The impossibility of standardized international theory in occupational therapy

I was interested to read the comments of Dr. Moses Ikiugu who is a candidate for AOTA delegate to WFOT.  His full post addressing the AOTA's future priorities in context of the Centennial Vision can be found here.

First of all, I would like to thank Dr. Ikiugu for sharing this thoughts because this is an important topic and not all candidates take the time to document their positions.

One of his more interesting comments was a call for WFOT to develop and support  theory-based clinical decision-making.  He states:
The hallmark of professionalism is the ability to explain how what we do in the process of providing our services works to address the problems that are within our domain of practice. This explanation usually comes from the theoretical base of the profession. That is why we should develop a strategy to ensure that theories that guide occupational therapy practice are clear and every occupational therapy practitioner in the world can use such theories to guide clinical decision-making... What seems to be problematic as indicated by may (sic) research reports (see for example Ikiugu, 2012) is the lack of uptake of these theoretical conceptual practice models by the rank and file of occupational therapy practitioners. If we are to survive as a profession, this adoption of theory-based clinical practice is essential. WFOT should ensure that this threat to our survival is addressed by developing policies that define global standards for theory-based clinical decision-making in the profession. As a delegate, I would strongly advocate for such a strategy.

I am interested in the idea that there could be global standards for theory-based clinical decision making.  I am also interested in the idea that 'rank and file' practitioners resist the use of theory-based clinical decision making. 

The reason why this concept makes me pause is due to the vast literature that has been generated by academics who are interested in the notion of multiculturalism and occupational therapy.

As a starting point of definition, multiculturalism relates to recognition and action related to the rights of minority populations within a society.  It can be held against the notion of cultural assimilation, which is the dominant American model that was popularized by Zangwill's play 'The Melting Pot.'

Hammell (2010) was concerned about theoretical imperialism, which she defines as power structures that would force theoretical constructs on less powerful people.  Kinebanian and Stomph (2010) believe that we need to reflect on "the underpinning values of occupational therapy which until a decade ago were mainly derived from white middle class norms and values.  Individualism, independence, and autonomy are highly valued in western societies, whereas collectivism, interdependence, and communalism might be valued more highly in other cultures.  However, it seems that the influence of these western norms and values is diminishing due to rapidly changing international relationships."

There have been many calls from leaders in the occupational therapy profession to "embrace diversity." (Abreu and Peloquin, 2004; Iwama, 2007; Clark, 2013).   A common theme in all of these calls is that there is intrinsic discrimination based on power differentials between people and that the most correct pathway to address those problems is by promoting multiculturalism and the idea of 'cultural competence.'

Despite all of the internal conversation about diversity, some authors remain critical about historical diversity in the profession (Black, 2002).  Munoz (2007) suggested that cultural competence was not really possible, so a more reasonable objective would be "cultural responsiveness." 

Given the rather strong vocalization of many occupational therapy academicians about the problems that the profession has with matters of diversity, it is difficult to know exactly how to promote global standards.  Here everything begins to make me a little dizzy: According to diversity experts in our field existing power structures need to be removed or their power needs to be taken away, we need to promote multicultural understanding and respect, and we need to promote diversity in the workforce because presumably that diversity is the best solution for meeting the needs of minority groups.  However, we also need to somehow promote some standardization in our theoretical approaches while we are clamoring about the need for sensitivity about diversity.

I do not know how it is possible to construct a workable practice theory of occupational therapy that has cross-cultural meaning and relevance given the very different value sets that people place on occupations.

Additionally, a confused ethic is promoted by the same organizations that want to promote cultural competency or cultural responsiveness.  For example, the WFOT position paper on Telehealth (2014) states that "The WFOT's mission to develop occupational therapy worldwide presupposes access to services that are contextualized to local culture, resources, and occupations... Occupational therapy services are ideally delivered by locally trained and culturally competent occupational therapists."  A contradictory set of  objectives seems to be promoted.  On one hand we should value multiculturalism and diversity, training practitioners toward those objectives.  On the other hand we should acknowledge that culturally competent care can be best provided by locals.

I am kind of wondering: if culturally competent care is ideally delivered by locals, then what is the point of all the self-flagellation about needing to be more culturally competent?

Over the last year I have presented arguments about the problems associated with the United States occupational therapy community adopting global public health philosophies.  Global conceptualizations of health are not compatible in an American context, just as our conceptualizations are not compatible with others.  What kind of theory standard can there be?

This seems rather plain because it should be obvious to even casual observers of world events that the United States has its own cultural context that is decidedly not multicultural in its orientation.  Judging by headlines in Europe right now it seems that quite a few countries are reconsidering the value of their own multicultural contexts.

It is surprising that some would promote global standards when there is not enough agreement to create a standard.  There is no consensus on the nature of occupation because occupations are embedded in culture - and any attempt to hierarchically organize or conceptualize a way to promote occupation will be met by some person somewhere screaming "HEGEMONY" at the top of their lungs.  Even WFOT knows that, it seems, based on their statement that OT should be conducted by local folk.

The irony in the WFOT position, of course, is that preferential promotion of OT by local folk is condescending to those who would attempt to be 'culturally responsive.'  It fits with the notion that cultural competence is not even possible anyway.

In context of American theory, Mary Reilly (1962) asked "Is America the place to test the hypothesis" and she went on to discuss the concept of a "drive to action" that was part of an "American spirit which hates to be confined."  These are American ideals, deeply embedded in everything that defines occupational therapy in an American context.  That context is different than the context of other countries.  The notion of multiculturalism is an anathema to this culture - and if we promoted multiculturalism there would no longer even be a hypothesis that Mary Reilly proposed!

Of course that does not mean that cultural 'other-ness' is not present to some degree among all racial or ethnic groups in that American context.  It also does not mean that practitioners should not have sensitivity to those differences and work to incorporate them when understanding a patient's needs and goals.  However, we have to go back to consider the reality of the American context - and that reality is based on cultural assimilation, specific American values, and NOT on a value for multiculturalism.   Americans of all political persuasions understand cultural assimilation.  I fondly recall debating disarmament with my sociology professor in college.  He had an amusing strategy: he wanted us to unilaterally disarm because he could not wait for people from China or Russia to invade the United States and 'taste' our notion of American freedom, which in his opinion would lead to the final collapse of Communism worldwide!

As I have previously stated, we need to reconsider what seems to be the endless academic flirtation with multiculturalism and global standardization of our theoretical constructs.  The two ends do not meet, and they will not meet as long as we have different cultures.  Street level practitioners seem to already know this, and do a great job in my opinion of attending to the cultural needs of the people they serve.  Is it perfect? - probably not - and it can always improve - but I know that in the American context there is a respect for diversity as long as it is culturally assimilated.

It may come as a shock, but most people in the United States don't ascribe to the notion that cultural assimilation in an American context is inherently prejudicial. 

References:

Abreu, B.C. and Peloquin, S.M. (2004). The issue is: Embracing diversity in our profession. American Journal of Occupational Therapy, 58, 353-359.

Black, R.M. (2002). Occupational therapy's dance with diversity. American Journal of Occupational Therapy, 56, 140-148.

Clark, F. (2013). Farewell Presidential Address, 2013.  As viewed from above: Connectivity and diversity in fulfilling occupational therapy's Centennial Vision. American Journal of Occupational Therapy, 67, 624-632.

Hammell, K.W. (2010). Resisting theoretical imperialism in the disciplines of occupational science and occupational therapy. British Journal of Occupational Therapy, 74(1), 27-33.

Iwama, M.K. (2007). Embracing diversity: Explaining the cultural dimensions of our occupational therapeutic selves. New Zealand Journal of Occupational Therapy, 54 (2), 16-23

Kinebanian, A. and Stomph, M. (2010 May). Diversity matters: Guiding principles on diversity and culture.  World Federation of Occupational Therapy Bulletin, 61, 5-13.

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.
 
World Federation of Occupational Therapy (2014). Position Statement: Telehealth.  Downloaded from http://www.wfot.org/ResourceCentre.aspx


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