Monday, October 13, 2014

A syllabus and reference list regarding attempts to redefine the occupational therapy profession

The lynchpin of this conversation goes back to the patient v. client debates which quite clearly have not been resolved.  I think it is important to look at those issues very carefully.  Client-based ethics are simply different than patient-based ethics, and the more that we walk down paths of client-based ethics the more risks we take of straying too far from our roots, as we were clearly warned by Reilly (1984) and Yerxa and Sharrott (1985).

It should be very interesting to note that the entire argument for client-based ethics as originally made by Herzberg (1990) revolved around the allegedly 'faulty' logic of Reilly, Yerxa, and Sharrott.

Herzberg stated that the term ‘patient’ implies that people are sick.  She also argued that using the 'patient' term removed autonomy, limited participation, and restricted our roles in mental health and wellness.  She made that claim in 1990, and I would argue that nearly 25 years later of client-based ethics that our roles and functions within mental health and wellness arenas have not really done so well.  She also stated that although ‘client’ implies an economic-legalistic relationship, it does not preclude a medico-ethical relationship.  In other words, we would not stop 'caring' for people just because we call them clients.

There is strong evidence that she was incorrect.

It did not take long to tumble down the hill.  In 2003 Townsend, Langille, and Ripley wrote an article stating that a more effective methodology for solving client problems would be to focus on the tensions of the systems that the clients are in. They stated, "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?"

It got worse from there.  Further descent into client-based ethics is evident in Taylor's (2009) Intentional Relationship model.  I believe that issues related to therapeutic use of self are actually quite important for our profession, but there is little question that some very unusual turns have been taken with this work.  Specifically, I reference Kielberg, (2012) where they state:

“Importantly, this perspective does not always mean that the client should be entirely independent in his or her decision-making or that he or she should take the lead in defining problems, establishing plans, or setting goals for outcomes. In fact, this perspective on client-centred therapy does not necessitate that the client make decisions jointly with the occupational therapist. Instead, this perspective endorses being an advocate for the client’s welfare and desires, however explicit or subtle they may be. This perspective offers a well-rounded and comprehensive understanding of what it means to be client-centred. Client-centred therapy may involve empowering the client and collaborating during treatment or it may simply mean taking the time to appreciate and respect clients’ experience in occupational therapy, whatever it is, and advocate for their needs when they may not be able to do this for themselves.”

The argument FOR the 'client' term originally revolved around concerns of 'medical paternalism' and now those who support the 'client' term are stating that being client-centered MEANS taking some paternalistic stance about identifying and advocating for needs.  This is a stunning juxtaposition.  It only took 25 years, but now we have some academic occupational therapists providing full-throated support for the idea that we do not care for patients, but that we represent clients and their needs, and we do so using a model that acknowledges that they don't always know what is best.

This very brief syllabus and reference list documents the wellspring of ideas that informs the context of debates related to advocacy, politics, and the proper scope of occupational therapy as an allied health care profession.  It is true that some academic occupational therapists (and psychologists) are re-conceptualizing our expression of Core Values. 

I believe that whether or not these ideas represent the mainstream of actual practice and the values that practitioners hold remains an open question.


Herzberg, S.R. (1990). Client or patient: Which term is more appropriate for use in occupational therapy.  American Journal of Occupational Therapy, 44, 561-564.

Kjellberg, A., Kåhlin, I., Haglund, L. and Taylor, R. (2012). The myth of participation in occupational therapy: Reconceptualizing a client-centred approach, Scandinavian Journal of Occupational Therapy, (19)5, 421-427.

Reilly, M. (1984). The importance of the client vs. patient issue for occupational therapy. American Journal of Occupational Therapy, 38(6), 404-406.

Taylor, R.R., Lee, S.W., Kielhofner, G.W., & Ketkar, M. (2009). Therapeutic use of self: A nationwide survey of practitioners’ experience and attitudes. American Journal of Occupational Therapy , 63, 198 - 207 .

Townsend, E., Langille, L., Ripley, D. (2003). Professional tensions in client-centered practice: Using institutional ethnography to generate understanding and transformation. American Journal of Occupational Therapy, 57, 17–28

Yerxa, E.J. & Sharrott,G.W. (1985). Promises to Keep: Implications of the referent "patient" versus "client" for those served by occupational therapy.  American Journal of Occupational Therapy, 39(6), 401-405.

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