Monday, August 04, 2014

Comments re: recent RCT on sensory integration

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

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

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

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

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


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

Schaaf, R. et al (2013). An intervention for sensory difficulties in children with autism: A randomized trial. Journal of Autism and Developmental Disabilities, published online at

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

Wednesday, July 30, 2014

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

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

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

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

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

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

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

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

But what about occupational therapy?  Has it also changed?


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

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

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

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


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

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

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


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

Wednesday, July 09, 2014


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thursday, June 19, 2014

Crisis of confidence in AOTA governance

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

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

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

However, here are some statistics to consider:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I speak in favor of this motion.

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

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

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

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

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

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

These are beginning suggestions. 

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

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

Wednesday, May 07, 2014

Emmanuelism provided the Core Values to the developing occupational therapy profession

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

There were many others.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

Saturday, May 03, 2014

Academia knows best: Mandating doctoral education for entry level occupational therapy practice.

The American Occupational Therapy Association Board of Directors has issued a position statement that future occupational therapists will need to be doctorally prepared for entry-level practice by 2025.  They have arrived at this recommendation after undergoing an insular process that neglected to engage broad stakeholder participation.

I understand that this is a weighty charge, so I will outline the evidence as clearly as possible.

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

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

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

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

The absence of practitioner or employer or regulatory voices in these task groups is a glaring omission.   The Committees and Task Groups have been meeting over some time, and the results of their work has not even been broadly shared with the occupational therapy community until the release of this recommendation.

I am aware that during the April 23-24, 2013 Program Directors meeting a 'Top 10 FAQ' on entry level OTD education was circulated.  In June 2013 I requested a copy of Dr. Fisher's report but never received an answer to my request.  I am also aware of others who requested a full copy of the report in November 2013 and were never provided a copy.

In addition to restricting the groups to academic voices and opinions, there was an unwillingness to even share information about the work of these groups with the membership.  The reports that are now available only appear after all of the work is completed and after the AOTA Board of Directors already made their recommendation.

There is also the fortuitous timing of an article in AJOT from a group of academics who are supporting the change to mandatory doctoral level education.  The AJOT opinion piece (Case-Smith, et al, 2014) also fails to address pertinent concerns including:

1. What are the ROI impacts for students when we require increasing levels of education with static and shrinking levels of reimbursement?

2. What are the impacts of 'shutting out' students from higher ed by requiring doctoral level training?  What affordability factors are present?
3. Do affordability factors disproportionately impact minorities and what impact does this have on initiatives to promote a more diverse workforce?

4. What is the impact of a move to a doctoral level while at the same time decreasing access to community college/OTA levels by proposing OTA move to a baccalaureate level?
 5. What is the potential impact of this kind of a proposed change on the cusp on increasing demand for OT services (aging of population, etc.)?

Fisher and Crabtree (2009) brush away these types of questions saying they are 'concerns' but not 'barriers.'  The problem is that I have not seen any evidence that we are doing anything meaningful about the concerns. A survey of OT Program Directors conducted in 2004 and published by Griffiths and Padilla (2006) indicated that Program Directors held opinions in support of OTD education, despite objections from other stakeholders. That is a familiar theme.

How does the proposal square with what little evidence has been collected re: readiness and competence for practice? Mitchell and Yu (2011) conducted a study comparing BS and MS students on a test of critical reasoning, and in their results the students with the BS level actually scored higher than their MS students.  The study has limitations, including convenience sampling of one school and non-parallel admission practices, but these findings should be raising a few more eyebrows.

In a study of perceptions of 600 practitioners, Dickerson (2009) found that the majority of respondents did not approve of moving to the doctorate for entry-level practice.  Plain and simple - they did not see the point.  In a smaller study conducted by Smith (2007), there was not a strong opinion whether there is an advantage to a clinical doctorate degree, and only 22% agreed or strongly agreed that they would be interested in pursuing a postprofessional OTD.  Apparently these practitioners also do not see the point.

One might hope that intervening studies that quantify opposition to the proposal would have been considered by Case Smith et. al., but they remain impervious to the evidence even though there is notable and contradictory opinion.  The fact that these studies are excluded from the Case-Smith analysis is itself an example of academic cherry-picking, and automatically disqualifies their opinion because in fact they are not acknowledging all sides of this issue.  

Leaders of AOTA have a long history of doing what they want and remaining impervious to the evidence.  I will remind everyone that at the American Occupational Therapy Association's Annual Conference in 1999, the Representative Assembly passed Resolution J, mandating post-baccalaureate education for entry into the profession.  Following Resolution J, ACOTE formed a committee to look into the issues. The ESRC (Educational Standards Review Committee) identified some significant concerns about any move toward accrediting doctoral level programs. It seems that someone didn’t care what ESRC had to say because a different committee was formed (the ACOTE OTD Standards Committee) to develop standards for doctoral degrees despite what ESRC reported.  This started the ball rolling, and was prima facie evidence of how AOTA/ACOTE handles these issues.  It seems that history is about to repeat itself and again - once decided - things will go the way that AOTA wants them to go no matter who says what.

As a technical matter, AOTA can only provide an 'opinion' because ACOTE is theoretically a separate entity, but that is like saying the sock puppet is not controlled by the hand it sits on.  That is another whole topic.

So although I don't doubt that this change will happen anyway, I can't in good conscience close my eyes to the fact that many people oppose this, that there is very little evidence supporting this change, and that the issues that have been identified as 'barriers' have not been addressed at all.  Therefore, I predict that moving to doctoral level education without addressing the opinions of stakeholders and without considering the broader impacts on the workforce will contribute to unintended consequences that in the long run will harm the profession and more importantly harm the people who need the profession's services.

It is true that now there is an outlined process where stakeholder opinion will be solicited, but this is just the veneer of integrity.  This is just a superficial listening tour because the recommendation has already been made.  So what is the point?

My personal opinion: I am undecided, but leaning toward the opinion that mandatory doctoral training is at  best unnecessary and at worst could be harmful.  

But it sure would have been nice to solicit opinions before the horse got this far out of the barn. 


AOTA position statements and reports, linked above.

Case-Smith, (2014). The Issue is... The professional occupational therapy doctoral degree: Why do it?  American Journal of Occupational Therapy, 68, e55-e60.

Dickerson, A., & Trujillo, L. (2009). Practitioners' perceptions of the occupational therapy clinical doctorate. Journal Of Allied Health, 38(2), e47-e53.

Fisher, T. F., & Crabtree, J. L. (2009). The Issue Is—Generational cohort theory: Have we overlooked an important aspect ofthe entry-level occupational therapy doctorate debate? American Journal of Occupational Therapy, 63, 656–660.

Griffiths, Y., & Padilla, R. (2006). National status of the entry-level doctorate in occupational therapy (OTD). The American Journal Of Occupational Therapy: Official Publication Of The American Occupational Therapy Association, 60(5), 540-550.

Mitchell, A. W., & Xu, Y. J. (2011). Critical reasoning scores of entering bachelor’s and master’s students in an occupational therapy program. American Journal of Occupational Therapy, 65, e86-e94.

Smith, D. (2007). Perceptions by practicing occupational therapists of the clinical doctorate in occupational therapy. Journal Of Allied Health, 36(3), 137-140.

Saturday, April 26, 2014

The problem with the way occupational therapists address mental health issues

Yesterday I saw Daniel who was mad at his mother for lying to him - something to do with whether or not he could play his Nintendo DS - I am not sure.  He spent most of the time under the table so we couldn't complete much of an evaluation.  But this is what I could surmise through interview:

Daniel is 13 years old and his mom brought him to see me because she is concerned that he has a 'sensory processing disorder.'  The referral from his physician indicated that his diagnosis was bipolar disorder, r/o paranoid schizophrenia, oppositional defiant disorder, and ADHD. Of course the schizophrenia concerns are very preliminary but Daniel has reported seeing black caped shadowy figures scratching at doors and windows ever since he was old enough to talk.  He states that the combination of Lithium and Seroquel mostly keeps things in check.  His mom isn't so sure, because the family is walking around on eggshells for fear of contributing to his spiral into an emotional pit of anger and depression.  Anything can set him off: the television might be too loud, his brother might walk too close to his personal space, the batteries on the Nintendo DS might run out.  Anything can trigger "The Rage," which is what his mom called it several times.

Mental illness is so difficult for families to deal with, and it is usually difficult to express with words how much emotional pain people are in.  Although I don't hold to the notion that Daniel's problems have anything to do with a 'sensory processing disorder' there is no question that he has atypical sensory processing.  Parents in acute stress are not prepared to hear a clinically nuanced debate about primary and secondary diagnostic problems, and since my objective is to try to help and not to have a debate about 'sensory processing disorders,' I used the Adolescent Sensory Profile to gather some qualitative data on Daniel's perceptions.  The mom was working with Daniel to get him to answer the questions and before she handed it back to me she looked at the front of the booklet where it asks "Are there aspects of daily life that are not satisfying to you?  If yes, please explain."  She wrote,

"Daniel.  Shards.  White shards.  Red shards.  Crystal shards.  Daniel.  Grey shards.  Blue shards.  Daniel.  Shards.  More shards."

I told her that I wasn't sure what she meant by this, and she started crying, "When Daniel gets mad, he breaks things.  Everything in my house is broken."

Daniel got up from under the table and sat next to his mother.  I asked him, non-judgmentally, "Is that true Daniel?  If you get really mad, do you sometimes break things in the house?"

Daniel mostly stared forward in stony silence, occasionally visually orienting to the window.

After a while he opened up a little and we were talking about friendships in school.  "The kids said I am fat, so I punched one of them, and I got suspended."  Daniel has gynecomastia.  Kids that age can be merciless.  I noticed that he was only talking about a single incident, so I asked him "How often do you get bullied?"  His answer was interesting, "I never said I get bullied; I said that the kids said I was fat."  Apparently, bullying in his mind had something to do with having someone stealing lunch money or someone hitting him.  It didn't occur to him that verbal abuse was bullying, perhaps because it was just the norm.

Daniel has a 504 plan in school.  His grades are good and behavioral difficulties in school are rare.  His attendance is poor, because on days that he has difficulties he simply won't get out of bed.  He has access to the school counselor but Daniel believes that this is "worthless."  He has a counselor that he sees privately, and he sees a psychiatrist once monthly for medication management.  He had an OT evaluation in school which indicated that he had no need for school based services.  Granted, he had some sensory processing differences and once a month he flips a desk over, but the only suggestions offered were 'sensory breaks' to get up and walk around.

I am not certain that putting on the 504 an accommodation of getting up and walking will do anything about the shadowy caped figures scratching at the window, or the associated inability to test ego boundaries and find a way to cope.  Still, that is the school based paradigm.

By my assessment Daniel has severe anxiety and difficulty with situational coping.  He has poor social skills, poor impulse control, and a very constricted activity configuration.  He also has some illogical and confused thinking around social situations.  Functionally, he is breaking everything in the house and confining himself to his room.  It also happens in school, but only sometimes.

The mental health system in my state is rather expansive and New York is second in the US for per capita spending for mental health services (NRI, Inc., 2012).  Spending has trended upwards every year (NRI, Inc., 2010).  The same can not be said for many states, but the point is that funding has increased over time in NY.   According to a SAMHSA report, despite increasing amounts of money being spent, many people still do not receive treatment (Levit, et al., 2008).  This report also states that mental health expenditures may not be keeping pace with the growth of health care spending in general, and that proportionally there has been a shift over time where more money is being spent on pharmaceuticals and less is being spent on inpatient care.  As a final point,

"Three out of every ten dollars spent on MH treatment are expected to go for retail purchases of prescription drugs in 2014, up from 23 percent in 2003. Specialty and general hospitals are forecasted to account for 22 percent of total MH expenditures (down from 28 percent in 2003), physicians and other professionals for 16 percent (up from 14 percent in 2003), and MSMHOs for 10 percent (down from 13 percent in 2003)."

I try to understand this in terms of Daniel, because statistics are kind of meaningless when they are out of context of what they are supposed to represent.  By my understanding, there is plenty of money for mental health services in some places, and a lot of it is going toward medications.  Daniel has gynecomastia, probably from his meds, but the service providers in his school don't think that he has any needs for services.  He is destroying everything in the house, but there are no real services for the family to access except for 911.  The parents are grasping at straws, and that is why they show up in my office praying for a sensory processing disorder miracle cure.

That is about as blunt as I can put it.  I hope people reading see the problem.

OK so what are we supposed to do about this problem?  I noticed a blog post from Heather Parsons, the AOTA Director of Legislative Advocacy.  She states, "While almost everyone I talk to in Congress feels there is a need to do something, that our current services are not meeting the needs of people with serious mental illness, there may not be enough agreement on how to meets those needs, and how to fix our system, for a mental health bill to pass this Congress."

Evidence indicates that in those places where we have a lot of money to spend that the services are still terrible.  I am not convinced that legislative advocacy can provide a solution to this problem.  It is a tree, and I think we can bark up it, but I don't know that this is what will help Daniel most.

What would happen if we looked into the mirror instead of hoping a politician can solve this problem?  Politicians are busy trying to sneak in gun legislation with mental health bills, and that will keep those bills stalled indefinitely.  Pharmaceutical lobbies have also had obvious success in getting legislation crafted that funnels reimbursements for meds.  There are different ways we can address this problem.

According to the NBCOT Practice Analysis (2012) for both OTRs and COTAs, only 2-3% of all practitioners surveyed report working in mental or behavioral health settings.   These statistics are consistent with an AOTA Workforce Study completed in 2006.  Despite the low numbers of practitioners working in exclusive mental health settings, the NBCOT Practice Analyses indicate that large percentages of practitioners report seeing patients who have mental health concerns (e.g. anxiety, mood disorders, etc.). 

This matches Daniel's problem precisely.  He ENCOUNTERED occupational therapy in school, even though that is not a 'mental or behavioral health setting.'  The problem is not that he didn't have access to an OT.  The problem is that the OT couldn't be bothered with Daniel's problems.

Why didn't the OT think that Daniel needed related services?  There was a perspective that his problems were not impacting his educational performance.  This is a paradigm problem.  It is a problem of limited thinking.  It is a problem of preference for seeing really cute 6 year olds who have difficulty with handwriting, and doing everything possible to avoid seeing the not as cute 14 year olds who are overturning desks when the edges of reality start to get a little blurred.

Perhaps a better tree to bark up is how we are training our own workforce.  I find this quote from a SAMHSA-commisioned report (Annapolis..., 2007) fascinating

Another group that has voiced strong concerns comprises managers within organizations that employ the workforce. Their constant lament is that recent graduates of professional training programs are unprepared for the realities of practice in real-world settings, or worse, have to unlearn an array of attitudes, assumptions, and practices developed during graduate training that hinder their ability to function. University-based training programs and professional schools, despite their academic base, are largely viewed as out of touch with the realities of contemporary practice and as failing to provide substantive training in evidence-based practices. These concerns exist regardless of the professional discipline. It is simply difficult to overstate the level of concern among workforce employers about the current relevance of professional education in the behavioral health disciplines.

I suggest that we spend more time and resources on looking in the mirror and improving our own training programs.  There is no evidence that when money is available that it is doing anything to improve the quality of mental health care.  There is ample evidence that although occupational therapists encounter people who have mental health problems regularly, that they don't have the knowledge, interest, or skills to intervene.


Annapolis Coalition on the Behavioral Health Workforce (2007). An Action Plan for Behavioral Health Workforce Development: A Framework for Discussion.  Downloaded from

AOTA (n.d.) Workforce Trends in OT.  Downloaded from

 Levit, K.R., et al (2008). Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment, 2004­–2014­. SAMHSA Publication No. SMA 08-4­326. Rockville, MD: Substance Abuse and Mental Health Services Administration.

National Association of State Mental Health Program Directors Research Institute (NRI, Inc.). (2012, September). FY 2010 State Mental Health Revenues and Expenditures.  Downloaded from

National Association of State Mental Health Program Directors Research Institute (NRI, Inc.). (2010). State Mental Health Agency Profiles Systems and Revenues Expenditures Study.  Downloaded from

National Board for Certification in Occupational Therapy (2012). 2012 Practice Analysis of the Occupational Therapist Registered.  Downloaded from

National Board for Certification in Occupational Therapy (2012). 2012 Practice Analysis of the Certified Occupational Therapy Assistant .  Downloaded from

Parsons, H. (2014). Can Congress Pass Comprehensive Mental Health Legislation.  Downloaded from