Sunday, February 12, 2006

awkward positions

This will be boring for non-OTs - sorry. But it is an issue that begs to be broadcast. I am hoping some students will find this as they do web searches on top-down and bottom-up approaches to practice.


There is a growing divide between academia and practice in occupational therapy. This is not necessarily new. Back in 1972 Phil Shannon wrote a wonderful article talking about the 'derailment' of occupational therapy practice as practitioners were focusing on biomedical models of intervention as opposed to 'biosocial' models - those that were more expansive and systems based.

The problem is that the issue was defined for the profession over 30 years ago and there is still considerable disconnect between academically espoused models or frameworks and what actually occurs in occupational therapy practice 'in the trenches.' The latest iteration of this massive disconnect is reflected in the broad clinical brush-off to the OT Practice Framework (AOTA, 2002). Academics espouse a performance based top down method of intervention, and from my view of current practice most clinicians could care less.

When reviewing advantages and disadvantages of a specific intervention approach it is necessary to identify the nature and quality of that approach. In-depth analysis of occupation as a concept has led some to believe that occupational therapy is only “authentic” (Yerxa, 1967) when an occupation-based approach is embraced. However, there are forces within the profession that pragmatically reject this analysis and practice without considering occupation at all. An overview of these disparate approaches to occupational therapy intervention is helpful to fully understand the schism between those that more strongly identify the advantages and those that more strongly identify the disadvantages.

The Advantages of Occupation-Based Intervention

Many important leaders of the occupational therapy profession have historically professed the advantages of occupation-based intervention approaches. Mary Reilly was concerned with the profession’s adoption of a medical model that did not focus on occupation - but she openly questioned whether or not American society had “tolerance” (Reilly, 1985, p. 91) for the premise that occupation was central to health. Reilly’s conceptual understanding of intervention broadly encompassed the concepts of productive occupation and were not limited to the traditional medical model. She suggested that intervention should be primarily concerned with occupational satisfaction and that the aim should be the support of the patient’s development of competency and achievement oriented urges and the development of pre-conditional skills that support occupational role (p. 100). By focusing on occupation, Reilly believed that occupational therapy could realize its “magnificent purpose” (p. 104).

There has been and continues to be strong and vocal support from academia for occupation based interventions. Important developments in occupational therapy theory have identified that occupation based interventions can include use of occupation as both a means and as ends in intervention, and that there is power in use of occupation in both circumstances (Trombly, 1995; Gray, 1998).

David Nelson’s work is an example of basic research that demonstrates the value of occupation as means. He has completed several studies that have demonstrated the beneficial effects of occupation as a means of improving functional performance; these studies are referenced in his Eleanor Clark Slagle Lecture (Nelson, 1996). Nelson’s contributions are important because of the strength of his methodological work and the support he has been able to demonstrate for occupationally embedded exercise on recovery after injuries. The Well Elderly Research Study (Clark,, 1997) is an example of use of the power of occupation as a therapeutic end following an intervention that focused on lifestyle redesign. This study concluded that preventative occupational therapy reduced the health risks of older adulthood and was widely heralded for its methodological rigor.

The Disadvantages of Occupation-Based Intervention

Despite the vocal support and expert opinion of occupational therapy leaders, and despite some evidence that supports occupation based interventions (both means and ends), the fact remains that many clinicians choose to practice from a reductionistic or more biomedical frame of reference. It is difficult to find literature that has been published by those who see strong disadvantages of occupation based interventions. This may be due to a possibility that those clinicians who believe that there are disadvantages are not likely to be publishing their opinions in peer refereed journals because their focus is on clinical practice and not research or publication.

Still, several opinion pieces have been published that express the inherent disadvantages of occupation-based approaches. English, et. al. (1982) expresses that it is important for occupational therapists to be able “to use many different treatment techniques at various stages in each person’s recovery process in order to give quality care.” (p. 201). Furthermore, they wrote that “the move to confine ourselves to Purposeful Activity destroys our role... [and that] support for the restorative skills of physical disability occupational therapists is necessary for the survival of the practice of physical disability occupational therapy.” (p. 201).

Bissell and Mailloux (1981) documented a declining use of occupation-based interventions in their survey that measured the use of crafts in the practice of physical disability occupational therapy. They posit that “as scientific advancements and overall medical progress brought changes that emphasized technique rather than theory, treatment modalities that appeared more precise were substituted for craft activities in therapy.” (p. 373).

Howard (1991) explored the extent to which third party reimbursement dictated occupational therapy practice. She identified that therapists have to treat within the boundaries of the descriptions of available coverage as they are identified by insurance companies. Thus, there are strong disadvantages to the use of occupation-based interventions, particularly if such services are not likely to be reimbursed.

Most practitioners would argue that the nature of the medical model is entirely “bottom-up.” Practitioners don't see any revolution in health care that the profession is positioned to miss out on. If there will be some revolution, what will happen to medicine? — will there be some wholesale transition to a different value regarding the way medicine is delivered? Despite the publication of the ICF, people would argue that it hasn’t changed the delivery of medicine one whit. The reductionistic practitioners would argue that perhaps we should investigate the possibility that we may need separate health and illness models – particularly if we still wish to participate in the medical arena.


After reviewing the advantages and disadvantages of occupation-based intervention, the original question seems to be even more magnified in its importance: which approach is good, and which is not good? There is strong support from academics for use of occupation based interventions, yet there is evidence that clinicians remain committed to other approaches. These positions seem diametrically opposed and raise important issues that range from the importance of our professional values, the nature of our professional identity, and the reality of the society’s expectations and support of occupational therapy. An understanding of this rift between theory and practice is enhanced by our study of these dynamics.

Thomas Kuhn (1970) detailed the process by which disciplines undergo change and defined a paradigm as a set of values and beliefs that are shared by members of scientific communities or professional groups. Occupational therapy experienced its first paradigm crisis in the 1940s. At that time the core knowledge of occupational therapy, namely occupation, was dismissed as mere common sense while the profession pursued mechanistic explanations of human behavior. This pursuit toward biomedicine was in direct response to society’s demand to produce scientific rationale for medically related interventions. A second paradigm crisis occurred during the 1970s after Reilly’s Slagle Lecture and the subsequent work of her graduate students. When the biomedical model was challenged there was discomfort between the traditional roots of the profession and the newer ways that were available for describing concepts.

What will our next paradigm be? Bottom-up or top-down? We are doing both now, which in all honestly is not a very flattering position.


American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56(6), 609-639.
Bissell, J.C. & Mailloux, Z. (1981). The Use of Crafts in Occupational Therapy for the Physically Disabled. American Journal of Occupational Therapy, 35, 369-374.
Clark, F., (1997). Occupational Therapy for Independent Living Older Adults: A Randomized Controlled Trial. Journal of the American Medical Association, 278, 1321-1326.
English, C., et. al. (1982). On the Role of the Occupational Therapist in Physical Disabilities. American Journal of Occupational Therapy, 36, 199-202.
Gray, J.M. (1998). Putting Occupation into Practice: Occupation as Ends, Occupation as Means. American Journal of Occupational Therapy, 52, 354-365.
Howard, B.S. (1991). How High Do We Jump? The Effect of Reimbursement on Occupational Therapy. American Journal of Occupational Therapy, 45, 875-881.
Nelson, D.L. (1997). Why the profession of occupational therapy will flourish in the 21st century: The 1996 Eleanor Clarke Slagle Lecture. The American Journal of Occupational Therapy, 51, 11-24.
Reilly, M. (1985). The 1961 Eleanor Clarke Slagle Lecture: Occupational Therapy Can Be One of the Great Ideas of 20th Century Medicine in AOTA (Ed.), A Professional Legacy: The Eleanor Clarke Slagle Lectures in Occupational Therapy, 1955-1984, (pp. 87-105). Rockville: AOTA.
Shannon, P.D. (1977). The derailment of occupational therapy. The American Journal of Occupational Therapy, 31, 229-34.
Trombly, C.A. (1995). The 1995 Eleanor Clarke Slagle Lecture: Occupation: Purposefulness and Meaningfulness as Therapeutic Mechanisms. American Journal of Occupational Therapy, 49, 960-972.
Yerxa, E. J. (1985). Authentic occupational therapy: 1966 Eleanor Clarke Slagle Lecture. in AOTA (Ed.), A Professional Legacy: The Eleanor Clarke Slagle Lectures in Occupational Therapy, 1955-1984, (pp. 155-174). Rockville: AOTA.


Polly said...

I notice this is from 2006 - I wonder if Chris is still around?

I am a student occupational therapist currently grappling with this subject and would value a brief dialogue - so if available -let me know.


Sookey said...

I notice this is from 2006.

Is Chris still around?

If so I would welcome a dialogue as am a final year student OT and grappling with this topic.


Chris said...

I am still around :).

So is the issue, sadly. I am happy to discuss it though!

Anita Hamilton said...

Hi Chris, I'm glad this topic came up again. I'd love to participate.
I teach my students this way: To practice occupationally is to understand first and foremost what meaningful occupations the client has or wishes to have in their life, then to analyze the level(s) at which they cannot complete the task (using the taxonomic code of occupation: Enabling II) and then to identify where remediation (therapy) needs to occur, which is likely to be a combination of person and environment levels.
The next task is to carefully assess to determine the aspects of person (phys, cog, mental) and the environment (phys, social, institutional) and collaborate with/educate the client about their options/choices in order to make a plan. Once the plan is underway we need to keep our eye on the goal, return to meaningful occupations, through meaningful occupation.
I therefore think that this approach comes between the top down and bottom up approaches... in the middle, at the level of the client.
At times you are working big picture, at other times you are considering the minutiae of the issues that exist (ie: impairment and limitations leading to disability) ICF words selected on purpose :-)
The phase of involvement called monitor and modify (in the Canadian Practice Process Framework) is probably one of the most important as this is where the OT collaborates with the client to finesse the intervention. It won't work first go, you need to tailor make each program! And...the goal is always to re-engage the client in the occupations that they need and want to do.
You mention in your 2006 post that arts and crafts are no longer widely used in OT, and that is true where I have worked (Aus and Canada), but in my mind therapeutic occupations are not necessarily just arts and crafts. Working occupationally is a very broad concept for me, it is about using meaningful activities to restore the individual's ability to resume the occupations they identified in the outset of their OT program. Maybe they want to resume their role as a parent, this may include cooking, budgeting, driving, cleaning, shopping, participating in social activities, it may include photography, or even writing a blog.
As long as therapy is not relentless "cone stacking" but uses meaningful tasks that truly work towards the final occupational goals, then I believe it is occupational therapy.

Then there's the whole issue of working with communities and society :-)
Cheers, Anita.