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.

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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.

SUMMARY:

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.

References:
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.

Wednesday, February 11, 2015

Can use of an occupational justice model in an American context result in accusations of professional misconduct?

Can use of an occupational justice model in an American context result in accusations of professional misconduct?

Conceptual practice models are interrelated bodies of theory, research, and practice resources that are used by OTs to guide practice (Kielhofner, 2009). One such conceptual practice model is the Occupational Justice Model (Townsend, 1993; Townsend and Nillson, 2010).  According to these sources, the Occupational Justice Model is framed around the concept that injustice occurs due to inherent governance and social structures that allegedly restrict the occupational performance of some populations and individuals.

Concepts associated with occupational justice models have filtered into some official documents of the American Occupational Therapy Association.  For example, the AOTA 2010 Code of Ethics included a new principle of 'Social Justice' (AOTA, 2011).  That new principle required occupational therapy personnel "to provide services in a fair and equitable manner and to advocate for just and fair treatment ... and encourage employers and colleagues to abide by the highest standards of social justice and the ethical standards set forth by the occupational therapy profession."

The social justice requirement has been controversial.  The challenge with this requirement is that there has not been any corresponding statements that provided meaningful guidance on what practicing in a social justice context means for practitioners.  Disagreement about social justice terminology and whether this philosophy was congruent with OT Core Values has been a significant debate that has lasted over four years.

Occupational justice is also mentioned in the new (3rd) edition of the OT Practice Framework (AOTA, 2014).  This document states that children who have psychiatric disabilities placed in alternate schools face occupational injustice because they may have limited opportunities to participate in sports, music programs, and organized social programs (p. s9).  No specific references are provided for this claim, and this is not in accordance with my own lived experience as an occupational therapist, so I must assume that this reflects the observations of a therapist who last practiced many years ago, perhaps pre-dating 1973 when federal law prohibited such discrimination. 

Nonetheless, whoever wrote the Practice Framework also believes that such discrimination occurs in other settings as well.  Other examples provided (p. s9) are residential facilities that don't allow people to engage in meaningful role activities and poor communities that lack accessibility and resources.  Again, this is not in accordance with my lived experience as an occupational therapist in the United States, so I am thinking that whoever wrote this must have been reflecting on some mission trip to a former Soviet-bloc country's orphanage, or something.  I am very aware that conditions of such institutions are rather grim in some parts of the world.

The fact that the OT Practice Framework 3rd edition includes elements that are grossly out of step with reality of practice in the United States is something that probably requires some discussion and hopefully correction.  This is particularly true because this document is used so heavily in academic programs to teach students how to practice and is referenced in many other AOTA documents.

The AOTA Practice Framework 3rd edition states that OTs "work to support policies, actions, and laws that allow people to engage in occupations that provide purpose and meaning in their lives." (p. s9).  Outcomes of interventions for populations "may include health promotion, occupational justice and self-advocacy, and access to services." (p. s16).  Specifically, related to outcomes, the AOTA Practice Framework 3rd ed. references the work of Townsend and Wilcock (2004).

The Canadian Association of Occupational Therapy has published helpful information about how to practice from Townsend's occupational justice model (Wolf et al, 2010). In the article an example is given about occupational deprivation.  The example is a child who has developmental delay and limited access to toys because of poverty.  According to the article, "the injustice is predicated by a social system which does not provide enough funding to support children’s development."  The therapists actions as a result are to write letters to politicians, obtain grants, and other advocacy activities.

Surprisingly, the document does not state that the therapist actually addresses the motor delays.

The problem that I see with this practice model is that it does not reflect any reality that I have experienced in almost 30 years of practice.  Actually, most therapists I know would have given the child toys themselves, left toys for the family to use, or referred them to a toy lending library, or placed them on a list to receive charitable donations like from the US Marines Toys for Tots Foundation.

While doing all of this the therapist would be working with the child and family on the motor delays.

Maybe a therapist would develop a side interest in obtaining grant funding but that would be a long term project and certainly not tied to outcomes for any one specific child.  Using this occupational justice framework to address problems of occupational deprivation seems to be a disconnected and confused idea that does not reflect actual practice.

It is important to note that this article is written from the context of Canadian practice, about which I claim no expertise at all.  However, using this occupational justice model in a United States context could cause the well-intentioned therapist to be accused of professional misconduct.

Specifically, a therapist in the United States could be accused of failing to respect the procedural rules and laws associated with care of children that age.  Those procedural rules and laws do not support the advocacy activities of writing political letters as a part of OT practice.

Additionally, there could be accusation of failing to address those issues that ARE within the scope of practice, particularly the specific client factors (developmental delays) that the therapist found were severely delayed.

Unfortunately, the guidance provided by Wolf et al (2010) is that "occupational injustices like those faced by Sarah and her family cannot be resolved at an individual level" and that "occupational justice is achieved through a change in social attitudes which acknowledge the value of diversity and support the engagement of all persons in meaningful occupations." I am not sure if writing letters to politicians in Canada is a legitimate intervention method for occupational therapists.  American therapists attempting to get reimbursement for writing political letters that might have some long-term or downstream impact on the person who is supposed to be receiving help now would generally not be considered occupational therapy.

Therapists might engage in varying degrees of advocacy-related activities depending on their own philosophies and inclinations.  That is very different than using advocacy activities as intervention as this model proposes, particularly in context of using them and NOT providing actual occupational therapy to address those developmental delays.

American therapists using an occupational justice model could reasonably expect a threat of disciplinary action.  I am hopeful that by pointing out the dangers of an occupational justice model applied in an American context will cause the American Occupational Therapy Association to reconsider its reference to these models in its official documents.


References:

see embedded links

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

AOTA (2014). Occupational Therapy Practice Framework: Domain and Process, 3rd ed. Bethesda: AOTA Press.

Kielhofner, G. (2009). Conceptual foundations of occupational therapy practice.  Philadelphia, PA: FA Davis.

Townsend E. (1993). Muriel Driver Memorial Lecture: Occupational therapy’s social vision. Canadian Journal of Occupational Therapy, 60, 174-84.

Townsend, E. and Nillson, I. (2010). Occupational justice: Bridging theory and practice. Scandinavian Journal of Occupational Therapy, 17, 57-63

Townsend, E. and Wilcock, A. (2004). Occupational justice and client centered practice: A dialogue in progress. Canadian Journal of Occupational Therapy, 71, 75-87.

Wolf, L. et. al. (2010). Applying an occupational justice framework.  OT Now,  12, 15-18.


Monday, February 09, 2015

From Social Gospel to the New Deal: A values juxtaposition that has been whitewashed by OTs

I was interested to see some comments from Dr. Elizabeth Townsend (2015) in an online forum asking "How are we building leadership for key posts at universities in support an [sic] occupation focus - both in the science and therapy of occupation?"  She asked this question in context of an open position at Dalhousie's School of Occupational Therapy in Halifax, Nova Scotia but was interested in a more general sense of how to build leadership outside of large metropolitan areas. 

This interested me because I have been studying recruitment and spread of occupation workers at the time of the founding of the occupational therapy profession.  I began to wonder if a study of this history could provide context for interpreting the current recruitment call.

An important early supporter of proto-occupational therapy was a man that is not often cited in American textbooks.  Sir Wilfred Thomason Grenfell is described as a "physician, medical missionary, social reformer, and author."  I encourage readers to visit this link and study the life of Grenfell who was quite an interesting person.  I have been reading all of Grenfell's books and have been particularly interested in what drew him to Newfoundland and Labrador to do his mission work.

In a previous blog post about the Core Values of the occupational therapy profession I stated 
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 ...

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.

Dr. Grenfell was similarly motivated and he discusses his religious conversion and values in his books (Grenfell, 1910; Grenfell, 1927).  He knew that he had to recruit others to help him with his work, and he was impressed with Jesse Luther, who was an early occupation worker often associated with Dr. Herbert Hall (Rompkey, 2011).  Luther's roots extend all the way back to Hull House, where her 'occupation work' actually pre-dated the work of Eleanor Clark Slagle (Rompkey, 2011). 

So I was reflecting on Grenfell and Luther when I read Dr. Townsend's call for recruiting into the far Eastern portion of Canada - and I thought of what motivated the first occupation workers to that region and how different that was from Dr. Townsend's interest in social justice (1993).

There is evidence of conflation between Christian philanthropy and 'social justice' in the occupational therapy literature (Harley and Schwartz, 2013; Head and Friedland, 2011).  It is important to consider that 'social justice' was not even conceptualized until after the New Deal that placed the government into a position of resource redistribution (Rawls, 1971).

This is what makes Dr. Townsend's call to Eastern Canada somewhat ironic in context of the history of the profession and in context of Grenfell and Luther's mission work there.

Grenfell, like many of his contemporaries at that time, were interested in solving social problems.  The Social Gospel movement was an application of Christian theology to social problems.  It is very unusual that this movement is completely left out of conversation about the founding values that motivated the philanthropic work of Jane Addams, Phillip King Brown, Wilfred Grenfell, Elwood Worcester, and so many others.

It is true that the Social Gospel Movement was not cohesive, with some branches promoting philanthropy and other branches promoting collectivism and labor movements. As governments became more involved in welfare acts, philanthropy took a back seat.  This is described in excellent detail in an analysis by Harnish (2011) who writes:
Charity has long been described as an expression of God’s love as opposed to a policy measure aimed at lowering the unemployment rate or the labor hours necessary to buy a loaf of bread. As an expression of God’s love, charity knows no boundaries; it goes to friends and enemies alike—quite a difference from redistribution measures, long known to be but another means of funneling cash and favors in order to secure political reelection. Further, charity is a religious virtue and an ethical statement. It claims to be capital “G” Good and a worthy choice for human action simply because it is a reflection of God’s fixed and eternal nature. This claim the Social Gospel rejected outright. The only place left to find a justification of its welfare-state measures was...the refuge of pragmatic successes.

There is evidence that Christian Ethics motivated the majority of proto-founders who were interested in the 'occupation cure.'  Some of that may have morphed into seeking governmental programs to prop up their philanthropic efforts, particularly in context of financial stressors in trying to meet severe needs.  Some of that may have been pragmatic more than philosophic, particularly in consideration of the very overt religiosity that was expressed by those proto-founders.

So now there is a new call for OT leaders in Eastern Canada - and that call is in context of a new Social Justice that is rooted in a model of governmental control and redistribution of resources.  That call occurs in a whitewashing of our actual history that is rooted in philanthropy and Christian Ethics.

Understanding our history provides us a proper context for examining where we are.  Understanding our history also provides us with meaningful background information to evaluate the current value system and philosophic trajectory.

My how things have changed in 100 years.


References:

(see embedded links)

Grenfell, W. (1910). A Man's Helpers. Toronto: Musson Book Co.

Grenfell, W. (1927). What Christ means to me. Boston: Houghton-Mifflin.

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.

Harnish,  B. (2011). Jane Addams's Social Gospel synthesis and the Catholic response: Competing views of charity and their implications.  The Independent Review, 16, 93-100.

Head, B. and Friedland, J. (2011, Jan/Feb). Jesse Luther: A pioneer of social justice.  OT Now, downloaded from http://www.caot.ca/otnow/jan11/luther.pdf

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

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

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

Townsend, E. (2015, February 8). Advancing occupational science and occupation-based practices globally - how are we building leadership for key posts. Message posted to https://groups.google.com/forum/#!topic/occupational_science_intl/ajdBHCjjVk8

Thursday, January 22, 2015

Follow up on 'Ways you will be paid'

Follow up to PTE Speech in 2012: Ways you will be paid.

I said in that speech that "The people who need you the most might not be able to pay you the most."  I thought about that this morning, because several things that I did are not 'reimbursable.'

The idea of my talk to those students was to tell them that over the longer course of their careers that it is likely that they will make enough money to repay their student debt, but that it would be short-sighted to measure success in monetary terms because sometimes the ways you are paid can't be identified as a quantifiable amount in your Account Receivables, or it might not be noticed by the widget counters that reside in the Halls of Productivity, Outcomes, and Cost-Control.

This morning a mom called to cancel their appointment, and then asked sheepishly, "I have a question, and I hope that you don't think it is silly.  My son deleted his Minecraft world and do you have any idea how we might be able to get it back?  He is just beside himself and it is really a concern for us."

The reason why I loved this question is because somehow this parent received the message that I am in tune with children's interests, and she also received the message that I care about her child.  I don't consider her question silly at all; in fact, it might be the best question I have been asked in a really long time.

So I researched the Minecraft problem and provided a solution that I hope might work.  I spent an hour on the issue, because "Needs are an indispensable part of human nature, and imperatively demand satisfaction," and if she thought enough of me to ask that question then I have a responsibility to generate a top-quality response.  I also made a note to myself to check on the child's situational coping over this issue, because we have been working on coping skills in therapy.  There is no CPT code for this, but that is why I got to thinking about my PTE speech.

My second non-reimbursable task was writing a letter to a child's MD.  The parent brought the child to see me due to concerns with intolerance to clothing.  The mom carried the child into my office, and all the while the child was having an Epic Meltdown.  No developmental or sensory assessment was possible, and based on the whole interaction it was obvious that there were some acute contextual elements that were contributing to the Epic Meltdown.  After 30 minutes the parent was able to get the child back OUT the door, and the entire encounter that is not a billable encounter was a stressful event for both the parent and the child.  After they left I called the pediatrician and wrote a letter of my observations and recommendations.  I hope that they can help the family with those acute contextual problems, because they are clearly in distress.  There is no CPT code for this either, and that is why I got to thinking about my PTE speech for a second time today.

I write about this because I feel some frustration.  I am NOT frustrated about the parents or the children.  I am NOT frustrated with the lack of CPT codes or that these are not reimbursable activities.  I am frustrated because it bothers me to see our profession slip into the clutches of 'care' models that are all about accountability, documentation of outcomes, cost-savings, designated care pathways that are 'evidence based,' etc etc.  All of that is fine, and I don't really disagree with many of the conceptual values, but when we adopt those 'care' models we also generally lose our focus on the kind of caring that people needed in my office today.

Today I was not productive by the measure of my accountant or by Higher Powers that place quantifiable metrics on my activities.  But actually I was very productive by the measure of the people who needed help.

Like I told those PTE students, I have a Faith that the financial piece will all work out in the end.  And in the meantime, I keep reminding myself that "The people who need you the most might not be able to pay you the most.  Pay you the most money, that is."

Wednesday, January 21, 2015

The hands of a pediatric occupational therapist

When I get home from work I have things to do, like everyone else, and sometimes those things make my hands dirty.  Sometimes it is some minor maintenance on my car, or repairing something in the house, or doing a little gardening.  I know that I have to scrub my hands clean after these activities so that there is no evidence of dirt or paint or grease.  I keep my fingernails very short for precisely this reason.

What would I tell a parent the next day - that I have the residual stain of grease on my hands because I was elbow deep into my engine compartment the night before?  I suspect that most parents would understand, but it would not feel comfortable.  If you work on cars or paint a room you know how difficult it is to remove all traces of those occupations from your hands.

Cultural stereotypes abound surrounding the nature of a person's hands.  We even have idiomatic language about 'getting your hands dirty.'  This is a positive concept that means someone is not afraid to engage something or to work on something 'hard.'  Oddly, we have an opposing idiom about 'keeping your hands clean' which is supposed to be a positive attribute also.  I find it interesting that we have developed language with opposing analogies that are both meant to reflect something positive.

I guess I try to keep my hands clean, but I am not afraid to get them dirty when it is required.

My hands get 'dirty' in my job as an occupational therapist also.  A parent came in this morning and as I joyfully picked up her two year old into my arms she looked at my hands, which were undeniably marked by my occupations earlier in the morning.  "Looks like you have been doing some coloring with markers today, Dr. Chris!" she said with a smile.  There was no concern that my hands were 'dirty' because every mom knows that even the so-called water soluble markers don't come off in one scrubbing.

I guess that people ascribe meanings to things based on their perceptions.  The marker on my hands was a sign to this mom that I was elbow deep in trying to help some child learn how to write, and that made her smile.  It is a different kind of engagement than working on my car or in my garden, which might not have been met with a smile, even though my hands would have been no less 'clean.'

I guess there will come a day when I will no longer have marker all over my hands.  Someday I will not have to be so cognizant about how my hands look.  But today it is still a badge of engagement and I will wear it with honor.  I am a pediatric occupational therapist, and this is what my hands look like every day.

Wednesday, January 14, 2015

The impossibility of standardized international theory in occupational therapy

I was interested to read the comments of Dr. Moses Ikiugu who is a candidate for AOTA delegate to WFOT.  His full post addressing the AOTA's future priorities in context of the Centennial Vision can be found here.

First of all, I would like to thank Dr. Ikiugu for sharing this thoughts because this is an important topic and not all candidates take the time to document their positions.

One of his more interesting comments was a call for WFOT to develop and support  theory-based clinical decision-making.  He states:
The hallmark of professionalism is the ability to explain how what we do in the process of providing our services works to address the problems that are within our domain of practice. This explanation usually comes from the theoretical base of the profession. That is why we should develop a strategy to ensure that theories that guide occupational therapy practice are clear and every occupational therapy practitioner in the world can use such theories to guide clinical decision-making... What seems to be problematic as indicated by may (sic) research reports (see for example Ikiugu, 2012) is the lack of uptake of these theoretical conceptual practice models by the rank and file of occupational therapy practitioners. If we are to survive as a profession, this adoption of theory-based clinical practice is essential. WFOT should ensure that this threat to our survival is addressed by developing policies that define global standards for theory-based clinical decision-making in the profession. As a delegate, I would strongly advocate for such a strategy.

I am interested in the idea that there could be global standards for theory-based clinical decision making.  I am also interested in the idea that 'rank and file' practitioners resist the use of theory-based clinical decision making. 

The reason why this concept makes me pause is due to the vast literature that has been generated by academics who are interested in the notion of multiculturalism and occupational therapy.

As a starting point of definition, multiculturalism relates to recognition and action related to the rights of minority populations within a society.  It can be held against the notion of cultural assimilation, which is the dominant American model that was popularized by Zangwill's play 'The Melting Pot.'

Hammell (2010) was concerned about theoretical imperialism, which she defines as power structures that would force theoretical constructs on less powerful people.  Kinebanian and Stomph (2010) believe that we need to reflect on "the underpinning values of occupational therapy which until a decade ago were mainly derived from white middle class norms and values.  Individualism, independence, and autonomy are highly valued in western societies, whereas collectivism, interdependence, and communalism might be valued more highly in other cultures.  However, it seems that the influence of these western norms and values is diminishing due to rapidly changing international relationships."

There have been many calls from leaders in the occupational therapy profession to "embrace diversity." (Abreu and Peloquin, 2004; Iwama, 2007; Clark, 2013).   A common theme in all of these calls is that there is intrinsic discrimination based on power differentials between people and that the most correct pathway to address those problems is by promoting multiculturalism and the idea of 'cultural competence.'

Despite all of the internal conversation about diversity, some authors remain critical about historical diversity in the profession (Black, 2002).  Munoz (2007) suggested that cultural competence was not really possible, so a more reasonable objective would be "cultural responsiveness." 

Given the rather strong vocalization of many occupational therapy academicians about the problems that the profession has with matters of diversity, it is difficult to know exactly how to promote global standards.  Here everything begins to make me a little dizzy: According to diversity experts in our field existing power structures need to be removed or their power needs to be taken away, we need to promote multicultural understanding and respect, and we need to promote diversity in the workforce because presumably that diversity is the best solution for meeting the needs of minority groups.  However, we also need to somehow promote some standardization in our theoretical approaches while we are clamoring about the need for sensitivity about diversity.

I do not know how it is possible to construct a workable practice theory of occupational therapy that has cross-cultural meaning and relevance given the very different value sets that people place on occupations.

Additionally, a confused ethic is promoted by the same organizations that want to promote cultural competency or cultural responsiveness.  For example, the WFOT position paper on Telehealth (2014) states that "The WFOT's mission to develop occupational therapy worldwide presupposes access to services that are contextualized to local culture, resources, and occupations... Occupational therapy services are ideally delivered by locally trained and culturally competent occupational therapists."  A contradictory set of  objectives seems to be promoted.  On one hand we should value multiculturalism and diversity, training practitioners toward those objectives.  On the other hand we should acknowledge that culturally competent care can be best provided by locals.

I am kind of wondering: if culturally competent care is ideally delivered by locals, then what is the point of all the self-flagellation about needing to be more culturally competent?

Over the last year I have presented arguments about the problems associated with the United States occupational therapy community adopting global public health philosophies.  Global conceptualizations of health are not compatible in an American context, just as our conceptualizations are not compatible with others.  What kind of theory standard can there be?

This seems rather plain because it should be obvious to even casual observers of world events that the United States has its own cultural context that is decidedly not multicultural in its orientation.  Judging by headlines in Europe right now it seems that quite a few countries are reconsidering the value of their own multicultural contexts.

It is surprising that some would promote global standards when there is not enough agreement to create a standard.  There is no consensus on the nature of occupation because occupations are embedded in culture - and any attempt to hierarchically organize or conceptualize a way to promote occupation will be met by some person somewhere screaming "HEGEMONY" at the top of their lungs.  Even WFOT knows that, it seems, based on their statement that OT should be conducted by local folk.

The irony in the WFOT position, of course, is that preferential promotion of OT by local folk is condescending to those who would attempt to be 'culturally responsive.'  It fits with the notion that cultural competence is not even possible anyway.

In context of American theory, Mary Reilly (1962) asked "Is America the place to test the hypothesis" and she went on to discuss the concept of a "drive to action" that was part of an "American spirit which hates to be confined."  These are American ideals, deeply embedded in everything that defines occupational therapy in an American context.  That context is different than the context of other countries.  The notion of multiculturalism is an anathema to this culture - and if we promoted multiculturalism there would no longer even be a hypothesis that Mary Reilly proposed!

Of course that does not mean that cultural 'other-ness' is not present to some degree among all racial or ethnic groups in that American context.  It also does not mean that practitioners should not have sensitivity to those differences and work to incorporate them when understanding a patient's needs and goals.  However, we have to go back to consider the reality of the American context - and that reality is based on cultural assimilation, specific American values, and NOT on a value for multiculturalism.   Americans of all political persuasions understand cultural assimilation.  I fondly recall debating disarmament with my sociology professor in college.  He had an amusing strategy: he wanted us to unilaterally disarm because he could not wait for people from China or Russia to invade the United States and 'taste' our notion of American freedom, which in his opinion would lead to the final collapse of Communism worldwide!

As I have previously stated, we need to reconsider what seems to be the endless academic flirtation with multiculturalism and global standardization of our theoretical constructs.  The two ends do not meet, and they will not meet as long as we have different cultures.  Street level practitioners seem to already know this, and do a great job in my opinion of attending to the cultural needs of the people they serve.  Is it perfect? - probably not - and it can always improve - but I know that in the American context there is a respect for diversity as long as it is culturally assimilated.

It may come as a shock, but most people in the United States don't ascribe to the notion that cultural assimilation in an American context is inherently prejudicial. 

References:

Abreu, B.C. and Peloquin, S.M. (2004). The issue is: Embracing diversity in our profession. American Journal of Occupational Therapy, 58, 353-359.

Black, R.M. (2002). Occupational therapy's dance with diversity. American Journal of Occupational Therapy, 56, 140-148.

Clark, F. (2013). Farewell Presidential Address, 2013.  As viewed from above: Connectivity and diversity in fulfilling occupational therapy's Centennial Vision. American Journal of Occupational Therapy, 67, 624-632.

Hammell, K.W. (2010). Resisting theoretical imperialism in the disciplines of occupational science and occupational therapy. British Journal of Occupational Therapy, 74(1), 27-33.

Iwama, M.K. (2007). Embracing diversity: Explaining the cultural dimensions of our occupational therapeutic selves. New Zealand Journal of Occupational Therapy, 54 (2), 16-23

Kinebanian, A. and Stomph, M. (2010 May). Diversity matters: Guiding principles on diversity and culture.  World Federation of Occupational Therapy Bulletin, 61, 5-13.

Reilly, M. (1985). The 1961 Eleanor Clarke Slagle Lecture: Occupational Therapy Can Be One of the Great Ideas of 20th Century Medicine in AOTA (Ed.), A Professional Legacy: The Eleanor Clarke Slagle Lectures in Occupational Therapy, 1955-1984, (pp. 87-105). Rockville: AOTA.
 
World Federation of Occupational Therapy (2014). Position Statement: Telehealth.  Downloaded from http://www.wfot.org/ResourceCentre.aspx


Tuesday, January 13, 2015

Attending to the Manifesto: The importance of idiographic data collection in pediatric occupational therapy

The occupational therapy profession is unique because it is positioned as a stepping point to help people escape the despair of a liminal disability state and move toward the function that people wish to achieve, for themselves or for their children.

I have written previously on the occupation of writing and the notion of interactivity through written text.  I have come to understand over time that parents are Manifesto-writers, often taking pen to page to attempt to make sense of their parenting occupations.  I frequently evaluate children and in that context am handed Manifestos of parents who have so much to say and want to be sure that their message is adequately conveyed during what they perceive as an all-critical evaluation process.

The evaluation is a moment in time that is pulled outside of the stream of other normal interactions and it is often elevated in contextual importance.  The parent may have expectations that the evaluator is expert and many hopes are precariously stacked on the possibility that the evaluator will be able to help the parent with the meaning making process, or even to possibly find some pathway that will make sense for their child's development.

Of course the parent doesn't view any of it in such a detached phenomenological way, but nonetheless this is what often happens.

It is my hope that occupational therapy evaluators will spend more time analyzing and considering the Manifestos of those they evaluate.  Sadly, many occupational therapists don't even avail themselves of the idiographic parent Manifesto.  Instead they restrict their information to nomothetic data sets and the results are a rather incomplete understanding of occupational problems.

I am concerned that theoreticians don't spend enough time talking to actual parents and reading their Manifestos.  As a result, I imagine it must be very difficult for them to understand that the grist of the occupational therapy profession is found in the everyday stories of people who ask for help.  It is not found anywhere associated with some governmental think tank that wants the field to start bending cost curves for some nebulously defined objective of improving population health. 

One parent wrote to me:

Somedays I feel guilty for wishing my problems away.  I love my children, but I don't always love the reality that we are dealing with disabilities.  So what am I wishing away?  Some day my refrigerator won't be covered with crudely drawn images of flowers and hearts, rainbowed by the words "I love you, Mama."  I will never step on a lego, and cut my foot, leaving a blood trail from the play area, through the living room and hall into the bathroom again. Some day I will actually, at times, have to throw out milk before I get a chance to drink it all. I will do laundry once a week and all of my dishes will always be clean.  I will lose my official title of "Mom" and be forced to live the rest of my days as, simply, "Ma'am."  Is that what I really want?  I just want help.

Another parent wrote this stream of consciousness for me:

My son lives in a video game world.  I am so sick of video games.  He plays them from the time he wakes until he goes to bed.  I have to force him outside and play for a while and he doesn't ever want to leave the house.  When I force him to take a break he acts out the games saying "I am the big end guy and you are the witch so I have to hit you three times and I win" and so on and so on.  It is heartbreaking for us to see him like this.  He used to watch videos when he was younger but he would watch the same part over and over again until the tape broke.  I thought the world would end each time those tapes broke.  He takes everything literally so he is not a child that you can tell to 'hop out of the tub' because he will actually try.  When he was a baby he showed no preference to us and he would be just as happy with my sister.  But then at an appointment he thought I was leaving the room and he attacked the therapist, scratching her until she bled, because he was terrified.  The school won't give him OT because he is too smart and because he knows how to write his name.  They didn't care when I told them that he was obsessed with worksheets last year and wrote his name on papers hundreds of times a day.  What am I supposed to do?  He can write his name perfectly but every moment of every day is a stressful disaster for him and for our whole family  How can I even send him to school?

Who else can parents write to?  Sartre tells us that writing provides a medium for interactivity between the inner world of ideas and the outer world of reality. All good writing is social writing.  Solitary writing is only a dream or hallucination; real writing is a process constructed by the writer and the reader.  By this definition, I can’t write as a lone individual – there must be some ‘Other’ that answers or responds to my assertions.  In this sense, writing becomes an act of witness, and a medium for self-affirmation.

The issue for therapists to tune in to is the Appeal, typically found in whatever form the Manifesto takes.  Sometimes it will be an actual written Manifesto.  Sometimes it will be a comment.  Sometimes it will be a phone call.  Sometimes it will be unspoken, but if you are paying attention, you will read it all over the face of the parent who brings their child in for an evaluation.

The Appeal forms the basis of our social contract and it is why people come to us for help.  If we fail to attend to the Appeal and if we only gather nomothetic data to satisfy the outcome recording requirements for our government patrons then we have really missed the point, and our actual responsibility.