Can use of an occupational justice model in an American context result in accusations of professional misconduct?

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 activities.

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.

While 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.


References:

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.


Comments

Cayzle said…
"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." LOLOL!
This post has generated some interesting email - and it is becoming increasingly clear that occupational therapists do not understand the difference between advocacy and lobbying, particularly as it relates to allowable activities within non-profit entities in the United States.

It is important for occupational therapists to know the limits of lobbying activities and how such activity can cause IRS trouble for their agencies. It is also important for occupational therapists to understand rules for conduct when an agency is funded with federal dollars.

The feedback that I have received on this post so far has strongly indicated that many occupational therapy leaders who are promoting advocacy and lobbying as an intervention model do not understand the peril they are creating for therapists.
Cheryl said…
"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 activities.

Surprisingly, the document does not state that the therapist actually addresses the motor delays. "

From my reading of it, I would think that the "justice" model is more for extracurricular OT activities than your actual 9-5. No grant or institutional change would help that hypothetical child in the near future. It just doesn't make sense to me that the OT would have a main focus on justice as opposed to motor development. Wouldn't the justice model have to be second to other models of practice? It couldn't really stand on its own. And if it is a secondary model, guiding therapists to put on free clinics to empower parents or writing grants, wouldn't that be OK?
Hi Cheryl - The problem is that those who promote this approach don't mean for it to be a secondary method. Wolfe (2010) stated, Occupational injustices like those faced by Sarah and her family cannot be resolved at an individual level." Similarly, Townsend, Languille, and Ripley (2003)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?"

This method is incompatible with our tradition and theory, and is promoted by international academics who seem to be divorced from actual practice. American scholars went along with the bandwagon and have not even stopped to consider that a therapist acting within such a model would be completely out of step with practice. This does not even address the ethical and legal problems that I noted above.

Many therapists engage in some levels of advocacy with their patients/families, but these models suggest abandoning client centered care because we supposedly won't effect real change until we change systems. It is bizarre and it does not represent any kind of OT that I have ever seen practiced - but it is getting infused into our practice documents with increasing frequency because most clinicians rarely speak out against such things. That leaves the international OT community and a willing cabal of American OT academics to run roughshod over the profession's practice documents.


References:

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

Wolf, L. et. al. (2010). Applying an occupational justice framework. OT Now, 12, 15-18.
Cheryl said…
But how would anyone expect to get paid using the justice model? Or expect measurable results in less than a year timeframe? To me is hard to understand this as a primary model since there would be no reimbursement, and therefore no one would do it.
Your points are all valid - but remain unanswered by justice proponents.

When you 'oppose' a justice model you will be labeled as uncaring or even discriminatory. This is an unfortunate tactic used by some who will push this model at any cost.

The primary issue is whether or not this model is compatible with OT practice, and in fact it is not. Reimbursement is just one pragmatic expression of its ill-fit.

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