Tuesday, October 21, 2014

Comments on 'Validity of Sensory Systems as Distinct Constructs'

Chia-Ting Su and Diane Parham (2014) wrote an interesting article that appears in this month's American Journal of Occupational Therapy.  Their study involved use of confirmatory factor analysis to test constructs within sensory integration theory.  Results of their analysis have rather broad implications and raise many important questions.

A highly popularized notion based on Dunn's (2001) Slagle lecture is that sensory processing can be identified as occurring within different systems where there might be over or under responsiveness to incoming stimuli.  Su and Parham applied data to this model and could not confirm that this conceptualization fit their data.  This in itself is a significant finding because it puts into question whether or not SOR/SUR models are the most appropriate way to explain problems with sensory processing.

Also germane to this finding is the concern that tools like the Sensory Profile confound analysis by including questions about temperament that may not have much or anything to do with a distinct 'sensory processing' factor.  Su and Parham (2014) state, "the inclusion of items on the Sensory Profile that are highly sensitive to temperament is another plausible reason why the Sensory Profile factors differed from ESP factors in the current study." This is an issue that I have blogged about previously, particularly in context of the Shea and Wu (2013) article about children in the criminal justice system.  I stated
This analysis should help us to more deeply understand that our current assessment tools, which are apparently measuring something, may not just be measuring a sensory processing construct.  In my opinion, the assessment tool also includes many questions that are broad and general and could represent a number of behavioral phenomenon, primarily dependent on the interpretation or labeling of the examiner.

I believe that we should consider pausing when we use tools like the Sensory Profile to report an incidence of "sensory processing disorder."   It is apparent that atypical scores on this assessment may indicate co-morbid issues that are interwoven with a number of other behavioral and social and psychiatric diagnostic constructs.

The prevalence concern may be even more significant.  Claims about prevalence (Ahn, Miller, Milberger, and McIntosh, 2004; Ben-Sasson, Carter, and Briggs Gowan, 2009) of a proposed 'sensory processing disorder' have to be reconsidered in context that the Dunn Model may not adequately parse out sensory concerns from temperament concerns.  Again, this is something that many clinicians have known for a very long time but this study validates those opinions.

The reality is that significant damage is done when non-validated or non-replicated research is rushed into clinical practice.  One can only speculate on the efforts that will be required to unwind these notions that turn out to be only partially correct.

There are other important issues raised in the Su and Parham (2014) study.  The authors state that one of their primary interests was to "test the discreteness of sensory system measures in preparation for further research examining whether functions of the tactile, vestibular, and proprioceptive systems serve as a foundation for visual and auditory functioning, as Ayres theory proposes."  I do not understand why occupational therapists are still interested in applying hierarchical models to describe complexities of neurobehavioral function.  For over 25 years that I have been studying and lecturing on sensory processing concerns I have left out hierarchical models because of all the research that has been done that supports heterarchical organization.  There is simply too much research to even begin making citations, but descriptions of heterarchical neural organization can be found across all disciplines from neurology to psychology to robotics and computer engineering.  As a primer into the notion of heterarchy and multilevel cross-disciplinary understanding of neurobehavioral concerns I recommend any of the articles written by Berntson and Cacioppo (seminal articles on heterarchy and social neuroscience referenced below).

Even if we can discretely reduce processing concerns into modality-specific categories, where is this going to lead us?  It is very difficult to understand why occupational therapists continue to be interested in sensory-level intervention strategies when we have had such historic challenge with finding strong evidence for this kind of treatment approach. In contrast, other disciplines are developing evidence based cognitive-behavioral methods for addressing regulatory problems or for mediating stress-level responses.  As an example I refer to research being conducted by Stanley (2009) that is being applied in a military context but that I suspect will be gaining much broader consideration due to the raw effectiveness of the techniques.

In summary, the Su and Parham (2014) study provides many interesting discussion points for occupational therapists who are interested in sensory processing and resultant behaviors.  It is promising to see that there is some progress in our research that validates concerns that have been expressed by practitioners.  However, there is evident need that as a profession we need to continue questioning our basic premises.  So many other professions have moved beyond models of hierarchical organization, now embrace hetararchical and dynamic systems explanations for behavior, and are in the process of validating alternate non-sensory based intervention methods.   Reading the literature of other disciplines provides strong evidence that occupational therapists are not at the forefront of relevancy on ideas about sensory processing and regulation.


Ahn, R. R., Miller, L. J., Milberger, S., and McIntosh, D. N. (2004). Prevalence of parents’ perceptions of sensory processing disorders among kindergarten children. American Journal of Occupational Therapy, 58, 287–293

Ben-Sasson, A., Carter, A.S., and Briggs Gowan, M.J. (2009). Sensory over-responsivity in elementary school: prevalence and social-emotional correlates. Journal of Abnormal Child Psychology, 37, 705-716.

Berntson, G.G., Boysen, S.T. and Cacioppo, J.T. (1993).  Neurobehavioral organization and the cardinal principle of evaluative bivalence, Annals of the New York Academy of Sciences, vol. 702, pp. 75–102.

Cacioppo, J.T., Berntson, G.G., Sheridan, J.F., and McClintock, M.K. (2000).  Multilevel integrative analyses of human behavior: Social Neuroscience and the complementing nature of social and biological approaches.  Psychological Bulletin, 126(6), 829-843.

Dunn, W. (2001). The sensations of everyday life: Empirical, theoretical, and pragmatic considerations.  American Journal of Occupational Therapy, 55, 608-622.

Shea, C. and Wu, R. (2013). Finding the Key: Sensory Profiles of Youths Involved in the Justice System. OT Practice 18(18),  9–13.

Stanley, E.A. and Jha, A.P. (2009). Mind Fitness: Improving operational effectiveness and building warrior resilience. Joint Force Quarterly, 55.4, 144-151. 

Su, C. and Parham, D. (2014). Validity of sensory systems as distinct constructs, American Journal of Occupational Therapy, 68, 546-554.

Monday, October 13, 2014

A syllabus and reference list regarding attempts to redefine the occupational therapy profession

The lynchpin of this conversation goes back to the patient v. client debates which quite clearly have not been resolved.  I think it is important to look at those issues very carefully.  Client-based ethics are simply different than patient-based ethics, and the more that we walk down paths of client-based ethics the more risks we take of straying too far from our roots, as we were clearly warned by Reilly (1984) and Yerxa and Sharrott (1985).

It should be very interesting to note that the entire argument for client-based ethics as originally made by Herzberg (1990) revolved around the allegedly 'faulty' logic of Reilly, Yerxa, and Sharrott.

Herzberg stated that the term ‘patient’ implies that people are sick.  She also argued that using the 'patient' term removed autonomy, limited participation, and restricted our roles in mental health and wellness.  She made that claim in 1990, and I would argue that nearly 25 years later of client-based ethics that our roles and functions within mental health and wellness arenas have not really done so well.  She also stated that although ‘client’ implies an economic-legalistic relationship, it does not preclude a medico-ethical relationship.  In other words, we would not stop 'caring' for people just because we call them clients.

There is strong evidence that she was incorrect.

It did not take long to tumble down the hill.  In 2003 Townsend, Langille, and Ripley wrote an article stating that a more effective methodology for solving client problems would be to focus on the tensions of the systems that the clients are in. They stated, "Given the drive by people with disabilities to become more empowered in their everyday lives, does it make sense for occupational therapy to work for institutional change or to abandon client-centered practice as too idealistic and too unrealistic in the real world?"

It got worse from there.  Further descent into client-based ethics is evident in Taylor's (2009) Intentional Relationship model.  I believe that issues related to therapeutic use of self are actually quite important for our profession, but there is little question that some very unusual turns have been taken with this work.  Specifically, I reference Kielberg, et.al. (2012) where they state:

“Importantly, this perspective does not always mean that the client should be entirely independent in his or her decision-making or that he or she should take the lead in defining problems, establishing plans, or setting goals for outcomes. In fact, this perspective on client-centred therapy does not necessitate that the client make decisions jointly with the occupational therapist. Instead, this perspective endorses being an advocate for the client’s welfare and desires, however explicit or subtle they may be. This perspective offers a well-rounded and comprehensive understanding of what it means to be client-centred. Client-centred therapy may involve empowering the client and collaborating during treatment or it may simply mean taking the time to appreciate and respect clients’ experience in occupational therapy, whatever it is, and advocate for their needs when they may not be able to do this for themselves.”

The argument FOR the 'client' term originally revolved around concerns of 'medical paternalism' and now those who support the 'client' term are stating that being client-centered MEANS taking some paternalistic stance about identifying and advocating for needs.  This is a stunning juxtaposition.  It only took 25 years, but now we have some academic occupational therapists providing full-throated support for the idea that we do not care for patients, but that we represent clients and their needs, and we do so using a model that acknowledges that they don't always know what is best.

This very brief syllabus and reference list documents the wellspring of ideas that informs the context of debates related to advocacy, politics, and the proper scope of occupational therapy as an allied health care profession.  It is true that some academic occupational therapists (and psychologists) are re-conceptualizing our expression of Core Values. 

I believe that whether or not these ideas represent the mainstream of actual practice and the values that practitioners hold remains an open question.


Herzberg, S.R. (1990). Client or patient: Which term is more appropriate for use in occupational therapy.  American Journal of Occupational Therapy, 44, 561-564.

Kjellberg, A., Kåhlin, I., Haglund, L. and Taylor, R. (2012). The myth of participation in occupational therapy: Reconceptualizing a client-centred approach, Scandinavian Journal of Occupational Therapy, (19)5, 421-427.

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

Taylor, R.R., Lee, S.W., Kielhofner, G.W., & Ketkar, M. (2009). Therapeutic use of self: A nationwide survey of practitioners’ experience and attitudes. American Journal of Occupational Therapy , 63, 198 - 207 .

Townsend, E., Langille, L., Ripley, D. (2003). Professional tensions in client-centered practice: Using institutional ethnography to generate understanding and transformation. American Journal of Occupational Therapy, 57, 17–28

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

Thursday, October 09, 2014

Investigation into the Mendability program

On a professional occupational therapy forum some participants were asking for more information about the Mendability program, which is a 'sensory enrichment' therapy for autism.  I decided to post my response here for broader distribution.


Here are some additional resources so  people can learn more about Mendability.

Kim Pomares and Eyal Aronoff are the co-founders of Mendability.  Pomares is a Social Media and Content Development Creator and Aronoff is co-Founder of Quest Software.  It does not appear that they have any clinical training in autism or any kind of therapies that I could find.

Pomares' mother reportedly has the "clinical" ideas behind the program:

"The theory behind Mendability originated out of France by Pomares’ mother. He said she came to Canada to train nurses in hospitals to do this therapy, but she only had an idea and needed scientific evidence for validation. After extensive research efforts, he secured the money and scientific backing to be able to validate his mother’s theory and created an inexpensive version to make it accessible to everyone."

Claudie Gordon-Pomares is Kim Pomares mother and is currently the Director of Mendability. 

According to her Linked In profile she has a BA in English and an MEd in psychology.

Aronoff's clinical connections are that his daughter had autism and was cured through the Mendability program.  See their TedX talk.

Aronoff made substantial financial contributions to UC Irvine, specifically to researchers Cynthia Woo and Michael Leon in their department of Neurobiology and Behavior.  The researchers did not receive any financial compensation from Aronoff, but they did produce a paper that was supportive of sensory enrichment therapy.  Mendability is not mentioned in the research study directly.

The Mendability website now cites the UC Irvine study as evidence of how the program works.

These are the facts.  Draw your own conclusions.

Wednesday, October 08, 2014

Why OT Rex is an appropriate mascot for the OT Profession

This picture, and some similar to it, were widely passed around social media within the last year as an expression of the occupational therapy profession.  The picture is a play on the humorous limitations of T-Rex, and how adaptive equipment presumably supplied by an OT could help him with his 'reach.'

There have been discussions on social media sites about the divide between academia and clinical practice.  This is not a new debate but it has become more important as the profession discusses a possible switch to a doctoral degree for entry level practice.

One primary criticism is that that AOTA Ad Hoc group that came up with the recommendation was populated almost entirely by academics.  It is an undeniable reality, and underscores a problem with not properly consulting all stakeholders before publishing a position statement.

Unfortunately, constricted regard for feedback continues.  The AOTA Board of Directors announced that there would be opportunities for members to participate in the process and offer feedback.  One such opportunity was publication of the meeting schedule where the topic would be discussed.  There is a Joint Academic Leadership Council (ALC) and Academic Fieldwork Coordinator (AFWC) meeting later this month.    This information has not been widely publicized, is buried deep on the AOTA website, and of course direct questions to share information about this meeting in the OT Connections forums have been ignored. I wrote this post and it has never been answered:

Dear AOTA BoD,
This opportunity for communication was created one month ago.  Given that this online forum is not an apparent opportunity for conversation and as there is no confirmation or acknowledgement of most of the questions asked other than the promise of future FAQs, I would like to ask for clarification on the meetings that are being held throughout the year and that are listed on this page: www.aota.org/.../OTD-Schedule.aspx
In the FAQs posted at www.aota.org/.../OTD-FAQs.aspx it states "We encourage members to participate in the meetings mentioned above, and we will be holding an open forum discussion on April 17 in Nashville, during AOTA’s 2015 Annual Conference and Expo."
There is very little detail about these meetings available.  For each meeting, can we please have the dates, times, and locations - specifically including the times that the OTD issue will be discussed - or are these entire meetings dedicated to discussing the OTD issue?  Additionally, I would like to know
1. Would you kindly provide an operational definition of "encourage members to participate in the meetings" so we can understand our opportunity?
2. Will there be a mic available for public comment?
3. What is the time limit for presenting information?
4. Are you accepting a written statement to accompany any oral testimony?
5. Do you require the written statement in advance?
6. Are you scheduling people for comment or is everyone simply showing up at the same time and having an opportunity to speak?
As the opportunities for participation are constricted given the available geographic locations, I am sure you can understand the need for as much advance planning as necessary in order to secure favorable flight and hotel rates.  This is particularly important for planning as substantial travel and expense may be required in order to participate in this process.
Thank you for providing this information as soon as possible.
Christopher J. Alterio, Dr.OT, OTR

I happened to find out about this meeting as a function of my part time status in academia.  It is unfortunate when a member of a professional association has questions ignored and the only way to gather information is by happenstance.

Well now I have found a copy of the meeting agenda, and I see that conversations about 'what practice will look like for an OT or OTA beyond 2017' will be discussed.  This is a pivotal issue in the debate about need for an entry level doctorate.

In true OT REX fashion, AOTA has constricted its reach with who is presenting.  They have chosen an AOTA Board Member, an ACOTE Board Member, and a member of the Ad Hoc Group that recommended the entry level doctorate.  That hardly seems like a panel that will stray far from the company line or that even represents the interests of street level practitioners.

Setting the agenda are the Chairs of the Academic Leadership group.  What follows is a parade of AOTA Board members and other academic leaders.  The one exception is that the Executive Director of NBCOT will speak for 30 minutes, who would seem to represent an outside stakeholder group.

What the AOTA BoD continues to fail to understand is that it should not continue to constrict this conversation to academics and people who are populating the halls of the AOTA and ACOTE boardrooms.

What practitioners need to know is that the reason why our profession has a reach like OT REX without his adaptive equipment is because our leadership is not interested in a real conversation - they are only interested in pushing a conclusion that they have all already reached a very long time ago.

If only OT Rex would remember its clinical skills and extend its reach a little - maybe it would be a little more unstoppable.

Tuesday, September 23, 2014

When your legacy is OT education and the Sarbanes-Oxley Act

I support free market capitalism, and respect ownership rights people have in the money they have earned through voluntary trade.  Since the money belongs to them they should be able to spend it or give it away at their own discretion.

This week we all learned that the University of Southern California Division of Occupational Science and Occupational Therapy received a $20 million gift from the Chan family.  The gift creates the first named and endowed occupational therapy program in the nation, according to the school's website.

The article states that USC is a pioneer in occupational science and occupational therapy.  An interesting feature of occupational science is that it purports to be an interdisciplinary field that is intended to inform the occupational therapy profession by providing basic research knowledge about the occupational nature of human behavior.

Since the inception of this 'new science,' several scholars have pursued studies relating to the social and political nature of occupations (Wilcock, 1998; Townsend and Wilcock, 2004; Pollard, Sakellariou, and Kronenberg, 2008).  These authors have all been proponents of a concept of occupational justice, which is loosely equivalent to the political concept of social justice, except focusing on the occupational nature of the issue.  Embedded within these beliefs are concepts including occupational apartheid, occupational deprivation, and occupational alienation.  The solutions to these perceived problems is proposed as the political activation of the occupational therapy profession.

These initiatives have not gone unchallenged.  The social justice debates within the profession have focused on whether or not ethical requirements to follow specified political initiatives is a proper scope for a professional health care field.  Some people, myself included, don't believe that politics is the proper field for a health care profession.  Others disagree.

The social justice thread has also been evident through the profession's literature including  a special issue of the American Journal of Occupational Therapy (Braveman and Bass-Haugen, 2009) and it has been infused into the AOTA Code of Ethics and Occupational Therapy Practice Framework.

This heavy interest in social justice that was birthed at USC is what makes the $20 million gift all the more interesting.

 The gift was made by Ronnie C. Chan, who is also a USC TrusteeMr. Chan is a Chairman of a major Hong Kong real estate firm, and was also a Director of Enron Corporation and a member of its audit committee when it filed for bankruptcy as a result of fraud.  Enron became infamous in the early 2000s for its well publicized bankruptcy that was necessitated because of accounting fraud.  Deceptive accounting practices caused average people to lose billions of dollars while Enron insiders, including some of its senior management and Board, sold their shares before the bankruptcy filing.  According to the Washington Post, many of the Directors of Enron remained largely unscathed by the bankruptcy, but they did collectively have to pay a combined $13 million to settle a shareholder lawsuit alleging insider trading.  Mr. Chang was one of the Directors in that group.

 Chan also resigned from the Motorola Board after the Enron collapse. The AFL-CIO, which represented the interests of many Motorola shareholders, called on Procter and Gamble to reject Chan's re-nomination to the Motorola Board.  As reported in Bloomberg Businessweek, the AFL-CIO was motivated to block former Enron Directors from other public boards because its members lost more than $1 billion on their 3.1 million Enron shares.

The occupational science scholars have been concerned with social forces that contribute to limitations on people's ability to engage in occupations, including oppressive political forces, oppressive economies, oppressive banking systems, oppressive sociocultural practices, and so on.  This is what makes the USC/Chan alliance so unexpected.  The Enron scandal epitomizes the kinds of structures that many occupational scientists point to as constituting primary sources of oppression in society.

In the week prior to the announcement of the USC gift, the Chan family announced an even larger gift of $350 million to Harvard University's school of public health.  Commenters and bloggers were quick to note that Ronnie Chan was not mentioned in many of the Harvard news releases.  Some commenters wondered why money allegedly made off of the backs of poor renters in Hong Kong should go to support elite private colleges in the United States.  Others reflected on "Ronnie’s Teflon status [that] also allowed him to emerge unscathed from the SARS epidemic in Hong Kong when Amoy Gardens, a middle class housing development, became the epicenter of infection with 321 cases and several deaths. The high number of cases in this one location was attributed to poor maintenance of water pipes. Hang Lung was the developer of Amoy and managed the buildings."

Hang Lung Properties is Mr. Chan's company.  That is quite a notorious historical record in consideration of a hefty donation in the interest of public health.

The acceptance by USC of this gift, however, tells me quite clearly that I should no longer accept the proselytizing of do-gooder occupational therapists who claim to be concerned about structures that contribute to problems with social or occupational justice.  If they are going to hold out their hands and accept money like this while promoting an opposing agenda, then their message cannot be taken seriously.

I am not a social/occupational justice proponent, but point out these facts so they can be considered for intellectual and ethical consistency.


Articles linked above.

Braveman, B. and Bass-Haugen, J.D. (2009). Social justice and health disparities: An evolving discourse in occupational therapy research and intervention. American Journal of Occupational Therapy, 63, 7-12.

Pollard, N., Sakellariou, D., & Kronenberg, F. (2008). A political practice of occupational therapy, Edinburgh: Elsevier.

Townsend, E. & Wilcock, A. (2004). Occupational justice and client-centred practice: A dialogue in progress, Canadian Journal of Occupational Therapy, 71(2), 75-87.

Wilcock, A. (1998). An Occupational Perspective of Health, Thorofare, NJ: Slack, Inc.

Tuesday, September 09, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


(direct links above)

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

Background reading:

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

Friday, August 29, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thirty years ago Mary Reilly stated

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

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

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


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

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

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

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

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