Thursday, July 04, 2013
A Fourth of July message for the occupational therapy profession
I write this second installment regarding public health in an attempt to document the pathway that the occupational therapy profession has taken with regard to its perspective on client autonomy, client-centered occupational therapy practice, and now calls to move toward public health models of intervention.
An analysis of this topic can correctly start all the way back to the founding of the profession - including conversations about the musings of George Barton as he convalesced from tuberculosis - but for purposes of controlling the length and depth of the analysis I feel comfortable restricting the conversation to what I will label as the modern period, beginning in the 1960s. It is during the 1960s that important leaders and theorists promoted a return to the philosophical roots of the profession and a re-focus on occupation and habits which functionally reflects a respect for our philosophical core.
There is too much volume of material to be absolutely complete so I will pick pertinent issues that I hope will fairly illustrate and document the footsteps.
A modern analysis can begin with acknowledging Mary Reilly's Slagle lecture. Everyone knows the famous quote from that lecture so I won't use it because I think that we have become numbed by seeing it so much. Instead I want to bring attention to what she says AFTER that quote. She states that the central idea of occupational therapy falls into a class of ideas that is so great that it advances civilizations. She states that the core construct of occupational therapy is "that man, through the use of his hands, can creatively deploy his thinking, feelings and purposes to make himself at home in the world and to make the world his home."
What would make Mary Reilly believe that this concept is so great that it could advance a civilization? I believe that at the core of this concept she understood that there was the deepest respect for the autonomy of human beings. This concept of autonomy did advance a civilization; I am posting this analysis on July 4th for a reason.
Autonomy can never be pure or absolute for many moral and ethical reasons that are constantly debated. Still, the core idea of respect for autonomy in itself is an extraordinarily powerful construct to base a profession around. Mary Reilly wanted the profession to test her hypothesis about the action orientation and autonomy of humans.
In 1966 Elizabeth Yerxa's Slagle lecture was entitled "Authentic Occupational Therapy" and she highlighted the concept of autonomy throughout the lecture. She stated "Authentic occupational therapy is based upon a commitment to the client’s realization of his own particular meaning. The authentic occupational therapist recognizes that although initial dependency might require a temporary suspension of the patient’s right to choice, the therapeutic experience is primarily an opportunity for self-actualization. Therefore, the occupational therapist does not force his value system upon the client. But rather, through using his skills and knowledge, exposes the client to a range of possibilities which constitute his external reality. The client is the one who makes the choice."
Again, absolute autonomy from a technical standpoint is very challenging, but the point here is that Yerxa also expressed deep respect for the concept. Here is another quote from her lecture that is worth considering: "This active role of the occupational therapist in helping the client delineate his choices takes more knowledge, skill and sensitivity plus more faith in the individual than an authoritarian role of “you must do this because it is good for you."
Here is a final quote from Yerxa about the nature of man: "We are viewing the client, not as an object or thing to be manipulated, controlled or made to conform but as a unique individual whose very humanness entitles him to choices in determining his own destiny. For if the client interprets himself as a thing (one thing among others in the world) he might sacrifice his selfhood and neither recognize nor realize his potentials."
Reilly and Yerxa took what I believe to relatively unequivocal stands on the nature of human agency and autonomy. These beliefs fueled theory development through the 1980s with Kielhofner's Model of Human Occupation and also subsequently informed creation and growth of 'occupational science' as an academic discipline in the 1990s. Yerxa's ideas in particular also contributed to the entire notion of 'client centered practice' that was introduced by Mary Law in her book on the topic.
There were early debates about whether or not there were dangers in creating occupational science as a separate academic discipline. Particularly, Ann Cronin Mosey wrote a very controversial proposal to separate occupational science from occupational therapy entirely. Mosey was concerned about several issues, including the possibility that occupational science would generate basic research that did not speak to the applied research needs of clinical practice. This proposal was subsequently countered by Clark, et.al. and here it is interesting to take careful note of some statements made in defense of their position. Clark, et. al rebutted the notion that basic and applied research had to be defined in absolute dichotomy, which is a point that generated a lot more debate on continuous vs. dichotomous research models. I think that the conversation got so confusing that some people tuned out at that point. However, review of some of their defense in context of our current standing with regard to the drift away from the philosophical core of the profession is interesting. They wrote: "We feel that Mosey exaggerated greatly when she speculated that such outcomes as occupational therapists confusion over the identity of their own discipline or the pursuit of poorly focused research would result if occupational therapy and occupational science were not completely divorced."
Following the Mosey and Clark, et.al. debate there was no division between occupational science and occupational therapy. Instead, we almost immediately began to see different messages coming out of the occupational therapy literature and from academics. One very clear example that served to portend the future was an article by Townsend, Langille, and Ripley in 1993 that began taking steps back away from the notion of client centered practice. I have pointed criticism about this article, but I believe that the author's argument about the challenges of client centered practice can be summed up in the simple statement of, "This is too hard to do!" With the level of detailed analysis applied to the specific case and the use of ethnographic analysis to try to frame their problem, I can't help wonder that if just a fraction of that same effort was directed toward trying to generate solutions that there would have been no need for the article. So, with one fell swoop, we began to see the decimation of the client centered concept. This quote from the article is interesting: "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?"
In the mid-1990s as this was being played out and we have to consider the impact of the Internet and globalization of the profession. Occupational science became a world-wide academic discipline, and we saw heavy influence from international scholars such as Elizabeth Townsend and Ann Wilcock. Suddenly we were contending with concepts of occupational justice, sustainability, climate change, and broad public health. The academics of the profession changed dramatically as we absorbed all of this and pushed the profession into the masters and now the doctoral level of training.
In my opinion, this globalization generated a new wave of occupational therapy academic thinking that has since provided us with a vision of occupational therapy practice that is very unlike and often at direct odds with our philosophical core that respects autonomy and human agency. The occupational therapy profession has taken a sharp turn off course. I will readily admit that this is an American perspective and opinion, but it is not intended as protectionism as it is based on an analysis of our philosophical core and on the statements of some of our most important theorists.
It is very interesting to analyze Clark et.al.'s article in context of present-day practitioner statements about the equivocal value of some research published in the American Journal of Occupational Therapy, the statements made to AOTA in their business meetings that the annual conference does not have enough practical information for clinicians, that the AOTA itself is over-represented by academicians and students (who are often mandated to join by their academic programs), that there is vocal opposition to such issues as inclusion of social justice in the AOTA Code of Ethics, and most recently the concern about adoption of public health models that are not aligned with the philosophical core of the profession and respect for autonomy and human agency. Perhaps Mosey had a point after all? Has occupational science, as a global academic discipline, steered us off course?
Clark addressed the basic vs. applied science debate in her 2013 Ann Cronin Mosey Lecture and defended occupational science as now being a 'translational' science of everyday living - but at the same time acknowledged that not everyone agreed with her and that the plurality that is now occupational science represents a wide range of thinking. I believe that is an understatement, because even if Dr. Clark is attempting to keep her occupational science work practical - we can easily follow the footsteps of this entire process and see that occupational science has taken us away from our philosophical core - particular in the influence from international scholars.
So now we are deep into debates about social justice and public health - concepts deeply embedded within the international occupational science literature. Public health, just like social justice, is based on the notion of egalitarianism. Application and respect of autonomy is often very challenging within the public health context. Buchanan wrote an article that all OTs who are quick to jump to a public health model should read. The article outlines (in a fairly even handed fashion) the intertwining concerns with autonomy and paternalism as it relates to activities conducted within a public health context. Buchanan provides an excellent reminder of the apparently forgotten idea that the best strategies to promote health occur through the autonomous and informed decisions of people in action.
That notion of autonomy is an original American ideal. Globalization has taken us sharply off course of our original principles.
Autonomy and human agency were ideals that Mary Reilly said could move a civilization and on a smaller scale could move a profession.
We have such a rich theory base, but it is being abandoned for something else. This theory base has been discarded by proponents of social justice and public health, because apparently to wave this flag of autonomy and free agency is just 'too hard.' It is apparently easier for some to create a dogmatic and oppressive authority over others and to tell them what is good for them. It is apparently easier to try to be a planet-saving freedom fighter based on someone's paternalistic ideals of what that means and how it should be constituted.
We have failed to prove Mary Reilly's hypothesis. What could have been the greatest idea in 20th century medicine is currently being sold out to a global model of paternalism and egalitarian justice.
Maybe there are people who would label this progress. I label this abandonment of principle, despite the efforts of some academicians to keep the discipline pragmatic and relevant.
References and background reading:
Buchanan, D.R. (2008). Autonomy, paternalism, and justice: Ethical priorities in public health. American Journal of Public Health, 98, 15-20.
Clark, F. (2013). NYU Steinhardt Department of Occupational Therapy 2013 Anne Cronin Mosey Lectureship. Accessed July 4, 2013 from http://vimeo.com/62729507
Clark, F. A., Zemke, R., Frank, G., Parham, D., Neville-Jan, A. M., Hedricks, C., Carlson, M. E., Fazio, L., and Abreu, B. (1993). Dangers inherent in the partition of occupational therapy and occupational science [The issue is]. American Journal of Occupational Therapy, 47, 184-186.
Kielhofner, G. (2008). Model of human occupation: Theory and application (4th ed.). Philadelphia: Lippincott, Williams & Wilkins.
Law, Mary (1998). Client Centered Occupational Therapy. Thorofare: Slack, Inc.
Mosey, A.C. (1992). The Partition of occupational science and occupational therapy. [The issue is]. American Journal of Occupational Therapy, 46, 851-853.
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.
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.