Can use of an occupational justice model in an American context result in accusations of professional misconduct?
Conceptual practice models are interrelated bodies of theory, research, and practice resources that are used by OTs to guide practice (Kielhofner, 2009). One such conceptual practice model is the Occupational Justice Model (Townsend, 1993; Townsend and Nillson, 2010). According to these sources, the Occupational Justice Model is framed around the concept that injustice occurs due to inherent governance and social structures that allegedly restrict the occupational performance of some populations and individuals.
Concepts associated with occupational justice models have filtered into some official documents of the American Occupational Therapy Association. For example, the AOTA 2010 Code of Ethics included a new principle of 'Social Justice' (AOTA, 2011). That new principle required occupational therapy personnel "to provide services in a fair and equitable manner and to advocate for just and fair treatment ... and encourage employers and colleagues to
abide by the highest standards of social justice and the ethical
standards set forth by the occupational therapy profession."
The social justice requirement has been controversial. The challenge with this requirement is that there has not been any corresponding statements that provided meaningful guidance on what practicing in a social justice context means for practitioners. Disagreement about social justice terminology and whether this philosophy was congruent with OT Core Values has been a significant debate that has lasted over four years.
Occupational justice is also mentioned in the new (3rd) edition of the OT Practice Framework (AOTA, 2014). This document states that children who have psychiatric disabilities placed in alternate schools face occupational injustice because they may have limited opportunities to participate in sports, music programs, and organized social programs (p. s9). No specific references are provided for this claim, and this is not in accordance with my own lived experience as an occupational therapist, so I must assume that this reflects the observations of a therapist who last practiced many years ago, perhaps pre-dating 1973 when federal law prohibited such discrimination.
Nonetheless, whoever wrote the Practice Framework also believes that such discrimination occurs in other settings as well. Other examples provided (p. s9) are residential facilities that don't allow people to engage in meaningful role activities and poor communities that lack accessibility and resources. Again, this is not in accordance with my lived experience as an occupational therapist in the United States, so I am thinking that whoever wrote this must have been reflecting on some mission trip to a former Soviet-bloc country's orphanage, or something. I am very aware that conditions of such institutions are rather grim in some parts of the world.
The fact that the OT Practice Framework 3rd edition includes elements that are grossly out of step with reality of practice in the United States is something that probably requires some discussion and hopefully correction. This is particularly true because this document is used so heavily in academic programs to teach students how to practice and is referenced in many other AOTA documents.
The AOTA Practice Framework 3rd edition states that OTs "work to support policies, actions, and laws that allow people to engage in occupations that provide purpose and meaning in their lives." (p. s9). Outcomes of interventions for populations "may include health promotion, occupational justice and self-advocacy, and access to services." (p. s16). Specifically, related to outcomes, the AOTA Practice Framework 3rd ed. references the work of Townsend and Wilcock (2004).
The Canadian Association of Occupational Therapy has published helpful information about how to practice from Townsend's occupational justice model (Wolf et al, 2010). In the article an example is given about occupational deprivation.
The example is a child who has developmental delay and limited access
to toys because of poverty. According to the article, "the injustice is
predicated by a social system which does not provide enough funding to
support children’s development." The therapists actions as a result are
to write letters to politicians, obtain grants, and other advocacy
Surprisingly, the document does not state that the therapist actually addresses
the motor delays.
The problem that I see with this practice model is that it does not
reflect any reality that I have experienced in almost 30 years of
practice. Actually, most therapists I know would have given the child
toys themselves, left toys for the family to use, or referred them to a
toy lending library, or placed them on a list to receive charitable
donations like from the US Marines Toys for Tots Foundation.
doing all of this the therapist would be working with the child and
family on the motor delays.
Maybe a therapist would develop a side
interest in obtaining grant funding but that would be a long term
project and certainly not tied to outcomes for any one specific child. Using this occupational justice framework to address problems of
occupational deprivation seems to be a disconnected and confused idea
that does not reflect actual practice.
It is important to note that this article is written from the context of Canadian practice, about which I claim no expertise at all. However, using this occupational justice model in a United States context could cause the well-intentioned therapist to be accused of professional misconduct.
Specifically, a therapist in the United States could be accused of failing to respect the procedural rules and laws associated with care of children that age. Those procedural rules and laws do not support the advocacy activities of writing political letters as a part of OT practice.
Additionally, there could be accusation of failing to address those issues that ARE within the scope of practice, particularly the specific client factors (developmental delays) that the therapist found were severely delayed.
Unfortunately, the guidance provided by Wolf et al (2010) is that "occupational injustices like those faced by Sarah and her family cannot be resolved at an individual level" and that "occupational justice is achieved through a change in social attitudes which acknowledge the value of diversity and support the engagement of all persons in meaningful occupations." I am not sure if writing letters to politicians in Canada is a legitimate intervention method for occupational therapists. American therapists attempting to get reimbursement for writing political letters that might have some long-term or downstream impact on the person who is supposed to be receiving help now would generally not be considered occupational therapy.
Therapists might engage in varying degrees of advocacy-related activities depending on their own philosophies and inclinations. That is very different than using advocacy activities as intervention as this model proposes, particularly in context of using them and NOT providing actual occupational therapy to address those developmental delays.
American therapists using an occupational justice model could reasonably expect a threat of disciplinary action. I am hopeful that by pointing out the dangers of an occupational justice model applied in an American context will cause the American Occupational Therapy Association to reconsider its reference to these models in its official documents.
see embedded links
AOTA. [Slater, D.Y. (Ed.).] (2011) Reference guide to the occupational therapy
code of ethics and ethics standards. Bethesda: AOTA Press.
AOTA (2014). Occupational Therapy Practice Framework: Domain and Process, 3rd ed. Bethesda: AOTA Press.
Kielhofner, G. (2009). Conceptual foundations of occupational therapy practice. Philadelphia, PA: FA Davis.
Townsend E. (1993). Muriel Driver Memorial Lecture: Occupational therapy’s social vision. Canadian Journal of Occupational Therapy, 60, 174-84.
Townsend, E. and Nillson, I. (2010). Occupational justice: Bridging theory and practice. Scandinavian Journal of Occupational Therapy, 17, 57-63
Townsend, E. and Wilcock, A. (2004). Occupational justice and client centered practice: A dialogue in progress. Canadian Journal of Occupational Therapy, 71, 75-87.
Wolf, L. et. al. (2010). Applying an occupational justice framework. OT Now, 12, 15-18.