Welcome to the Crisis Conversation
Interest, because I agree with the basic premise. Occupational therapy is in a period of identity instability. The profession is struggling with questions about its theoretical base, its view of humans, its scope of practice, and its methods of creating change. Those are not small questions - they are the questions that define a profession.
Frustration, because this crisis did not suddenly appear in 2026. I have been writing and presenting about these same tensions for years, often in less formal spaces and often without the kind of protective language that makes professional journals comfortable.
So, welcome to the crisis conversation.
I actually mean that sincerely. I am glad the issue is being named in AJOT. I am glad the word “crisis” is being used. I am glad there is some recognition that occupational therapy may not have a shared understanding of what it is, what it does, or how it explains itself to the public. But I do not think this crisis is sudden, mysterious, or primarily external.
The profession did not wake up one morning and discover that artificial intelligence, social media, political polarization, population health, climate change, or health care reimbursement had created an identity problem. Those forces matter, but the profession has been participating in its own destabilization for a long time.
That is the part we still need to talk about.
In 2014, I wrote a post called “Pushing back against a ‘Fourth Paradigm’ in the occupational therapy profession.” That post responded to AOTA Representative Assembly debate over language in the Philosophy of Education document. The issue may have seemed narrow at the time, but it was not. The proposed language referred to occupational therapists addressing the occupational needs of individuals, groups, communities, and populations. That was a significant change from the profession focusing on the needs of individuals. That may sound like inside baseball, but it was not.
The concern expressed at the time was that occupational therapists work within institutions, and may consult with institutions, but they do not provide therapy to institutions. Occupational therapy is directed toward human beings who have occupational needs. That distinction matters. It mattered then, and it matters now.
My argument in 2014 was that the proposed language reflected a broader effort to redefine occupational therapy by shifting its focus away from people and toward systems, institutions, economics, public health, and social justice frameworks. I called that shift a “Fourth Paradigm.” I did not use that term as a compliment.
The problem was not that occupational therapists should ignore systems. Of course systems matter. Environments matter. Institutions matter. Payment structures matter. Culture matters. Policy matters. Any occupational therapist who has worked in a school, a hospital, a nursing facility, a home care agency, or a community program knows this.
The problem begins when the contextual elements become the object of therapy.
That is where occupational therapy starts to lose focus. We begin with the legitimate observation that systems shape occupation. Then we move to the less obvious claim that changing systems is occupational therapy practice. Then we move again, often without saying so clearly, into the belief that occupational therapy’s mission is social reconstruction. That is a significant move. It should not happen quietly through committee language, framework revisions, or conference themes.
In 2017, I returned to the same concern in a post called “The meaning of a word cloud.” The specific artifact was a word cloud presented during an AOTA presidential address. The words included population health, care coordination, Triple Aim, outcomes, and patient-centered care.
The word cloud was not the problem by itself. It was a symptom. My question at the time was simple: what does it mean? Were those words supposed to represent occupational therapy practice? Occupational therapy values? A reimbursement strategy? A public health framework? A new philosophical direction? A collection of preferred terms from professional leadership? We were not told. We were simply shown the words and invited to accept their importance.
That post was about professional language, but it was also about professional method. Word clouds are crude tools even when they are generated from actual data. In that case, the source of the data was not clear. The words were presented in attractive colors and varying sizes, creating the impression of meaning without requiring the burden of explanation.
That has become a familiar pattern in occupational therapy.
The profession often introduces new conceptual directions through appealing language before doing the harder work of defining terms, testing assumptions, identifying practice implications, and explaining reimbursement realities. We are told that certain words matter. We are not always told why they matter to occupational therapy in particular.
Population health was one example. Occupational justice was another. Sustainability, climate change, and broad public health language were also moving into occupational therapy discourse. Some of these topics are important. Some may have legitimate relevance to occupational therapy. But relevance is not the same as professional identity.
Everything that affects human life can be connected to occupation if the definition is stretched far enough. That does not mean every human problem becomes occupational therapy.
That was the concern in 2017, and it remains the concern now.
By 2025, I was still writing about the same basic pattern, but the terrain had changed. In “The Ant Mill of Occupational Therapy,” I used the image of army ants trapped in a spiral. Each ant follows the one in front of it, using a rule that usually works well enough. But when the pattern becomes disconnected from the larger context, the ants circle until exhaustion.
That metaphor still seems apt.
Much of occupational therapy’s current professional discourse has become circular. We repeat the same approved language. We reinforce the same assumptions. We reward the same conceptual gestures. We cite the same frameworks. We call this progress, but it often looks like a tightening loop. In that post, I was writing in response to AOTA’s Vision Statement and proposed changes to the Code of Ethics. My concern was not that the profession should avoid ethics, inclusion, dignity, or fairness. My concern was that ethical language was increasingly being used to narrow, rather than broaden, professional dialogue.
There is a difference between asking therapists to treat people with dignity and requiring practitioners to adopt a specific sociopolitical interpretation of justice, power, and professional responsibility.
There is a difference between advocating for access and converting advocacy into a generalized method of occupational therapy intervention.
There is a difference between acknowledging inequity and making ideological conformity a test of professional virtue.
These distinctions are not distractions. They are central to the crisis.
Many clinicians sense that the profession’s official language has moved away from their daily realities. They may not have the time, the security, or the vocabulary to object in formal venues. They are busy doing the work - and that is why I refer to most of us as 'lunch-bucket occupational therapists.' We are seeing patients, documenting services, talking to families, adapting environments, negotiating school systems, trying to secure equipment, responding to productivity expectations, and explaining to administrators why occupational therapy is necessary.
Then we look up and see the profession describing itself in language that feels increasingly unfamiliar.
That gap matters.
It is tempting to dismiss practitioner discomfort as resistance to change. Sometimes it may be. But sometimes practitioners are correctly sensing that the profession’s language has moved faster than its logic.
In August 2025, I wrote “A Living Archive: Twenty Years of Blogging Occupational Therapy.” That post was partly a reflection on the blog itself. Since 2005, I have used this space to document occupational therapy as it unfolded: controversies, contradictions, policy shifts, ethical debates, educational mandates, professional governance, and repeated struggles over identity.
The archive is not tidy. It was never intended to be. It includes frustration, argument, revision, and occasional sharp edges. That is part of its value. It captured professional tensions in real time, not after they were cleaned up for journal publication. That is why the archive matters now.
When AJOT publishes an article naming occupational therapy as being in crisis, it enters a conversation that has already been happening. That conversation has happened in blogs, clinics, classrooms, Representative Assembly meetings, conference hallways, private emails, online forums, and quiet conversations among practitioners who are not always represented in formal scholarship.
Once a concern appears in AJOT, it becomes part of “the literature.” Before that, it may be treated as noise, resistance, nostalgia, or professional crankiness. I have heard all of those labels - I assure you. But sometimes the unofficial spaces see the problem first.
The current AJOT article is useful because it returns to the paradigm question. It places the current moment alongside prior professional crises in the 1940s and 1970s. It asks whether the current performance paradigm still explains occupational therapy. It asks whether the profession is health care, social change, or both. It asks how we understand participation, population health, advocacy, inequity, evidence, technology, and artificial intelligence.
Those are important questions. But the article does not go far enough.
It identifies the crisis, but it does not fully ask how much of the crisis was created by occupational therapy’s own official documents, academic discourse, accreditation standards, ethics revisions, and leadership language.
It identifies external pressures, but it does not fully address internal authorship. That is where I think the conversation needs to go next.
Occupational therapy has spent decades revising its official self-description. Each revision may seem modest in isolation. A word changes here. A phrase expands there. A new concept is added. A new responsibility is implied. A new population is named. A new level of intervention is introduced. A new moral framework is adopted.
Taken together, those changes matter.
They shape how students are taught. They shape what faculty emphasize. They shape what gets rewarded in scholarship. They shape what accreditation reviewers expect to see. They shape what practitioners feel permitted to question. They shape what the profession tells the public it does.
The crisis is not only that society has changed around occupational therapy. The crisis is that occupational therapy has repeatedly changed its own language without adequately resolving the contradictions created by those changes.
We want to be a health care profession, but we also want to be a social change profession.
We want to be occupation-centered, but we often struggle to explain what occupation means when the term is stretched to include nearly every human concern.
We want to claim population health, but we have not always explained how population-level goals translate into occupational therapy methods.
We want to claim advocacy, but we have not clearly distinguished professional advocacy from political action.
We want to claim justice, but we have not agreed on whether justice is an ethical aspiration, a practice domain, a political framework, or a therapeutic method.
We want to engage technology and artificial intelligence, but we have not fully developed the conceptual tools to explain what these technologies do to human agency, adaptation, access, performance, and occupation.
We want to educate doctoral-level practitioners, but we have not always explained how doctoral preparation strengthens practice rather than simply increasing abstraction.
These are not minor issues. They are the crisis. Before the profession rushes to name a next paradigm, it should probably ask WHO AUTHORIZED THE PARADIGM ANYWAY!
That is not a procedural question only. It is a professional question. Who gets to define occupational therapy? Who gets to decide when the profession has changed? Who gets to introduce new concepts into official documents? Who gets to determine whether disagreement is legitimate critique or failure to understand the future?
The profession often talks about inclusion, but it has not always been inclusive of dissent. It talks about dialogue, but it often prefers consensus. It talks about disruption, but mainly when disruption moves in the approved direction. It talks about occupation, but often in ways that make it harder for ordinary people to understand what occupational therapists actually do.
That is not sustainable.
Occupational therapy can and should address complex modern problems. It should engage technology. It should understand systems. It should acknowledge inequity. It should prepare practitioners for emerging practice areas. It should take seriously the ways that occupation is shaped by social, cultural, institutional, economic, and political forces.
But it also needs boundaries. Boundaries are not a failure of imagination. They are what make a profession intelligible.
If occupational therapy can be anything connected to human doing, then it becomes very difficult to explain why occupational therapy is needed for anything in particular. That is not a theoretical problem only. It is a practical problem for patients, families, students, payers, referral sources, and practitioners.
The public does not need another abstract statement about occupation. The public needs to understand what occupational therapists do, why it matters, and when occupational therapy is the right answer.
Practitioners need the same thing.
That is why I welcome the AJOT article, but I also want the conversation to be more honest. The crisis has a history. Some of that history has been visible in official documents. Some of it has been visible in failed motions, amended language, ethics debates, framework revisions, and conference messaging. Some of it has been visible in practitioner uneasiness. Some of it has been documented here for years.
In 2014, the question was whether occupational therapy was quietly redefining its object of concern.
In 2017, the question was whether population health language was being promoted without enough connection to actual practice.
In 2025, the question was whether the profession had become trapped in a circular discourse that narrowed critique while calling itself progressive.
Now, in 2026, AJOT says occupational therapy is in crisis. Fair enough.
Welcome to the crisis conversation.
But let’s not pretend the crisis just arrived. Let’s not pretend that broader social conditions alone explain it. Let’s not pretend that practitioners who raised these concerns earlier were simply resistant to change. Let’s not pretend that new language is the same as new understanding.
If the profession is serious about resolving this crisis, it needs to do more than name the next paradigm. It needs to examine how its own language, documents, educational systems, and leadership choices helped produce the instability in the first place.
That will be a harder conversation. It will also be a better one.
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