Wednesday, January 27, 2016

On retained primitive reflexes

Each year I receive several emails from colleagues about 'retained primitive reflexes.'  I am also seeing an increased number of reports from local 'health care' providers who are documenting these alleged problems so I thought I would write a summary of my opinion on this topic.  

Predatory 'health care' providers including some OTs, PTs, chiropractors, and behavioral optometrists are creating a new 'market' for treating this alleged 'problem.'  Parents should be very wary of these practitioners and other professionals should challenge these practices whenever they are seen.

The following is the kind of information that causes concern and was provided to me by a colleague as a sample from a student's IEP:
The student continues to demonstrate the following retained primitive reflexes that at times interfere with his ability to demonstrate appropriate adaptive responses: Fear Paralysis Reflex, Moro Reflex, Palmer Reflex, Tonic Labyrinthine Reflex, Asymmetrical Tonic Neck Reflex (ATNR) and Symmetrical Tonic Neck Reflex (STNR). If the primitive reflexes are retained past the first year of life (at the very latest) they can interfere with social, academic and motor learning. Basically, the perception of our inner and outer environment and our response to it may be disturbed; that is, conscious life may be disturbed. Each reflex is associated with one or more of the Sensory Processing Systems: Auditory, Taste, Tactile, Smell, Visual, Vestibular, Proprioceptive and/or Interoceptive (automatic “gut” responses related to emotions). Therefore, if retained, a child may experience dysfunction within one or several of the sensory processing systems. This can lead to what is known as Sensory Processing Disorder.

This is the kind of hokum that is being placed in the IEPs of our children and is being subsidized by taxpayers.  This will ultimately lead to the demise of related services in schools if our tax-supported colleagues who work in educational programs don't get on board with science-based and evidence-based practices.

 Reflexes are normal motor patterns that are developmentally specific and they tend to become 'integrated' as motor skill increases.  In simple terms, a baby's initial movements will be reflex-based and those movements are predictable, repetitive, and subject to specific incoming stimulus.  If a newborn baby is on its belly then it will tend to curl up into a ball.  That reflex is integrated as the child learns to crawl and sit and walk.

In children who have nervous system damage, like cerebral palsy, some of those reflexes never go away.  You can see them long after the child should have 'integrated' that reflex and those reflexes are often associated with motor delay.

There have been some observations over time that some children with mild learning problems have some small evidence of those reflexes. These children don't have the same motor deficits as a child who has cerebral palsy, but they may have some mild or even moderate motor incoordination even if they can walk and talk and keep up with their peers (to varying degrees). 

There is great variability in whether or not there is any residual evidence of those reflexes in children with mild learning problems, and even more problematically, there has never been any research that indicates that 'integrating' those reflexes does anything to help the children!  There is also no standard or recognized protocol for evaluating, quantifying, or even treating the problem - although the Internet is full of snake oil about this topic.

So what do we know:

1. Children who have severe nervous system damage (like cerebral palsy) don't develop their motor skills and primitive reflexes persist.  We know that motor learning, normal practice, constraint-induced practice, and similar techniques help some children with these problems learn how to move with more skill.  For many years therapists used techniques based around those reflexes and their was very little evidence that those techniques were helpful.  Most therapists have largely abandoned those practices.

2. Children who have mild neurological or behavioral problems sometimes have very slight evidence of those residual reflexes.  No one knows if that is significant, and in fact it likely is NOT significant because it is so variable and there is no evidence to support the premise.  At best, there is a weak CORRELATION between those reflexes and some learning problems.  We also know that CORRELATION DOES NOT INDICATE CAUSATION.

3. We know that there are no studies that indicate that any protocol to 'integrate' anything that is being called a 'retained primitive reflex' is effective for any child.  Since there are many evidence-based methods which are KNOWN to help children who have specific motor or learning problems, it is UNETHICAL to subject children to experimental theories.

4. Practitioners who are not influenced by evidence, science, and standards of acceptable practice should be avoided.  Seeing statements in an IEP that  'retained reflexes' and 'sensory processing disorder' causes 'conscious life to be disturbed' is an embarrassment to any thinking person who is actually trying to help children.

+++

If parents see statements on their child's IEP about retained primitive reflexes they should immediately complain to their CSE and school board.  Therapists or other practitioners have no right experimenting with outdated and largely discredited theories on children.  Parents should demand that evidence-based methods are used to educate their children in public schools.

.

Tuesday, January 26, 2016

Early intervention providers: Stop demanding more payment. Demand more freedom.


It is budget negotiation season in New York State, and you can tell this by the long line of elected municipal leaders and other special interests who get invited into budget hearings to beg for more funding.

People who watch the process closely call this the 'tin cup brigade' and that is an apt description of the process even if it does ruffle the feathers of those in line.  Leading the line are the Counties and other municipalities who are forced to endure the unfunded mandates passed onto them by the State.  A prime example is the New York State Early Intervention Program.

Funding the early intervention program has been a nightmare for many years.  As the program has grown the costs were shifted around - most recently this involved a complex payment scheme that used an intermediary acting as a fiscal agent that billed the private insurance companies.  The idea behind that was to create a cost sharing context with the private insurance sector, but all that was accomplished was that the program lost participating providers, small women-owned early intervention businesses were decimated, disabled children were placed on waiting lists, and an out of state fiscal agent contractually skimmed millions of dollars out of the woeful trickle of payments that made it into state coffers.  To top it all off, the Counties remained the payer of last resort anyway as only a fraction of payments were processed and collected.

 There are a number of legislative proposals made last year and this year that intend to 'solve' the funding problems with this program.  Legislation has been (re)introduced that creates large grant funding mechanisms so that payments flow directly from the State to the Counties for administration of the program (S4372/A6517); there are proposals that involve 'refund payments' made from the State to the Counties for purposes of property tax relief (S6486); and there are proposed mandates on insurance companies to pay claims (A135).

It is difficult to know which, if any, of these will gain any traction - but the takeaway is that the creation of the intermediary system has failed and Counties are still bearing large amounts of unfunded costs.

The screams from within the Counties are not 'PLEASE TAKE CARE OF OUR CHILDREN.'  The screams are 'STOP TAXING US SO MUCH.'

It is important to understand why the screams are what they are.  If you ask people individually you will not find many who would oppose funding programs that provide care for disabled children.  That is particularly true if we are in a good economy.  However we are not in a bountiful economy and everyday people are struggling to meet their basic expenses.  That is why the voices that scream 'STOP TAXING US SO MUCH' are so notable.

Don't believe politicians who are telling you how great our economy is.  The fact that no one wants to pay for funding programs for disabled children is direct evidence that the economy is a mess.

Ironically, many of the people who would hold out their tin cups and beg for political largesse are also those who believe that they are being taxed too much.   Not only is the economy a mess but our population is currently unable to understand the dynamics of WHY it is a mess.

Government solutions are almost always re-distributional in nature and that is why we see such boondoggles for payment schemes because all of them ultimately fail and all of them ultimately create undue burden on taxpayers.  Unfortunately, providers do not clearly understand the complexities of reimbursement and funding so they end up joining the end of the Tin Cup Brigade Line and joining the chorus of demands for more payment.

Since it is budget time I remind my colleagues of the importance of studying basic economics and of becoming proficient in understanding the complex web of social services funding.

I also encourage them to put down their tin cups and to try another tactic.

Stop demanding more payment.  Demand more freedom.

If the State got out of the way, providers could interact with families and their insurance companies directly - and I assure everyone that any provider could do better with getting claims reimbursed than the State Fiscal Agent.   Local providers could become in-network providers with their local insurers.  They would know and apply the local rules for coding and reimbursement.  The money would flow in a cost-sharing fashion from the private sector just as it properly should.

Private practice providers successfully bill private insurance.  EVERY. DAY.  Why can't we model the early intervention program after a model that we know already works?

The State could then resume its proper role as Payer of Last Resort and those funds could be funneled to Counties in the form of much smaller grants.  Municipalities could contract with those providers who are most efficient in their service provision and billing.  The system would be functionally privatized but would include a safety net as appropriate.  Quality in the program would be ensured by monitoring the outcomes and billing performance of the providers.

+++++

I have virtually no expectation that the State would ever implement a functionally privatized model of care that involves cost sharing and has built in quality drivers.  But I can dream.

 +++++

Consider demanding more freedom.  You might be surprised at what that freedom gives you.


Wednesday, December 09, 2015

How history repeats itself when we plan for OT Anniversaries!

Near the beginning of this series on the history of the occupational therapy profession I documented how many of the details about George Barton and Consolation House were beginning to fade.  A concerted effort near the 50th anniversary of the profession helped to preserve some memory and connection to Consolation House, but planning for this event was very complicated.

I was excited today to hear that there was some beginning plans to commemorate the occupational therapy Centennial by having some ceremony or re-dedication plaque in Clifton Springs.  This is all in the beginning stages of planning, but it reminded me about the initial plans to celebrate the 50th anniversary in Clifton Springs.  I thought I would share some of the source documentation that went into that planning.

During the planning stages for the 50 year celebration the Consolation House was privately owned by Mr. William Wright.  Here is a letter that was written to Mr. Wright from AOTA President Florence Cromwell outlining some of the details associated with the plans for the 50th Anniversary Celebration.  You will have to click on the letters and documents to see them in full size and resolution.:

 


Here is a picture of the proposal for the 50th Anniversary plaque that was placed on the Consolation House property:



There is an interesting backstory about the marker.  In correspondence there was debate about where to place the marker.  The original plan was to place the marker between the sidewalk and the street.  Mayor Copeland obtained approval from the Clifton Springs Board of Trustees and he felt there were advantages to having it in a more 'public' space. Here is a letter from Mayor Copeland indicating that the Village approved a public space but that it seems there was a change to place the marker on Consolation House itself:



AOTA President Florence Cromwell replied, indicating that it was Mr Wright's (the property owner) preference that the plaque be placed directly on the house:



Communicating by postal mail between California and New York in a constricted time frame made coordination of plans for this event a little difficult!

These are all small but still interesting details of how the planning progressed to celebrate the 50th anniversary of the OT profession.  The reason why I found this particularly interesting is because of a casual comment made to me by someone who informed me of plans to possibly organize a Centennial ceremony or re-dedication plaque in Clifton Springs.  The plans are complex and involve local folk in Clifton Springs, the New York State Occupational Therapy Association, and the American Occupational Therapy Association. 

The comment was, "Getting everyone talking to each other seems to be the biggest challenge."

Apparently, the challenges of coordination and communication may be no different than they were 50 years ago!  I am sure that just like then this will also eventually come together into a very nice plan - but it is amazing  how history repeats and repeats itself!

Tuesday, November 24, 2015

Analysis of the AOTA claim of a gender-based wage gap in occupational therapy


The American Occupational Therapy Association recently publicized a claim that although 90.9% of respondents in their workforce survey were women that male practitioners make 14.7% more than women, despite setting, years of education, or position.

 They added the following editorial comments: "Want to earn what you deserve and be more confident? You don’t have to join the boys’ club or be aggressive."

This is an interesting claim so I decided to research these statements and see if they could be validated.  Data on wage disparity was not previously collectible in OT because of low numbers of men responding to workforce or wage surveys.  There was a parallel problem in the nursing profession.  However, in a recent large scale study in the nursing profession (also dominated by women wage earners) male nurses made $5,100 more on average per year than female colleagues in similar positions (Muench, Sindelar, Busch, and Buerhaus, 2015).  However, the study reports that about half of that difference was accounted for by employment patterns and other measured characteristics like leaving the profession to raise children.  That leaves a small difference yet unexplained.  An economist for the American Nursing Association also reports that there is some volatility in the statistics based on the low numbers of men in the surveys. 

Peter McMenamin, a health economist and a spokesman for the ANA states “The folks who did the study are well qualified and they have lots of data,” he said. “But my main hesitance in terms of statistics is they have fewer men.” Only 7 to 10 percent of nurses are male, he acknowledged. But with a smaller sample, he said, “the reliability of the answers is less robust.” 

In sum, it seems fair and reasonable to state that some wage gap may exist but that small numbers of survey participants and the presence of unexplained confounding factors makes up for some of that difference.  It also seems fair and reasonable that there are likely to be similarities between female dominated health care professions, such as between nursing and occupational therapy.  Therefore, it seems in-bounds to look at data from other similar professions.

There is no real argument that there has been a historic gender-based wage gap but as gender roles have changed and evolved over the last several generations that wage gap has diminished.  Goldin (2014) provides an exhaustive review of the evolution of what she terms "gender convergence."  In simple terms, changes in gender roles and education and societal views have helped to drive wages closer and closer to equality.  The wage gap shrinks based on "explained" reasons related to role behavior but there is still a "residual" gap that requires analysis.  She explains that some people would attribute that residual gap to blatant gender discrimination or even due to women's alleged inability to bargain.  These attributions are in line with the AOTA statements.  These attributions are also not fact-centric.

 Through detailed mathematical and statistical analysis, Goldin identifies that the residual gap exists "because hours of work in many occupations are worth more when given at particular moments and when the hours are more continuous.  That is, many occupations earnings have a nonlinear relationship with respect to hours.  A flexible schedule often comes at a high price, particularly in the corporate, financial, and legal worlds."  Again, in simple terms, workers who require and/or take advantage of workplace flexibility do so at the peril of their own salaries.  It is a mathematically proven reality.

Therefore, evidence for the gap is not directly gender-related.  However, it is true that gender roles remain persistently traditional despite move towards convergence.  Everyone can apply their own anecdotes to this: my observations are that despite theoretical advancements in 'equality' it is still more likely for women to advantage workplace flexibility in order to meet other occupational demands.  If there are non-OTs reading this, I use the term 'occupational' in its broadest possible sense.

There is a difference between gender-based inequality and role-based inequality. It is unfortunate that people will conflate these concepts in order to suit a narrative. 

Goldin's research is corroborated by a U.S. Department of Labor study (2009) that reports that the gap can be brought down from 23% to between 4.8% and 7.1% once all of the "explained" reasons are controlled (human capital development, work experience, industry factors, and career interruptions).

What remains is the summary fact that economic analysis accounts for large amounts of any reported "gender-related" wage gaps.  The residual differential is unquestionably related to ways in which women tend to interact with their work environments, and whether or not that is reported as "gender discrimination" tends to vary with the political motivations of whoever is presenting the facts.  Again, there is a difference between gender inequality and role inequality.  You don't have choice over your biologic gender.  You have a lot of choice about the way you engage your roles.

Obviously there are some pockets of blatantly gender-discriminatory behavior in isolated workplace practices.  I don't feel the need to cite evidence to support that belief because after 35 years of employment I feel confident in the knowledge that discrimination can exist.  The question then is whether or not there is a culture of discrimination against women in the occupational therapy profession.

Perhaps the best way to test for this is to search for evidence related to the American Occupational Therapy Association's claims.  They reported that in order to get the salary you 'deserve' that "You don’t have to join the boys’ club or be aggressive."

After an exhaustive review I was unable to find any evidence that there is any kind of "boy's club" in the occupational therapy profession that is acting to suppress wages of women occupational therapists.  However, I did find documented evidence of what Peters (2011) described as an "old girl's club" and an "old girls' network" that used strategies like networking and mentoring to achieve their goals.  Peters explains that "In this connected system, community insiders watched over each other’s tutees who had ‘‘the right’’ occupational therapy pedigree."

Interestingly, the woman-dominated occupational therapy profession had an internal culture of 'taking care of each other' often to the detriment of anyone who was an 'outsider' to that network.  Peters describes several examples of gender, racial, and other forms of outsider bias that was perpetrated by the 'old girls network.' 

That is rather ironic.

In a more positive sense, Peters states that the network also openly identified the problems associated with conflicting home life vs. work life tensions.  Peters cites Jantzen (1972a, 1972b, Mathewson, 1975) that 34% of occupational therapists stopped working after ten years to raise families.  She explains that "One drawback to this pattern is that work discontinuation led women to be in a poor competitive position with men... typically, women continued to work around family needs first, placing them in a weaker economic position than working men... women experienced stress when balancing roles including wife, mother, homemaker, and worker with limited time..."  She also quotes Robert Bing

The real problem in the 50s was the fact that a typical OT practiced an average of 3 to 4 years, then disappeared, usually into marriage.  The schools could not turn out enough additional people to cover this loss.

It seems reasonable to believe that this pattern of concern persists into the present day.  These issues of discontinuous labor participation are faced by many women who choose to have children and who choose to take 'breaks' from their paid employment.

Peters' history goes on in rather extensive detail in describing and quoting a history of the occupational therapy profession that overtly promoted feminism and that overtly discriminated against men, rejected symbols of male dominance, and fought against any residual influence of a male-dominated medical system.  Her examples are not restricted to single anecdotes; she describes a culture that was pervasive and that was extraordinarily slow to change.  Peters concludes that

 Occupational therapy as a female dominated profession did not collapse or subsume to more dominant professions like physical medicine... rather than deferring, these women embraced gender inequities using their female networking strategies to overcome challenges... rather than becoming male-like or medicine-like, this female dominated profession strategically glorified its feminization as it became scientific, thus providing a unique template to gender specific professions.

There is no evidence of some 'old boy's club' that current therapists must avoid in order to 'get the wages that they deserve.'  That modern day OTs are subject to some specious narrative of victimization by social forces is not only historically incorrect but also in direct opposition to the economic analysis of respected scholars who have correctly described the nature of 'residual' wage gaps.  The actual historic evidence supports Goldin's research that describes the way women engage a career trajectory in context of a desire to also balance other life demands.  This is nothing new; female occupational therapists have been experiencing and documenting these challenges for many years.  These challenges are largely based on personal choices and not on gender-based discrimination.

The correct message for the predominantly female field of OT is to understand that they are not subject to a 'boy's club' mentality that is 'aggressive' and that suppresses the wages that they 'deserve.'  They also don't need to 'negotiate' better because that is not the problem.  These are all false narratives.

In the past occupational therapists have advantaged the reality of their own 'old girls' network' in order to support each other and to push forward.  I expect that there are residual forces within the profession that reflect that culture.  That old culture was never low on facts and high on finger pointing or excuse-making. 

I can't imagine that 'old girls' network' tossing down a blame card of discrimination and imagining a phantom network of gender-biased men who are protecting the club and holding down women's wages.  The narrative put forward on AOTA's social media is not supported by evidence.  Specifically, that narrative is not consistent with economic facts as explained by Goldin and as historically recognized by occupational therapists themselves.  It is also just not consistent with the cultural reality of this female dominated profession and the documented way it has framed its own challenges.

So is there a gap?  Probably not much of one if you adequately controlled for all the factors.  It is clear that any gaps that do exist are related to individual and personal choices people make about labor participation.  Evidence shows that OTs have known this and have documented this for years - and it has always been described in terms of occupational choices, not gender discrimination.

If a member association wants to raise the issue of the problematic nature of measuring and understanding salaries that is fine and actually should be encouraged.  Framing it in exaggerated terms without including an honest analysis of current economics and historical precedents is probably not helpful.



References:

CONSAD Research Corporation (for USDOL) (2009).  An analysis of the reasons for the disparity in wages between men and women. Pittsburgh, PA: Author.  Downloaded from http://www.consad.com/content/reports/Gender%20Wage%20Gap%20Final%20Report.pdf

Goldin, C. (2014). A grand gender convergence: Its last chapter. American Economic Review, 104(4), 1091-1119.

 Muench, U., Sindelar, J., Busch, S.H., Buerhaus, P.I. (2015) Salary Differences Between Male and Female Registered Nurses in the United States. JAMA. 313(12), 1265-1267.   doi:10.1001/jama.2015.1487.

Peters, C.O. (2011) Powerful Occupational Therapists: A Community of Professionals, 1950–1980, Occupational Therapy in Mental Health, 27:3-4, 199-410, doi: 10.1080/0164212X.2011.597328

Tuesday, November 17, 2015

Sad days

"Today is my sad day," stated Lauren, in a matter of fact tone.

I work with many children who have superior language skills.  Often, those language skills outpace motor expression and emotional coping ability.  Sometimes doctors or psychologists call it a non-verbal learning problem or sometimes they will label it Asperger's Syndrome if the child has other behavioral quirks.  Either way, I am accustomed to hearing kids say things to me that would take the average listener off guard.

Lauren was a quick-witted and confident child with uneven red bangs from her own attempts at hair-styling.  Besides those bangs she had long tangled curls cascading down her back because she could not stand having her hair brushed.  Lauren had a habit of curling and twisting her hair in her hands, contributing to the tangles.  The mom intended to cut her hair to her shoulders but Lauren bargained herself a delay because she wanted long hair and also because she had the ability to perform verbal calisthenics and get things that she wanted.

I was seeing her because she had attention problems and some motor delays.  I know better than to respond too quickly, so I let her comment sink in a moment.  "What do you mean that 'Today is your sad day?" 

She reached into her backpack and pulled out a picture, directing it under my nose in a way that made me have to move my head back in order to focus.

"Today is the day that my dad died."

This was another one of those moments that you can never really be prepared for, because what do you say to a child that waves that information right under your nose?

It was an older picture with a deep fold down one side.  It was a picture of a baby, supported in her father’s arms, who seemed to be reflexively lifting her head to look at the other people surrounding her.  The baby had red hair; I imagine that it was probably as red as her father’s was when he was her age.  Now his hair was light brown.  As the baby looked at the strangers her dad teased the small curls in her hair with his fingers. 

"This is a picture of me and my Dad."  I knew that Lauren's dad died when she was a baby - her mom mentioned it to me during our first interview.  I started considering the pieces of the information that Lauren was giving me, and the implications of her statements started to fit together.

I stared at the picture and I thought how beautiful it was.  That dad loved his daughter.  Maybe his own parents held him the same way.  How else could he so effortlessly and perfectly hold his own daughter?  It was a perfect picture. 

"My mom told me that I used to be really fussy and all I had to do to calm down was let my dad hold me." 

I thought that was kind of funny, because little Lauren perceived her own intrinsic sense of control extending back to her infancy, as if she was letting her father hold her.  Her personality was so ingrained and she was only eight years old.  That made me smile.

"My mom told me that I would let my dad hold me on his chest and that would always make me close my eyes.  He would close his eyes, and I would close my eyes, and I would just listen to his heart beating and beating.  Sometimes I think I can still hear it, like when I am going to sleep and if I put my head on my pillow in a certain way.  Mom said that I am hearing my own heart, but I think I am hearing something else."

I stared at the picture that Lauren held in front of me as she talked and talked.  I imagined that it was his intention to remember this story himself twenty years after the picture was taken, and that she would not.  Instead she was developing a narrative of the event and she was doing the remembering. 

Death does that, I guess.  It takes the natural order of things and turns it all upside down.  Lauren now carried the memories that her father intended to have.

The story is now created and reinforced with the help of her mom.  It was originally supposed to be a love story that her dad had toward her.  What remains is a sense of love, but it is not the original love itself - because she only knows the story.  For Lauren that will have to be enough.

I thought about her uneven bangs, and her desire for long hair, and her ingrained habit of tangling it all together.  Then my perception shifted and I saw Lauren as a young woman, with long red hair that she would twirl wistfully with her own fingers.  I imagined her sitting and twirling her hair and dreaming about what it would be like to be loved.

She will understand that her father loved her, but she will know how that love was shown through a  shared and reconstructed story that will be as real as remembering the event herself.  Even on the sad days.

Friday, October 16, 2015

Thought exercise for occupational therapists


Thought exercise:
Take special note of the 'Service to society' section 
[my emphasis added].  Are we still providing this service? 
Or are we now chasing some other objectives that are out of 
sync with this original intent? 





REPRINTED FROM:
CAREERS FOR WOMEN 
EDITED BY CATHERINE FILENE 

THE OCCUPATIONAL THERAPIST 

MARJORIE B. GREENE 

Registrar, Boston School of Occupational Therapy 

Boston, 1920.
 
 
Description of occupation 

Occupational therapy is one of the new professions for 
young women. The necessity and importance of this work 
was firmly established in military hospitals during the late 
war and its future success is secure. The civilian hospitals 
are waiting for trained workers, and we believe that it is but 
a short time before every hospital and institution will employ 
at least one aide. 

The training is designed to develop not only artistic and 
mechanical skill and dexterity, but also ability to cooperate 
with every branch of the hospital service in order that there 
may result the highest standard of efficiency. This latter 
ability is quite as important as the former. 

Among the crafts used for their special therapeutic value 
are: Applied design, basketry, block printing, bookbinding, 
chair-seating, jewelry, leather work, modeling, rug-making, 
textiles, tin-can work, typewriting, weaving, wood-carving, 
woodwork and whittling. Also minor curative occupations; 
bead work, colonial mats, cord work, crocheting, knitting, 
netting. The work is carried on in hospital wards and shops 
and, when possible, with private cases. 

Preparation or training necessary 

General education, equivalent at least to high-school educa- 
tion. 

Previous training in any of the following subjects with satis- 
factory credentials will be credited the student upon entrance 
to the schools of Occupational Therapy: nursing, social 
service, physical education, mechanical drawing, psychology, 
arts and crafts. 
 
 
Training may be secured at the following schools: 

Boston School of Occupational Therapy, 7 Harcourt Street, 
Boston. 

Teachers College, Occupational Therapy Department, New 
York City. 

Flavell School, Chicago, Illinois. 

Philadelphia School of Occupational Therapy, Philadel- 
phia. 

Downing College, Milwaukee, Wisconsin. 

School of Occupational Therapy, St. Louis, Missouri. 
 
 
Qualifications necessary for success 

Strong physique, understanding of human nature, common 

sense, initiative and adaptability. 
 
 
Financial return 

Average, from $1200 to $1800 per year. 
 
 
Extent of occupation 

Occupational therapists are in demand in institutions such 
as State hospitals, private hospitals, Army and Navy hospi- 
tals, dispensaries. Government public health departments, 
work with private patients both in hospitals and at home. 
The demand for well-trained aides far exceeds the supply. 
 
 
Service to society 

To restore a patient's courage and his, or her, maximum men- 
tal, nervous, and physical ability is to add an asset to the 
community where there might have been a liability. To bring 
work out of idleness has economic value in time, morality, 
production, health, and happiness, and is elevating to the 
individual and to the entire world. 
 
 
Suggested reading 

"Ward Occupation in Hospitals," Bulletin No. 25. Issued by 
Federal Board of Vocational Training, Washington, D.C., 1918. 
"Handicrafts for the Handicapped" — Dr. Herbert J. Hall. 
"The Work of Our Hands" — Dr. Herbert J. Hall. 
"Teaching the Sick" — George Edward Barton. 
"Invalid Occupations" — Susan Tracy. 

Tuesday, October 06, 2015

A tale of two Mertons


In her famous Slagle lecture, Reilly describes the importance of criticism in professions in general and in occupational therapy in particular.  She stated that
"...a card-carrying critic must do more than merely engage in critical thinking. Judgments made by a critic must emerge from a discreet use of techniques which are difficult to master and dangerous to apply. Basically, the skill is dependent upon an ability to analyze, interpret and synthesize. A critic must have a sharply developed capacity to see deficiencies in data and fallacies in interpretation. The best stock in trade that any critic has is a discerning eye for trends and an ability to pattern and verbalize them. Whether a critic is worth listening to is usually decided by an ability to use language well, by a creativeness in synthesizing new relations and by courage to propose provocative hypotheses. Ultimately, however, a good critic rests his case upon how well he has been able to restructure the issue so that the necessary powers for its resolution can be freed."

Reilly understood that these were difficult standards because in her estimation criticism was not commonly employed or understood in professional affairs at the time she gave her lecture.

Unfortunately, not much has changed in this regard in 50 years.  The AOTA is proposing changes to the Bylaws that create an environment that will discourage member participation.  The current proposed revisions are posted online at http://www.aota.org/AboutAOTA/Get-Involved/BOD.aspx.

The new Bylaws create a process where any member can complain and call for the removal of another member based on the poorly defined concept of 'cause.'  Such complaints would be the type of complaints that would not rise to a full ethics violation.

There is an ugly history of people using association processes to air their personal disputes. Just ten years ago there were published allegations that the SEC (ethics commission) was becoming a place where "conflicts of interest or personality disputes [were] coming before the commission."  (Glomstad, 2005).  An AOTA member made a motion to eliminate the SEC because "The story behind the motion reveals that the SEC also has become an arena for airing personal conflicts among AOTA leaders and members." (Glomstad, 2005).

There was a lack of specificity in the new proposal.  After it was pointed out that there was no procedure for managing complaints, a document was created.  It does not appear that the brand new "Standard Operating Procedure for Investigation and Determination of Complaints to Terminate Membership" has even been reviewed by the BPPC or approved by the Board.  That leaves the impression that this is being made up on the fly.

After pointing out that there was no real definition of "cause" some clarification was given.  The FAQ was updated and now states that "This definition of “cause” is consistent with the longstanding description of “cause” used in AOTA policies for removing volunteer leaders from their positions."

It does not make sense to apply standards associated with volunteer leaders to members because the conditions do not apply to members.  The definition of 'cause' as stated in Policy 1.15 Removal and Appeal have no application to normal members.
That policy states:

1. All elected and appointed volunteer leaders may be removed for:
    a. Failure to accurately report or maintain qualifications for the office or position held, including maintaining the credentials and criteria for eligibility for the office, or
    b. Failure to perform official duties of the office or position held as defined in the governance documents, or
    c. Failure to declare a material conflict of interest in violation of the Association’s official policy or other action/omission of influence, or
    d. Misuse of proprietary or confidential information, or
    e. Violation of any fiduciary duty, or
    f. Proven unethical behavior in the conduct of the position held or proven conduct that reflects negatively on the reputation of the profession or Association.

None of this applies to regular members, except ethics concerns, which should be handled by the ethics commission.  Therefore, there is no compelling definition of 'cause' to apply to members and that reinforces the concern that this has the potential for serious misuse and abuse.

Additionally, the "Standard Operating Procedure for Petition to Challenge Association Action" places the Board in a position where it is essentially investigating itself and hearing appeals on its own actions.  That is not a functional process and any organization that hears appeals of its own decisions without some kind of external and independent arbitration is not offering any 'reasonable opportunity' for defense.

It is difficult to understand what the purpose of this new policy is.  It creates an environment where members can complain about each other and where there is  show trial conducted by a Board that has not really defined a due process procedure or opportunity for any reasonable defense.  The Board would be better off spending its time on governance.  Since there is already an Ethics Commission it is very difficult to know what kind of 'lesser' complaints and interpersonal grievances might be heard by this new process.

If this new policy goes into effect the AOTA will have a new mechanism for quelling member participation.  Who would want to speak out about anything or even participate in AOTA if that means that someone might complain about what you are saying and subject you to some whimsical Board process that can lead to membership revocation?

Considering this new proposed policy is what caused me to review Reilly's statements about criticism.  In her lecture she quoted Robert Merton who was a sociologist; he wrote about the role of professional associations and how they are supposed to foster exchange of ideas.  Merton (1960) wrote:
It is here that they can exchange ideas, experiences, and information that have not yet found there way to the printed page.  Some of this exchange is of the kind that seldom, if ever, gets into print.  That is why even the best of scientific journals is not a complete substitute for the give-and-take that, in the effective professional association, is provided by national meetings and all manner of other conferences.  That is why the professional society is the indispensable complement to schools and universities.  It provides for an interchange that would otherwise not take place.

Such profound words, and such a shame that interchange would be threatened by policies that allow members to complain about each other and attempt to have each other's membership revoked.  Criticism, debate, and information exchange is impossible in such a context.

In Reilly's Slagle lecture she invokes a very unusual term when talking about this topic.  She states that according to Merton (1960), "criticism stings a profession into a new and more demanding formulation of purpose and maintains a policy position of divine discontent with the state of affairs as they are."

"Divine discontent" is the unusual term that stands out, because it is an entirely DIFFERENT Merton that is commonly associated with that term.

Trappist monk and Catholic writer/social activist Thomas Merton (1948) was also a 'card carrying critic.'  He was chronically discontented with the way things were.  Although his path was tortured, his criticisms and questioning were always oriented toward growth.  His inherently critical nature did not make for an easy path because he constantly acted as a pebble in the shoe of nearly every authority figure that he met.  That led others to even take steps to silence him and to forbid him from writing or speaking on certain topics that would cause 'trouble' or 'embarrassment' for his superiors.

That reminds me a lot of this new proposal from AOTA.  It is a policy that threatens people who want to be card carrying critics and it is an oppressive action that will limit exchange of ideas.  Such policies have no legitimate place in a professional association that I want to participate in, so I ended my own membership.

I will just borrow a line from that other Merton (1948) that Reilly oddly and accidentally brings to mind:

Sit finis libri, non finis quaerendi.



Reference:

Direct links, and...

Glomstad, J. (2005, April 4). A stormy transition.  Advance for occupational therapy practitioners, available at occupational-therapy.advanceweb.com/.../A-Stormy-Transition.aspx

Merton, T. (1948) The Seven Storey Mountain.  New York: Harcourt Brace.

Merton, R.K. (1960). The search for professional status.  American Journal of Nursing, 60, 662-664.

Reilly, M. (1985). The 1961 Eleanor Clarke Slagle Lecture: Occupational therapy can be one of the great ideas of 20th century medicine in AOTA (Ed.), A Professional Legacy: The Eleanor Clarke Slagle Lectures in Occupational Therapy, 1955-1984, (pp. 87-105). Rockville: AOTA.