Will a public health model make occupational therapy more relevant?
I just finished watching the COT 2013 Annual Conference plenary by Michael Iwama. You can listen to his lecture by clicking here. Hopefully we will have accompanying slides in the near future. I was very anxious to listen to this presentation after watching the Twitter feed coming from the conference that included statements about our 'preoccupation with the individual' and that our 'practice has stalled' and that we were at a crossroads where we had an opportunity to take on a new role in a broader public health initiative.
I was a little concerned about some of these statements and was not sure that I agreed. I am in the beginning stages of my own Twitter-acceptance and was not sure if those conference tweets fairly represented the presentation. I am happy to report that the quotes and concepts that people were tweeting from the conference were actually quite accurate and representative of the presentation.
I encourage people to listen to the whole presentation, but if you can't I will summarize it as briefly as I can in outline format:
I. Question: Is occupational therapy functioning near our capabilities and are we a relevant profession?
II. Current problem: We function from the perspective of individual embodiment, from the medical model, and our practice is shaped more by policies and remuneration than by good theory.
III. Statement: We have had good theory development (OB/MOHO/OS)
IV. Analysis: We are hampered by our frameworks, we are not relevant, and we are not responsive enough to needs.
V. Reasons: We are stuck in understanding problems from what Durkheim's described as the cult of the individual.
VI. We need to focus on meta-environmental factors that shape people's life-course such as:
- social factors - we need to adopt postmodern and relativistic perspectives
- economic factors - we have to understand that globalization (Monsanto/Exxon/etc) impacts us
- environmental factors - we have to understand how climate change, catastrophe, and oil dependence impacts us
- technology advances - our use of technology and communication impacts us.
VII. The public health model is our new choice so we can be relevant. The community is our patient and changing society is our goal.
VIII. How can OT contribute to public health? We should DO OT on the field of public health.
IX. Health disparities in affluent societies are unconscionable. WHERE IS OT?
X. Role-emergent OT practice is a new path to relevance. We do good work on the medical path and we still need to be there, but will we walk this new path?
The presentation was a little thin on examples, and Dr. Iwama expressed that he would need more than the time allotted to more completely express what clinicians and researchers and administrators need to do. I am hopeful that we will learn more about specific public health interventions in the future.
The central question of relevance is what I would like to explore first and will be the focus of this particular post. Is it possible that I am not relevant, or that my practice is not relevant - and I just have not noticed?
Relevance is an interesting concept. The question of relevance is a question if something is practical, or if it is at all material to the problems at hand. The charge of irrelevance or of being less relevant than what should be is a rather serious charge and is worthy of exploration.
In a free market, relevance can be measured by existence - because if something is irrelevant than certainly it will not persist unless it is propped up by something else. Alternately, if something is not as relevant as it could be than it is likely that it would not flourish or that if it did manage to exist it would be weak or perhaps sickly and something else could be seen as being much more healthy. We can use these metrics to determine if occupational therapy has any relevance.
I am not sure how to apply some measurement to the entire field of occupational therapy so I will apply Fuller's Guinea Pig B methodology to the problem.
My occupational therapy clinic, which is quite humble, has persisted as my primary means of economic sustenance in a free market context for thirteen years. It has not been propped up by anything other than the fact that people walk into my front door and transact business with me. I provide an occupational therapy service and then I receive some money. In order to be practical I need to listen to the people who come into the front door and I need to meet some need of theirs that is valuable enough to them that they would engage a transaction. In a broader sense, 13 years of continuous operation is a metric I use to conclude that people have perceived the transactions as relevant - meaning that I provided something practical that was material to their problems at hand.
What have those transactions consisted of? Here Guinea Pig B methodology is helpful because I can very explicitly report what I do and I can do so with absolutely no reporting error. I can report that I have provided individual occupational therapy services to people of all ages who have needs ranging from developmental disabilities, learning problems, accidents or injuries, emotional problems, and many other conditions that could probably be labeled within a 'pathological' or 'medical' context. I can report with absolutely no error that the focus of those occupational therapy services has been related to the impact of those conditions on the occupational problems of concern to the individuals and their families.
I have reported relevance from an economic argument of continuity of existence in a free market context, but there have been other points of evidence about relevance along the way. Here are a couple I can think of off the top of my head just from this week:
1. We received an envelope in the mail yesterday from the parent of a child who had very constricted tolerance for foods. After a short course of therapy the child made great progress and was discharged. On the envelope the parent wrote: "We miss seeing you so much but we are doing GREAT!" I interpret this message written on the envelope as a sign of relevance, because if we were not relevant the parent might have written "Take this money that I owe you and shove it - this was all a ripoff and not helpful at all!" I think that the fact that the parent was happy to publicize her gratitude and well wishes on the front of the envelope is a rather powerful message about her perception of our relevance.
2. Today a parent told me, "I really think that Jasmine will be ready for school in September. I did not think that before, but you have helped us so much." Jasmine's progress in therapy has even surprised me it has been so dramatic - and I actually credit the parents for most of the work because THEY are the ones who were so willing to follow through on recommendations and were so diligent in changing routines at home. When I analyze the situation I understand that it was the partnership that made all the difference, and I know that my recommendations were relevant to their needs - the proof is as plain as that child's kindergarten readiness. Very powerful evidence.
Interestingly, I believe that these examples indicate that we were responsive to the needs of the people who were asking for services, EVEN THOUGH the families self-defined their problems from the perspective of the 'cult of the individual.'
There does not seem to be any evidence that we were hampered by policies or remuneration.
These families did not define their problems in any post-modern terms and they did not ask me to deconstruct their lived experience. As a former participant in occupational therapy doctoral studies I am fully competent in the academic playground of hermeneutic analysis and narrative interpretation but really all these parents wanted was for their children to eat healthy foods and to be ready for kindergarten. They parent of the child with feeding problems was not overtly concerned about globalization and whether or not Monsanto was genetically modifying their wheat. I don't recall any conversations about climate change. I tried to attend to their needs, to be RELEVANT, and I just didn't notice any of these meta-environmental themes expressed as being of primary concern.
If I think about it, I would have to state that the intervention was relevant and it was responsive to their needs.
This leads to some questions. If it seems evident that the intervention was relevant and responsive to their needs, why do academics in the occupational therapy profession worry so much that occupational therapy is not relevant and responsive to people's needs?
Some of my favorite occupational therapy 'textbooks' are those written by Cheryl Mattingly. If I am remembering correctly, she is an anthropologist by training. In her books she explores in great detail how occupational therapists meet the needs of their patients, in both explicit and implicit ways. Maybe some of the academicians should read Mattingly's books again - and maybe they should come visit my humble little clinic for a little dose of Guinea Pig B evidence.
I would like to challenge occupational therapy academicians to provide some evidence that occupational therapists are failing to meet the needs of their patients and are not relevant. It would seem to be important to provide some evidence to support this theory before we embark on some whimsical traipse into a public health experiment.
Perhaps, somewhere, there are people who are quite angry at their occupational therapists because the OT was focused on something silly like teaching them how to get dressed after they had a hip replacement, when the real issue at hand was whether or not getting a hip replacement at all was fair given all the health disparities on the planet and also whether or not recommending adaptive equipment was just propping up the medical-industrial complex and driving up health care costs unnecessarily. Maybe the patient really wanted the OT to partner with them on a letter writing campaign to their politicians to protest the lack of social justice that contributes to these problems?
I hope this will serve as a springboard into a long conversation about whether or not occupational therapy as currently constituted is relevant enough and meets the expressed needs of those seeking services.