Tuesday, February 24, 2015

The American Occupational Therapy Association: The new 'Concern Troll' in school-based mental health

Concern Troll: (noun) A person or persons who pretends to be 'concerned' about something and talks about it, all the while serving to actually disrupt the legitimate concerns and activities of people who are trying to address problems. Concern trolls are particularly skilled in derailing conversations, conflating issues, and leading people off track.

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AOTA recently released a new document on use of restraints and seclusion related to school based practice.  I will not link that document because I believe that it is fundamentally flawed and does not represent the thinking of many people who actually practice in school settings.  There is no value in spreading that faulty document, but I will describe the problems with a hope that more conversation will be generated about the issue broadly.

The paper has some positive aspects, including identification of the role of OT in helping teams understand and interpret personal and contextual factors that might lead to disruptive or dangerous behaviors.  OTs have good skills and abilities to participate on those teams.

However, the document takes a sharp turn off course.  The authors describe the negative problems with 'occupational deprivation' caused by restraints and seclusion practices and that OTs need to work on school teams to provide 'occupational enrichment' to counteract the alleged systemic or habitual use of restraints in schools.

I am uncertain if it is really appropriate to refer to therapeutic use of restraints in context of how scholars have defined 'occupational deprivation' in forensic or refugee or war contexts.  Restraint use in a treatment context usually has to do with preventing harm to self or others and is only used in a last-ditch context when all other methods have failed and only to prevent harm.

Certainly there are problems with the use of restraint but that has more to do with the de-professionalization of care teams and lack of oversight or sound policies in 'treatment' contexts than it does with forensics or willful removal of rights in a punishment or war or refugee context.  When there is conflation between the two it sounds as if OTs are confused that we are still in a pre-Moral Treatment period, which of course we are not.

When a restraint method is used the issue of 'occupational deprivation' is not a factor.  The only factor that I am aware of is to prevent harm or injury.  Restraint methods are time limited and there is no 'occupational deprivation' associated with their use.   Conflating time limited restraint methods to prevent  harm and injury with 'occupational deprivation' (whatever that is) is ridiculous.

Also, conflating special education placement itself as a form of 'occupational deprivation' is an extreme and unusual perspective that does not comport with reality.  This is perhaps the most odd belief expressed in that document.

This bizarre concern about 'occupational deprivation' is fueled by the 'Trauma-Informed Practices' movement.  The notion underlying this movement is that care providers need to be sensitized to the trauma that many people who have emotional and behavioral disorders have lived.  Then with this new-found sensitivity they can engage in non-specific practices to help people understand the root causes of their behaviors.  It is all about being more SENSITIVE and CARING.  An entire industry has cropped up on how to create a Trauma-Informed Care Team.

Instead of attending conferences and writing papers and conducting trainings I would like to see OTs actually working in behavioral/mental health programs themselves and doing something DIRECTLY to address these problems.

The entire 'trauma informed' movement is  the ultimate in hashtag advocacy.  We fail to understand that the real reason that care systems are sub-optimal is because professionals have abandoned those treatment settings and left them in the hands of marginally trained people.  Then we complain when the marginally trained people aren't functioning the way that we want them to.

Instead of working in those populations ourselves now we have a giant push to 'educate' people and to make sure that they 'assume' that everyone in these settings has experienced trauma, and to 'train' staff to approach things with an improved sensitivity.  Maybe if we all FEEL BADLY ENOUGH about the problem it will get better!

It is Moral Treatment Redux.  Just like the first Moral Treatment movement failed this one will too - because the real answer involves investment of resources so large that no one is really willing to make that commitment.  It only took a short time before the beautiful design plans of the 1850s reverted to stinking cesspools that were labeled 'SNAKE PITS.'  Then we had a generation of new hope in a civil rights movement that de-institutionalized everyone but failed to really meet other needs.  And here we are again with a whole new generation of feel-good advocacy that puts the responsibility on the 'other' care providers.  Professionals of ALL STRIPES have abandoned treatment of people who have chronic conditions and REPLACE CARE with FEELING BADLY as if that will serve to purify themselves of guilt with their faux CONCERN.

People who care go out and do something about problems.  LIKE ACTUAL TREATMENT.

They don't attend conferences so they can be SENSITIZED about HOW HORRIBLE THE WORLD IS TO PEOPLE and how to MAKE OTHER PEOPLE TAKE CARE OF THINGS.

It is all about Dirty Jobs, that TV show that so many people love to watch.  We have a fascination with the work, but no interest in doing anything about it other than deep-sitting on our couches in the comfort and safety of our living rooms and then exerting just enough effort to lift our finger to turn up the volume.

This is why I label this movement as 'Most likely to bore the pants off of anyone who really cares.'

So now we have found a NEW PROBLEM of restraint use and we will label it in our own made-up terms of 'occupational deprivation' and we will conflate restraint use with some horrible injustice that the world is perpetrating on people.  Because there is no real leadership on TREATMENT of people who have mental illness the AOTA response is to turn us all into CONCERN TROLLS and will have us all attend conferences and then present on 'Trauma Informed Care' so that 'those other people' who are tying up school children and throwing them into rubber padded rooms will do a better job.

I strongly suggest that if the AOTA wants to get back into the business of providing services to people who have mental health problems, that it actually start with providing services to people who have mental health problems.  This current track of coming up with 'new problems' and calling it 'occupational deprivation' and promoting 'trauma informed models' seems a little bizarre.

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