When Theory Ignores the Shower Chair
Take one example: I once worked with a patient who was Native American and had diabetes complicated by years of substance abuse. He was blind and had bilateral above-knee amputations. His family had limited resources and limited support. They were doing the best they could. And so was I. My plan of care was entirely rooted in his problems—because that's what brought occupational therapy into the picture in the first place.
Clinicians don’t have the luxury of deconstructing outcome measures when they’re in a cramped living space, trying to help someone who can’t get into a shower. Rather, they are working with families who are struggling to care for their loved ones under impossible conditions. That is why it seems like such a strange thing to read high-minded critiques of tools like the Canadian Occupational Performance Measure (COPM). It was in that context—thinking about the tension between philosophical discourse and clinical work—that I came across an article titled "Openness to Critique is Essential."
The authors defend a critique of the COPM that claims it is too Western, too problem-focused, too individualistic, and therefore ill-suited for use with Indigenous patients. And while I support open dialogue and critical thinking, this feels like an opportunity to conduct a serious reality check in occupational therapy.
My patient couldn't bathe. He couldn't transfer safely. He was at risk for skin breakdown, infection, and a dozen other preventable crises. What exactly should I have done instead? Reflect on the colonial legacy of rehabilitation sciences while his wounds festered? Ask him about his relationship to land and spirit while he sat in his own waste? The dignity he wanted—and the dignity his family wanted for him—was not theoretical. It was practical. It was rooted in addressing the painful, difficult, and yes, deeply unjust reality of his life.
This isn’t to say that colonialism, racism, or systemic neglect shouldn’t be part of the conversation. Of course they should. But those conversations have to serve something more than the intellectual curiosity of academics. They have to lead to better care. And better care often starts with naming the problem and creating a plan to solve it. That's not colonial. That's compassionate.
The COPM, for all its imperfections, gives us a structured way to understand what matters to the patient and to set measurable goals that help us advocate for services and resources. That matters when you're in a trailer on a reservation with a family that just wants their father or husband to have a safe, dignified life.
This is not abstract. It's not a seminar. It's not a think piece. It's someone real who can’t get clean, who is stuck in a broken system, and who still deserves care.
This is where the debate needs grounding: in the everyday moments where patients live and therapists work.
So by all means, let’s critique. But let’s also remember what we're here to do. Because when you're face-to-face with someone who has lost nearly everything, the problem is not that the COPM centers problems. The problem is that we are even having to defend common sense.
This kind of academic detachment isn’t new. I reflected on similar frustrations over a decade ago in a post called Recurring Philosophical Questions, where I pushed back on over-theorizing that ignored the lived experience of our patients. It's a recurring theme because it’s a recurring problem.
It’s also a problem I revisited more recently in my post on The Problems with Polarity Frames in Occupational Therapy. There, I argued that the profession often becomes trapped in artificial binaries—like tradition vs. innovation, individual vs. community, Western vs. Indigenous—as if those are mutually exclusive positions rather than part of a larger, more nuanced reality. These polarity frames don't help us solve problems. They become distractions that keep us from focusing on what matters most: patient-centered, ethical, pragmatic care.
But beyond just labeling the polarity frame, that post went deeper into the core conflict: that these deconstructive framings are often incompatible with the practice realities of occupational therapy. We are all anchored in the systems where we quite literally are. Patients are not abstractions; they live in homes, in healthcare bureaucracies, in insurance networks, in pain. Therapists have to operate in these same systems. So why do we keep spinning critiques that don't produce practical action? It’s one thing to identify limitations in a measure—it’s another to offer something actionable in its place. And that’s the piece so often missing.
This gap between abstract critique and actionable practice isn't new either. I addressed a version of it back in 2014 in a piece titled Basic vs. Applied Science: The Ongoing OT and OS Debate. That post raised concerns about the growing split between occupational science and occupational therapy—between those who aim to generate knowledge about occupation and those whose daily work is helping patients through it. If occupational science wants to critique, it absolutely can—but it needs to do so with an understanding of practice constraints. Otherwise, the risk is that scholars end up developing elegant theories that have no functional relationship to care delivery. And that disconnect serves no one—not patients, not families, and not the profession.
Part of the irony is that occupational therapy’s philosophical roots are not hidden—they are grounded in pragmatism. The early founders of the profession were influenced by the American philosophical tradition of pragmatism, particularly the writings of Ralph Waldo Emerson, William James, and John Dewey. These thinkers emphasized the importance of experience, purposeful activity, and practical action as the basis for knowledge and growth. Pragmatism is not just a footnote in our history—it’s the very reason the profession exists.
The Progressive Era, which gave rise to occupational therapy, was saturated with these ideas: that humans adapt through doing, that knowledge is rooted in experience, and that health is inseparable from meaningful activity. These were not abstract concepts—they were reformist, practical, and deeply American. OT emerged in direct response to the complex needs of industrialized society, war injuries, mental illness, and poverty—not in pursuit of ideological purity, but in pursuit of help that worked. We were built on ideas of self-reliance, purposeful activity, and meaningful engagement as ways to support healing and well-being.
So here's a difficult question for the academy: if pragmatism is "too Western," what happens when we study our own history and discover that our entire raison d'être is based on individualism, self-reliance, and pragmatic problem-solving? Are we to dismantle the foundation of our profession because it was developed within a Western context? Or can we reconcile that history with present-day commitments by staying true to our purpose—helping people live better lives—without losing ourselves in the clouds of critique?
We need to keep things real. Keep the theory grounded. Keep the critique relevant. And for goodness' sake, don’t forget the shower chair. I can’t solve people’s real problems with a land use statement. Sometimes, they just need a shower chair.
Background reading:
Beagan, B. L., Kiepek, N., Lauckner, H., & Rushton, P. W. (2025). Openness to Critique is Essential. The Open Journal of Occupational Therapy, 13(1), 1-3. https://doi.org/10.15453/2168-6408.2418
McColl, M. A., Baptiste, S., Carswell, A., Law, M., & Polatajko, H. (2024). Letter to the Editor: The COPM: Culturally Sensitive by Design. Open Journal of Occupational Therapy 12(3), 1–2. https://doi.org/10.15453/21686408.2290
Price, T., & Pride, T. (2023). The Canadian Occupational Performance Measure (COPM): Critiquing its applicability with Indigenous Peoples and communities. The Open Journal of Occupational Therapy, 11(3), 110. https://doi.org/10.15453/2168-6408.2085
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