to delineate the role in case management for occupational therapy in primary care and mental health.

The rationale for the motion states that "The practice of occupational therapists (OTs) allows for the role of case managers, however, the profession recognizes the need for OTs to better define their role in the new model of care which is primary care and in mental health."

I would like to have a discussion about whether or not the core premise behind this rationale is valid.  I believe that someone trained in occupational therapy may have the requisite skills to serve as a case manager, but I am not convinced that the activities of a case manager constitute the practice of occupational therapy.  This is an important distinction.  If it is determined that this is not the practice of OT, then we should consider whether we should be allocating resources to supporting this employment pathway.

Based on my understanding of the literature on this subject, the role of 'case manager' has recently been pursued more in international contexts than it has in the US.  In fact, several articles have appeared in international journals debating whether or not case management was a legitimate role for the profession. (Krupa and Clark, 1995; Lloyd and Samra, 1997; Culverhouse and Bibby, 2008; Michetti and Dielman, 2014).  Based on a reading of this literature, it hardly seems settled that this is a legitimate role of OT practice.  There is less evidence for this role in the US literature.

AOTA published a statement on this topic in 1991 but I couldn't find anything updated since then.  For a long time OTs have served in case management roles.  The AOTA statement says that OTs might serve as case managers but that many other professionals do as well.  In a response to a letter about this issue, Mary Jane Youngstrom (2000) stated that it was difficult to discern  what was the 'practice' of OT vs. what was 'using OT skills and knowledge.'  It is an old theme and has been repeated many times throughout our history.

The question remains pertinent today.  

Case management, per se, is not a recognized domain of concern in the OTPF.  There have been changes to the Scope of Practice documents and the OTPF that support the concept of advocacy, but these have been controversial - particularly in context of the ongoing debate about social justice/occupational justice.

I do not see adequate justification that case management is OT practice.  I see that it is definitely something that someone may do with their OT skills and knowledge.  Delimiting our practice is critical, particularly if we are interested in re-engaging and defining our roles in mental health.  

Unfortunately, OTs are not doing a good job at explaining their proposed role in mental health.  Case management is a distinct role.  Consultation to systems (trauma informed care) is another distinct role.  Treatment of patients is a distinct role.  I don't get the sense that there has been a well thought out strategy about what will delimit our practice as we re-engage.  That is a problem in my perspective.

Rather than pursue another half-baked strategy that confuses stakeholders about what OT is and what it does, I believe that we should all get on the same page and make coherent internal decisions before we approach others about how we will define our practice.


AOTA (1991). Statement: The Occupational Therapist as Case Manager. American Journal of Occupational Therapy, 45(12):1065-1066.

Culverhouse, J., & Bibby, P. (2008). Occupational therapy and care coordination: the challenges faced by occupational therapists in community mental health settings. British Journal Of Occupational Therapy71(11), 496-498.

Hafez, A., & Youngstrom, M. (2000). Case management practice. American Journal Of Occupational Therapy54(1), 114-116.

Krupa, T., & Clark, C. C. (1995). Occupational therapists as case managers: responding to current approaches to community mental health service delivery. Canadian Journal Of Occupational Therapy. Revue Canadienne D'ergoth√©rapie62(1), 16-22.

Lloyd, C., & Samra, P. (1997). Professional issues. Occupational therapy and case management in mental health rehabilitation. British Journal Of Therapy & Rehabilitation4(2), 91-96.

Michetti, J., & Dieleman, C. (2014). Enabling occupational therapy: moving beyond the generalist vs specialist debate in community mental health. British Journal Of Occupational Therapy77(5), 230-233. doi:10.4276/030802214X13990455043403

Saturday, March 07, 2015

Daylight savings time and temporal contexts and stuff

Sometimes concepts all just pile on at once.

This morning I was putting together some lecture material for a class where I will be discussing contextual factors and why they are important to occupational therapists.  Ironic.

Contextual factors are defined as interrelated conditions that are within and surrounding the person.  We generally break them down into personal, cultural, virtual, and temporal categories.

The reason why it is ironic is because someone told me today that it is my Dad's anniversary.  Not really.  It is the anniversary of his death - five years ago now.  I never consider that it is his anniversary.  The five years since that event is an important example of temporal context, or maybe it is supposed to be.  Temporal contexts refer to stages of life, times of day or year, duration and rhythms of activity, and even history.  Basically, they provide a backdrop of time for the way that we consider things.

I don't always process time in quite the same way as other people, I notice.   I have a picture on my desk of when I was 4 years old and my Dad is holding my hand as we are walking down the steps of my grandmother's house.  It could have happened yesterday, by my reckoning.  It is kind of a timeless photo to me and it represents something that I don't want to ascribe time to.

Same goes with the way that I perceive some of my friendships.  I have been friends with a couple guys in my hometown since we were all kids.  I don't see them often, or even have contact with them on any social media.  But when I go down there, no matter how long it has been since we have seen each other, we just pick up as if we had all seen each other yesterday.

Today is also the beginning of Daylight Savings Time.  It is a concept that I have abhorred my entire life.  I can wrap my brain around some pretty heady concepts, but don't ask me to interpret what has been lost or gained around Daylight Savings Time.  I just don't get it.

Thoreau said "Time is but the stream I go a-fishing in.  I drink at it; but while I drink I see the sandy bottom and detect how shallow it is.  Its thin current slides away, but eternity remains."  I read that when I was 15 years old, flying across the country for a visit to family in Washington State.  Up until that time, I don't think I can recall a quote that made more sense to me.  That is why I remember reading it for the first time so vividly.  I can't even express how tickled I was to learn how transcendental concepts worked their way into the thinking of some OT founders.  Seriously, in consideration of all things that can happen in a person's life, how likely is it that one of the first quotes that ever made sense to me also happens to form the basis of a philosophy of self-reliance and autonomy that people built a whole profession around?  That's pretty amazing.

Anyway, I don't do time jumps.  I don't know what Daylight Savings Time means.  I don't forget history or say, 'The past is the past' because to me it just isn't - it is all a part of the eternity that we are floating in.  And five years ago is the same as yesterday.

That's about all I have to say about temporal contexts.

Tuesday, February 24, 2015

The American Occupational Therapy Association: The new 'Concern Troll' in school-based mental health

Concern Troll: (noun) A person or persons who pretends to be 'concerned' about something and talks about it, all the while serving to actually disrupt the legitimate concerns and activities of people who are trying to address problems. Concern trolls are particularly skilled in derailing conversations, conflating issues, and leading people off track.


AOTA recently released a new document on use of restraints and seclusion related to school based practice.  I will not link that document because I believe that it is fundamentally flawed and does not represent the thinking of many people who actually practice in school settings.  There is no value in spreading that faulty document, but I will describe the problems with a hope that more conversation will be generated about the issue broadly.

The paper has some positive aspects, including identification of the role of OT in helping teams understand and interpret personal and contextual factors that might lead to disruptive or dangerous behaviors.  OTs have good skills and abilities to participate on those teams.

However, the document takes a sharp turn off course.  The authors describe the negative problems with 'occupational deprivation' caused by restraints and seclusion practices and that OTs need to work on school teams to provide 'occupational enrichment' to counteract the alleged systemic or habitual use of restraints in schools.

I am uncertain if it is really appropriate to refer to therapeutic use of restraints in context of how scholars have defined 'occupational deprivation' in forensic or refugee or war contexts.  Restraint use in a treatment context usually has to do with preventing harm to self or others and is only used in a last-ditch context when all other methods have failed and only to prevent harm.

Certainly there are problems with the use of restraint but that has more to do with the de-professionalization of care teams and lack of oversight or sound policies in 'treatment' contexts than it does with forensics or willful removal of rights in a punishment or war or refugee context.  When there is conflation between the two it sounds as if OTs are confused that we are still in a pre-Moral Treatment period, which of course we are not.

When a restraint method is used the issue of 'occupational deprivation' is not a factor.  The only factor that I am aware of is to prevent harm or injury.  Restraint methods are time limited and there is no 'occupational deprivation' associated with their use.   Conflating time limited restraint methods to prevent  harm and injury with 'occupational deprivation' (whatever that is) is ridiculous.

Also, conflating special education placement itself as a form of 'occupational deprivation' is an extreme and unusual perspective that does not comport with reality.  This is perhaps the most odd belief expressed in that document.

This bizarre concern about 'occupational deprivation' is fueled by the 'Trauma-Informed Practices' movement.  The notion underlying this movement is that care providers need to be sensitized to the trauma that many people who have emotional and behavioral disorders have lived.  Then with this new-found sensitivity they can engage in non-specific practices to help people understand the root causes of their behaviors.  It is all about being more SENSITIVE and CARING.  An entire industry has cropped up on how to create a Trauma-Informed Care Team.

Instead of attending conferences and writing papers and conducting trainings I would like to see OTs actually working in behavioral/mental health programs themselves and doing something DIRECTLY to address these problems.

The entire 'trauma informed' movement is  the ultimate in hashtag advocacy.  We fail to understand that the real reason that care systems are sub-optimal is because professionals have abandoned those treatment settings and left them in the hands of marginally trained people.  Then we complain when the marginally trained people aren't functioning the way that we want them to.

Instead of working in those populations ourselves now we have a giant push to 'educate' people and to make sure that they 'assume' that everyone in these settings has experienced trauma, and to 'train' staff to approach things with an improved sensitivity.  Maybe if we all FEEL BADLY ENOUGH about the problem it will get better!

It is Moral Treatment Redux.  Just like the first Moral Treatment movement failed this one will too - because the real answer involves investment of resources so large that no one is really willing to make that commitment.  It only took a short time before the beautiful design plans of the 1850s reverted to stinking cesspools that were labeled 'SNAKE PITS.'  Then we had a generation of new hope in a civil rights movement that de-institutionalized everyone but failed to really meet other needs.  And here we are again with a whole new generation of feel-good advocacy that puts the responsibility on the 'other' care providers.  Professionals of ALL STRIPES have abandoned treatment of people who have chronic conditions and REPLACE CARE with FEELING BADLY as if that will serve to purify themselves of guilt with their faux CONCERN.

People who care go out and do something about problems.  LIKE ACTUAL TREATMENT.

They don't attend conferences so they can be SENSITIZED about HOW HORRIBLE THE WORLD IS TO PEOPLE and how to MAKE OTHER PEOPLE TAKE CARE OF THINGS.

It is all about Dirty Jobs, that TV show that so many people love to watch.  We have a fascination with the work, but no interest in doing anything about it other than deep-sitting on our couches in the comfort and safety of our living rooms and then exerting just enough effort to lift our finger to turn up the volume.

This is why I label this movement as 'Most likely to bore the pants off of anyone who really cares.'

So now we have found a NEW PROBLEM of restraint use and we will label it in our own made-up terms of 'occupational deprivation' and we will conflate restraint use with some horrible injustice that the world is perpetrating on people.  Because there is no real leadership on TREATMENT of people who have mental illness the AOTA response is to turn us all into CONCERN TROLLS and will have us all attend conferences and then present on 'Trauma Informed Care' so that 'those other people' who are tying up school children and throwing them into rubber padded rooms will do a better job.

I strongly suggest that if the AOTA wants to get back into the business of providing services to people who have mental health problems, that it actually start with providing services to people who have mental health problems.  This current track of coming up with 'new problems' and calling it 'occupational deprivation' and promoting 'trauma informed models' seems a little bizarre.

Can occupational therapists predict the future?

There is ongoing debate on the AOTA forums about move to an entry level doctorate.  Within that debate there is repeated discussion about the 'future.'  I am very interested in the concept that occupational therapists should attempt to 'focus more on what COULD and SHOULD be different for practitioners graduating in the future.'

Prognostication is an interesting endeavor, and I am wondering if this is something that most occupational therapists really have the skill set to accomplish.  I don't believe that there is evidence to support OTs having these skills.

R. Buckmister Fuller, who in my opinion was a tremendously gifted anticipatory design scientist, felt that he had an ability to prognosticate based on his model of integrative systems thinking and on his naval training in navigation and ballistics.  
In his book 'Operating Manual for Spaceship Earth' he explained how some people felt that he was 1000 years ahead of his time, which puzzled him because he did not understand how others thought they could understand events 1000 years into the future when he only felt confident about analyzing 25 year scientific, industrial, and innovation cycles.  As he got older, some people said that he was 'behind the times.'  An analysis of these varying assessments of his ability seems to be a good example that most people have absolutely no ability to prognosticate reliably or to assign time values to future events.

Nonetheless, this does not seem to stop people from thinking that they have the ability to prognosticate.

I thought it would be interesting to look at the accuracy of occupational therapy prognostications - so I would like to refer everyone to the special meeting of the Representative Assembly in 1978 that was held on 11/8 through 11/12 in Scottsdale Arizona.  The purpose of the meeting was to direct the course of the profession for the coming decades and to hear the thoughts of leaders of the profession at that time.  The thoughts of these leaders is encapsulated in a series of lectures that were published under the title Occupational Therapy: 2001 AD.

Several of the authors were so mired down in 1978 concerns that they could not really offer much specificity about the future.  At the time of the conference Wilma West and Alice Jantzen were talking about whether we would be a professional or a technical vocation.  This ended up being such an esoteric concern that by the time 2001 rolled around no one was really discussing it any longer.  

Nedra Gillette suggested that we would require post professional training in order to achieve 'professional' status, but it seems that professional status was conferred more by a robust certification process and state licensing than by conversion to graduate education, which didn't end up happening until 2007.  

Ruth Weimer thought we should develop knowledge in economics so that we could convince others of our value.  I don't know that we accomplished that; today OT persists in many environments by legal mandate and not because it is a 'valued service.'  Jerry Johnson focused mostly on the present failings of the Association and difficulties in responding to member needs.  

Elizabeth Yerxa focused on socialization requirements between what made for a caring and empathetic OT vs. what would be required to seize power and exert control in a professional context.  I think she failed to understand that the future would create a context whereby if someone raised this issue today that they would be accused of genderism.  Gail Fidler took Yerxa's comments and overtly discussed her perspectives on the fact that OT is a female dominated profession.  I can state with confidence that these kinds of conversations would not be openly appreciated in 2001.

Florence Cromwell believed that the proper place for OT would be in helping people with chronic illness.  It seems that she did not see the trends of OTs abandoning mental health, adults with developmental disabilities, and other populations of people with chronic health problems.

Mae Hightower-Vandamm's presentation stood out in that she took very bold positions on what she thought the future would hold.  She thought that AOTA would have 80,000 members in 2001.  She also thought that cities would not be able to handle conferences so there would be regional conference centers where there were no hotels but just modest rooming for attendees and that food would be available in a concentrated capsule form designed to be ingested with a liquid nutrient.  She actually wrote that.

She also believed that OTs would be integral to the unemployment system.  OTs would be available 24 hours a day, in shifts.  She was kind of repeatedly interested in closed circuit TV, thinking that it would be used for education as well as for certification.  Kind of like the Internet, I guess.  She was close on this one.

She thought that OT Aides in hospitals would be 'Quasar Men' and they would be programmed to do all craft preparation, monitor the clinic for safety, clean up, and transportation.


There is not much evidence to consider in analyzing OTs ability to predict future events.  In 1978 there was a concerted effort to plan for 2001, and important leaders at that time were overwhelmed with 1978 issues as opposed to what would be needed in order to move forward.  The primary issues at that time were concerns with professional vs. vocational training, inability to precisely articulate a scope of practice, and other sundry issues such as career laddering for OTAs, dominance of women within the profession, generalist v. specialty practice, and inefficiencies in professional training and in the Association itself.  Most of the OT leaders at that time were skilled in discussing present day concerns.  Most of those concerns were interesting, but few if any of them have ever been fully resolved.  Most of the OT leaders kind of avoided discussing the future even though that was the point of the conference.  Those who did discuss the future were generally off target.

Watching the current AOTA leadership seems similar.  They seem aware of problems (like the structure of the Association) but are not able to mobilize resources to change much.  They seem to be aware of the Affordable Care Act, but focus on primary care models that don't reflect any current realities of practice on a large scale.  They seem to value evidence based models, but can't grasp the reality that pediatric practice is rife with snake oil.  They understand that OTs abandoned mental health, but it is all a little johnny-come-lately.  They understand that there are opportunities for OTs in new areas of practice, but we have an academic faculty that is largely divorced from the clinics.  In sum there is a big focus on articulating current problems, but the solutions constantly fall short of fixing anything.  OTs seem to have skill in articulating present day problems.  OTs just are not skilled in prognosticating the future.

I believe that the status of the profession in 2014 is the same as it was in 1978 - the only difference being that there are different present day concerns on the table.  The French have a saying for this: Plus ca change; plus c'est la meme chose.  Translated, the more things change, the more they stay the same.

I am concerned that we are asking members to plan for the future.  Leaders don't seem to have good ability to plan for the future.  As an example, we are told that we need an entry level doctorate as a single point of entry for the profession.  A lot of ancillary issues about current problems are discussed, but there is no real evidence to support the recommendation.  I previously mentioned that OTs are skilled in chasing trends but not so much in leading change themselves.

For this reason I will place the prediction of this 'need' for entry level doctorates in the same category as the Quasar Man.  It is an interesting idea, loosely sensible on a superficial level, but lacking in any real substance of justification and practicality that is necessary to support its existence.

AOTA (1979). Occupational Therapy: 2001 AD. Papers presented at the special session of the Representative Assembly, November, 1978.  Rockville, MD: AOTA.

Fuller, R.B. (1968). Operating manual for Spaceship Earth, Carbondale: Southern Illinois University Press.