Thursday, July 30, 2009

Recurring philosophical questions

I have had a recurring question in my mind since the beginning of my occupational therapy career. At that time I was working in an urban acute care psychiatric facility and I was fresh out of college with my head full of lofty ideas about occupational behavior, occupational role, and the potential of occupational therapy to solve societal problems.

I read every word that Mary Reilly ever wrote, and listened as they were explained to me in the classroom by proxy of Phil Shannon and watched in amazement as they were practiced in a hospice home care setting while being mentored by Kent Tigges. Still, after work each day I took the Metro North to the safety of suburban living and I kept rolling over the question: "How can I remember NOT to transpose my values and my concept of Quality when working as an occupational therapist??"

My training told me that I wanted my patients to develop options, decision-making, problem solving, and agency relating to some return to occupational role. This was easy to comprehend if I was dealing with people who were students, homemakers, or workers but most of the patients that I saw were none of these things, nor did they aspire towards them. I was treating chronically ill people, people who were drug addicted, people who were on welfare or who were 'professional' patients.

The concept of helping people achieve occupational role functioning seemed like a very white and upper middle class attitude - which from the perspective of that particular demographic is not a bad way to organize the world with respect to sociology, economics, etc. - but it was anathema to THE SYSTEM and the real experiences of most of my patients. It just wasn't their brand of real.

So the idea of cultural competence comes into play, but for all the chatter about cultural competence it doesn't seem to bridge the gap between our theory base and the lived experience of many people who receive our services. I am not certain that we are improving and despite some of the wonderful advances in theory since the late 1980s I see that the divide remains as a real problem for our profession.

In concept I enjoyed Yerxa's article in the new AJOT, entitled "Infinite distance between the I and the It." I appreciate good philosophy and in many ways I can understand exactly what she is driving at - but the more I read the more I heard the repetitive tha-thunk and whoosh of the Metro North car as it sped toward the safety of the suburbs. The problem is in the basic premise where she writes, "Our purpose is to enable people to become agents of their intentions and to obtain satisfaction through actualizing their unique interests" (p. 491). I think this is often true but it is not always true.

Today I walked into a family's apartment; my responsibility is to provide early intervention services to a little two year old in the home. The family unit is comprised of the mother who works part time and receives welfare assistance, a boyfriend who is developmentally disabled and at least 40 years older than the mother, and the child. They live in abject poverty: there are no toys, there is little food, there is no money. The boyfriend was watching the child, and I immediately noticed the large and oozing hematoma on his forehead when he answered the door. It was hard to get information from him because he was frightened that his girlfriend would be mad but he eventually revealed that she hit him in the head with a pot because somehow the baby knocked the television off of the table. I'm not sure how these events are connected but that was his report. He was planning on going back to his home in a neighboring city, but he wasn't sure if he had the bus tokens to get him there.

Although the details are unique, the flavor of this scenario is not unique. The people in this story are not poised to receive a health service that helps them self-actualize. They need a service that respects their human dignity, provides them with a means of economic survival, and perhaps - if good fortune abounds - helps them develop skills for autonomy and independence that may one day lead to the beginning steps of self-actualization.

Similarly, we get 'thank you' notes from our patients constantly for the fine work of the therapists in our clinic that focuses on hand injuries. The notes always say the same kind of things: '"Thanks so much for helping my hand get better!" and "I am so happy that I was able to go back to work." I have not yet received a thank you letter that states, "Thank you for helping me determine how I will make a contribution with my life." Now in obtuse ways one could argue that the patients are indeed 'saying' this but I don't think so. I don't think that most people really think in those terms. Sure - some do - like Florence Clark's patient that she discussed in her Slagle lecture. But most patients are not asking us to conduct and compose metaphorical and allegorical tales to help them find meaning in their disability experience. In this sense I think that our theory is at risk of missing the mark on the lived experiences of many people who actually receive occupational therapy services. Many folks are happy to move their hands again - or happy to pick up their grandchildren again. For them, occupational therapy is not an "ethical quest, promoting human flourishing" (p. 496).

The 'I' that Yerxa discusses is so critically important - and I really do agree in part with what she is saying.. but not all of those I people live their I experience in the way she describes. Sometimes, people even subjugate their I in consideration of the larger cultural context - because the cultural context is sometimes more important than the I! A very clear example that comes to mind here is literary - the character Okonkwo in the novel Things Fall Apart. Okonkwo rigidly adheres to his cultural traditions - even though they lead to his own exile and eventually bring him into conflict with the introduction of Christianity - a conflict that causes him to commit suicide. There was no I for Okonkwo, or perhaps his I was defined by the We of his clan and its customs. In this case, would occupational therapy help the we flourish or would it help the I flourish? I am not sure.

The overall point here is that there is danger in assigning our personal values to Quality - and I believe it is possibly wrong-headed to believe that the self-actualizing, meaning-pursuing, and Forrest Gump questions of 'What's my destiny, mama?' are reflective of how everyone really experiences their lives.

This kind of philosophizing about the meaning of living kind of works for me, but I am a white upper middle class guy. When I try to think fairly and I think of the guy who has developmental disabilities and who literally has no resources and perhaps fewer options and is scraping up bus tokens to escape the domestic abuse of his girlfriend - it just becomes difficult to imagine his lived experience in terms of the word 'flourish.'

I think that there is something more germane to OT than a highfalutin preoccupation with I. I think it may have something to do with the basic dignity of human experience, and perhaps meeting needs across a broad spectrum of perspective - especially and particularly when that perspective has to do with finding ways to duck from flying pots.


Achebe, C. (1958) Things fall apart. New York: Anchor Press.

Yerza, E. (2009). Infinite distance between tne I and the It. American Journal of Occupational Therapy, 63, 490-497.

1 comment:

Geoff said...

This post struck a cord with me as I have also debated some of these same questions. I'm also a white guy from an upper-middle class culture. I really think that if somebody (like us) who has never been in a desperate situation, worrying about food, clothing, shelter, etc. starts our focus of OT on occupation and finding meaning and self-actualization, there will be NO follow-through by the client. I think a good way to classify it is to look at Maslow's hierarchy of needs- if our client isn't near the top on that, then I can't see an OT being successful. Isn't it somewhat similar to working with a patient in a hospital or nursing home on exercises?- we have to maintain/build the biomechanical strength so that they will have the ability to participate in ADLs/IADLs- maybe in the situation you described with the domestic abuse, maybe our role leads more in the direction of social work to create an environment where EI interventions can be successful?

Thanks for the post and the great blog- really enjoy your writing!