Wednesday, March 18, 2015

On 3D printing technologies and The Nature of Gothic

We want one man to be always thinking, and another to be always working, and we call one a gentleman, and the other an operative; whereas the workman ought often to be thinking, and the thinker often to be working, and both should be gentlemen, in the best sense. As it is, we make both ungentle, the one envying, the other despising, his brother; and the mass of society is made up of morbid thinkers and miserable workers. Now it is only by labour that thought can be made healthy, and only by thought that labour can be made happy, and the two cannot be separated with impunity. - John Ruskin, The Stones of Venice.

3D printing technology is a new fad that is capturing the attention of occupational therapists.  The technology is disruptive, primarily because of cost factors, but as is often the case there are important considerations lying underneath the alluring new technology.

During the Industrial Revolution society developed technological solutions that made mass-produced items readily available.  People seem to enjoy showcasing achievement, and I can't help but notice the similarities between our celebrations around 3D technologies and the mid-century celebrations of the Industrial Revolution.  YouTube and Facebook are our new Crystal Palace at The Great Exhibition.  I am not sure that much has changed in the last 150+ years.

Reading Facebook testimonials on the use of 3D technology is a descent into feel-good hashtag exaggeration.  We spend 3 minutes oohing and aahing as an outsider technophile delivers a neon-pink prosthesis to a child whose limb has been blown off by a landmine, but what happens when those cameras stop rolling and the video is over? 

Cost is undoubtedly a disruptive factor - but is all this really as inexpensive as is typically touted?  There are rampant claims about prosthetic hands that can be made for $50 as compared to a standard hook prosthesis that might cost hundreds or thousands of dollars - or as compared to a myolectric prosthesis that can cost tens of thousands of dollars.  Is the new technology really only $50?  Who pays for the printer?  Does the third world country littered with landmines have electric power in remote villages in case a part breaks?  Does the third world country have an outsider technophile at the ready in all the remote villages to print and then assemble and then custom-fit the device?  So is it really just $50?

The allure of the technology causes people to overstate its utility - as has always been the case.  

The mass production of goods in the Industrial Age caused people to yearn for a time when artisans were responsible for the creation of their own products.  Ruskin and then Morris believed that aesthestics were lost in the sea of mass production.  They argued that this was not just a loss of beauty but that it was also a loss of humanity.

So how aesthetic and human is this?

I fully understand that function matters, but functional alone is not enough.  History has taught this lesson rather clearly.

Where is the Nature of Gothic in our new technologies?  We should look at our technologies as a first and faltering step toward improvement.  However, if we fail to address aesthetics, and if we fail to consider that machines will not replace the artisan skills required to deliver help to humans in need, then we will have lost much more than we have gained.

Tuesday, March 17, 2015

Occupational therapy and case management

There is an RA Motion for consideration that charges the RA Speaker to appoint an ad hoc committee beginning the summer of 2015 to delineate the role in case management for occupational therapy in primary care and mental health.

The rationale for the motion states that "The practice of occupational therapists (OTs) allows for the role of case managers, however, the profession recognizes the need for OTs to better define their role in the new model of care which is primary care and in mental health."

I would like to have a discussion about whether or not the core premise behind this rationale is valid.  I believe that someone trained in occupational therapy may have the requisite skills to serve as a case manager, but I am not convinced that the activities of a case manager constitute the practice of occupational therapy.  This is an important distinction.  If it is determined that this is not the practice of OT, then we should consider whether we should be allocating resources to supporting this employment pathway.

Based on my understanding of the literature on this subject, the role of 'case manager' has recently been pursued more in international contexts than it has in the US.  In fact, several articles have appeared in international journals debating whether or not case management was a legitimate role for the profession. (Krupa and Clark, 1995; Lloyd and Samra, 1997; Culverhouse and Bibby, 2008; Michetti and Dielman, 2014).  Based on a reading of this literature, it hardly seems settled that this is a legitimate role of OT practice.  There is less evidence for this role in the US literature.

AOTA published a statement on this topic in 1991 but I couldn't find anything updated since then.  For a long time OTs have served in case management roles.  The AOTA statement says that OTs might serve as case managers but that many other professionals do as well.  In a response to a letter about this issue, Mary Jane Youngstrom (2000) stated that it was difficult to discern  what was the 'practice' of OT vs. what was 'using OT skills and knowledge.'  It is an old theme and has been repeated many times throughout our history.

The question remains pertinent today.  

Case management, per se, is not a recognized domain of concern in the OTPF.  There have been changes to the Scope of Practice documents and the OTPF that support the concept of advocacy, but these have been controversial - particularly in context of the ongoing debate about social justice/occupational justice.

I do not see adequate justification that case management is OT practice.  I see that it is definitely something that someone may do with their OT skills and knowledge.  Delimiting our practice is critical, particularly if we are interested in re-engaging and defining our roles in mental health.  

Unfortunately, OTs are not doing a good job at explaining their proposed role in mental health.  Case management is a distinct role.  Consultation to systems (trauma informed care) is another distinct role.  Treatment of patients is a distinct role.  I don't get the sense that there has been a well thought out strategy about what will delimit our practice as we re-engage.  That is a problem in my perspective.

Rather than pursue another half-baked strategy that confuses stakeholders about what OT is and what it does, I believe that we should all get on the same page and make coherent internal decisions before we approach others about how we will define our practice.


AOTA (1991). Statement: The Occupational Therapist as Case Manager. American Journal of Occupational Therapy, 45(12):1065-1066.

Culverhouse, J., & Bibby, P. (2008). Occupational therapy and care coordination: the challenges faced by occupational therapists in community mental health settings. British Journal Of Occupational Therapy71(11), 496-498.

Hafez, A., & Youngstrom, M. (2000). Case management practice. American Journal Of Occupational Therapy54(1), 114-116.

Krupa, T., & Clark, C. C. (1995). Occupational therapists as case managers: responding to current approaches to community mental health service delivery. Canadian Journal Of Occupational Therapy. Revue Canadienne D'ergoth√©rapie62(1), 16-22.

Lloyd, C., & Samra, P. (1997). Professional issues. Occupational therapy and case management in mental health rehabilitation. British Journal Of Therapy & Rehabilitation4(2), 91-96.

Michetti, J., & Dieleman, C. (2014). Enabling occupational therapy: moving beyond the generalist vs specialist debate in community mental health. British Journal Of Occupational Therapy77(5), 230-233. doi:10.4276/030802214X13990455043403

Saturday, March 07, 2015

Daylight savings time and temporal contexts and stuff

Sometimes concepts all just pile on at once.

This morning I was putting together some lecture material for a class where I will be discussing contextual factors and why they are important to occupational therapists.  Ironic.

Contextual factors are defined as interrelated conditions that are within and surrounding the person.  We generally break them down into personal, cultural, virtual, and temporal categories.

The reason why it is ironic is because someone told me today that it is my Dad's anniversary.  Not really.  It is the anniversary of his death - five years ago now.  I never consider that it is his anniversary.  The five years since that event is an important example of temporal context, or maybe it is supposed to be.  Temporal contexts refer to stages of life, times of day or year, duration and rhythms of activity, and even history.  Basically, they provide a backdrop of time for the way that we consider things.

I don't always process time in quite the same way as other people, I notice.   I have a picture on my desk of when I was 4 years old and my Dad is holding my hand as we are walking down the steps of my grandmother's house.  It could have happened yesterday, by my reckoning.  It is kind of a timeless photo to me and it represents something that I don't want to ascribe time to.

Same goes with the way that I perceive some of my friendships.  I have been friends with a couple guys in my hometown since we were all kids.  I don't see them often, or even have contact with them on any social media.  But when I go down there, no matter how long it has been since we have seen each other, we just pick up as if we had all seen each other yesterday.

Today is also the beginning of Daylight Savings Time.  It is a concept that I have abhorred my entire life.  I can wrap my brain around some pretty heady concepts, but don't ask me to interpret what has been lost or gained around Daylight Savings Time.  I just don't get it.

Thoreau said "Time is but the stream I go a-fishing in.  I drink at it; but while I drink I see the sandy bottom and detect how shallow it is.  Its thin current slides away, but eternity remains."  I read that when I was 15 years old, flying across the country for a visit to family in Washington State.  Up until that time, I don't think I can recall a quote that made more sense to me.  That is why I remember reading it for the first time so vividly.  I can't even express how tickled I was to learn how transcendental concepts worked their way into the thinking of some OT founders.  Seriously, in consideration of all things that can happen in a person's life, how likely is it that one of the first quotes that ever made sense to me also happens to form the basis of a philosophy of self-reliance and autonomy that people built a whole profession around?  That's pretty amazing.

Anyway, I don't do time jumps.  I don't know what Daylight Savings Time means.  I don't forget history or say, 'The past is the past' because to me it just isn't - it is all a part of the eternity that we are floating in.  And five years ago is the same as yesterday.

That's about all I have to say about temporal contexts.

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.


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.

Can occupational therapists predict the future?

There is ongoing debate on the AOTA forums about move to an entry level doctorate.  Within that debate there is repeated discussion about the 'future.'  I am very interested in the concept that occupational therapists should attempt to 'focus more on what COULD and SHOULD be different for practitioners graduating in the future.'

Prognostication is an interesting endeavor, and I am wondering if this is something that most occupational therapists really have the skill set to accomplish.  I don't believe that there is evidence to support OTs having these skills.

R. Buckmister Fuller, who in my opinion was a tremendously gifted anticipatory design scientist, felt that he had an ability to prognosticate based on his model of integrative systems thinking and on his naval training in navigation and ballistics.  
In his book 'Operating Manual for Spaceship Earth' he explained how some people felt that he was 1000 years ahead of his time, which puzzled him because he did not understand how others thought they could understand events 1000 years into the future when he only felt confident about analyzing 25 year scientific, industrial, and innovation cycles.  As he got older, some people said that he was 'behind the times.'  An analysis of these varying assessments of his ability seems to be a good example that most people have absolutely no ability to prognosticate reliably or to assign time values to future events.

Nonetheless, this does not seem to stop people from thinking that they have the ability to prognosticate.

I thought it would be interesting to look at the accuracy of occupational therapy prognostications - so I would like to refer everyone to the special meeting of the Representative Assembly in 1978 that was held on 11/8 through 11/12 in Scottsdale Arizona.  The purpose of the meeting was to direct the course of the profession for the coming decades and to hear the thoughts of leaders of the profession at that time.  The thoughts of these leaders is encapsulated in a series of lectures that were published under the title Occupational Therapy: 2001 AD.

Several of the authors were so mired down in 1978 concerns that they could not really offer much specificity about the future.  At the time of the conference Wilma West and Alice Jantzen were talking about whether we would be a professional or a technical vocation.  This ended up being such an esoteric concern that by the time 2001 rolled around no one was really discussing it any longer.  

Nedra Gillette suggested that we would require post professional training in order to achieve 'professional' status, but it seems that professional status was conferred more by a robust certification process and state licensing than by conversion to graduate education, which didn't end up happening until 2007.  

Ruth Weimer thought we should develop knowledge in economics so that we could convince others of our value.  I don't know that we accomplished that; today OT persists in many environments by legal mandate and not because it is a 'valued service.'  Jerry Johnson focused mostly on the present failings of the Association and difficulties in responding to member needs.  

Elizabeth Yerxa focused on socialization requirements between what made for a caring and empathetic OT vs. what would be required to seize power and exert control in a professional context.  I think she failed to understand that the future would create a context whereby if someone raised this issue today that they would be accused of genderism.  Gail Fidler took Yerxa's comments and overtly discussed her perspectives on the fact that OT is a female dominated profession.  I can state with confidence that these kinds of conversations would not be openly appreciated in 2001.

Florence Cromwell believed that the proper place for OT would be in helping people with chronic illness.  It seems that she did not see the trends of OTs abandoning mental health, adults with developmental disabilities, and other populations of people with chronic health problems.

Mae Hightower-Vandamm's presentation stood out in that she took very bold positions on what she thought the future would hold.  She thought that AOTA would have 80,000 members in 2001.  She also thought that cities would not be able to handle conferences so there would be regional conference centers where there were no hotels but just modest rooming for attendees and that food would be available in a concentrated capsule form designed to be ingested with a liquid nutrient.  She actually wrote that.

She also believed that OTs would be integral to the unemployment system.  OTs would be available 24 hours a day, in shifts.  She was kind of repeatedly interested in closed circuit TV, thinking that it would be used for education as well as for certification.  Kind of like the Internet, I guess.  She was close on this one.

She thought that OT Aides in hospitals would be 'Quasar Men' and they would be programmed to do all craft preparation, monitor the clinic for safety, clean up, and transportation.


There is not much evidence to consider in analyzing OTs ability to predict future events.  In 1978 there was a concerted effort to plan for 2001, and important leaders at that time were overwhelmed with 1978 issues as opposed to what would be needed in order to move forward.  The primary issues at that time were concerns with professional vs. vocational training, inability to precisely articulate a scope of practice, and other sundry issues such as career laddering for OTAs, dominance of women within the profession, generalist v. specialty practice, and inefficiencies in professional training and in the Association itself.  Most of the OT leaders at that time were skilled in discussing present day concerns.  Most of those concerns were interesting, but few if any of them have ever been fully resolved.  Most of the OT leaders kind of avoided discussing the future even though that was the point of the conference.  Those who did discuss the future were generally off target.

Watching the current AOTA leadership seems similar.  They seem aware of problems (like the structure of the Association) but are not able to mobilize resources to change much.  They seem to be aware of the Affordable Care Act, but focus on primary care models that don't reflect any current realities of practice on a large scale.  They seem to value evidence based models, but can't grasp the reality that pediatric practice is rife with snake oil.  They understand that OTs abandoned mental health, but it is all a little johnny-come-lately.  They understand that there are opportunities for OTs in new areas of practice, but we have an academic faculty that is largely divorced from the clinics.  In sum there is a big focus on articulating current problems, but the solutions constantly fall short of fixing anything.  OTs seem to have skill in articulating present day problems.  OTs just are not skilled in prognosticating the future.

I believe that the status of the profession in 2014 is the same as it was in 1978 - the only difference being that there are different present day concerns on the table.  The French have a saying for this: Plus ca change; plus c'est la meme chose.  Translated, the more things change, the more they stay the same.

I am concerned that we are asking members to plan for the future.  Leaders don't seem to have good ability to plan for the future.  As an example, we are told that we need an entry level doctorate as a single point of entry for the profession.  A lot of ancillary issues about current problems are discussed, but there is no real evidence to support the recommendation.  I previously mentioned that OTs are skilled in chasing trends but not so much in leading change themselves.

For this reason I will place the prediction of this 'need' for entry level doctorates in the same category as the Quasar Man.  It is an interesting idea, loosely sensible on a superficial level, but lacking in any real substance of justification and practicality that is necessary to support its existence.

AOTA (1979). Occupational Therapy: 2001 AD. Papers presented at the special session of the Representative Assembly, November, 1978.  Rockville, MD: AOTA.

Fuller, R.B. (1968). Operating manual for Spaceship Earth, Carbondale: Southern Illinois University Press.

Wednesday, February 11, 2015

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.


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.

Monday, February 09, 2015

From Social Gospel to the New Deal: A values juxtaposition that has been whitewashed by OTs

I was interested to see some comments from Dr. Elizabeth Townsend (2015) in an online forum asking "How are we building leadership for key posts at universities in support an [sic] occupation focus - both in the science and therapy of occupation?"  She asked this question in context of an open position at Dalhousie's School of Occupational Therapy in Halifax, Nova Scotia but was interested in a more general sense of how to build leadership outside of large metropolitan areas. 

This interested me because I have been studying recruitment and spread of occupation workers at the time of the founding of the occupational therapy profession.  I began to wonder if a study of this history could provide context for interpreting the current recruitment call.

An important early supporter of proto-occupational therapy was a man that is not often cited in American textbooks.  Sir Wilfred Thomason Grenfell is described as a "physician, medical missionary, social reformer, and author."  I encourage readers to visit this link and study the life of Grenfell who was quite an interesting person.  I have been reading all of Grenfell's books and have been particularly interested in what drew him to Newfoundland and Labrador to do his mission work.

In a previous blog post about the Core Values of the occupational therapy profession I stated 
There were many 'social movements' occurring at this time to counteract the changes people were experiencing during this 'Gilded Age.'  Most of these movements were taken up by the social elites and were based on charity, philanthropy, and Christian Ethics ...

A lot of change was desired.  A lot of effort was undertaken to effect those changes.  However, these efforts were not undertaken in a Rawlsian definition of Distributive Social Justice.  They were undertaken in a Christian Ethic that guided charitable deeds.

Dr. Grenfell was similarly motivated and he discusses his religious conversion and values in his books (Grenfell, 1910; Grenfell, 1927).  He knew that he had to recruit others to help him with his work, and he was impressed with Jesse Luther, who was an early occupation worker often associated with Dr. Herbert Hall (Rompkey, 2011).  Luther's roots extend all the way back to Hull House, where her 'occupation work' actually pre-dated the work of Eleanor Clark Slagle (Rompkey, 2011). 

So I was reflecting on Grenfell and Luther when I read Dr. Townsend's call for recruiting into the far Eastern portion of Canada - and I thought of what motivated the first occupation workers to that region and how different that was from Dr. Townsend's interest in social justice (1993).

There is evidence of conflation between Christian philanthropy and 'social justice' in the occupational therapy literature (Harley and Schwartz, 2013; Head and Friedland, 2011).  It is important to consider that 'social justice' was not even conceptualized until after the New Deal that placed the government into a position of resource redistribution (Rawls, 1971).

This is what makes Dr. Townsend's call to Eastern Canada somewhat ironic in context of the history of the profession and in context of Grenfell and Luther's mission work there.

Grenfell, like many of his contemporaries at that time, were interested in solving social problems.  The Social Gospel movement was an application of Christian theology to social problems.  It is very unusual that this movement is completely left out of conversation about the founding values that motivated the philanthropic work of Jane Addams, Phillip King Brown, Wilfred Grenfell, Elwood Worcester, and so many others.

It is true that the Social Gospel Movement was not cohesive, with some branches promoting philanthropy and other branches promoting collectivism and labor movements. As governments became more involved in welfare acts, philanthropy took a back seat.  This is described in excellent detail in an analysis by Harnish (2011) who writes:
Charity has long been described as an expression of God’s love as opposed to a policy measure aimed at lowering the unemployment rate or the labor hours necessary to buy a loaf of bread. As an expression of God’s love, charity knows no boundaries; it goes to friends and enemies alike—quite a difference from redistribution measures, long known to be but another means of funneling cash and favors in order to secure political reelection. Further, charity is a religious virtue and an ethical statement. It claims to be capital “G” Good and a worthy choice for human action simply because it is a reflection of God’s fixed and eternal nature. This claim the Social Gospel rejected outright. The only place left to find a justification of its welfare-state measures was...the refuge of pragmatic successes.

There is evidence that Christian Ethics motivated the majority of proto-founders who were interested in the 'occupation cure.'  Some of that may have morphed into seeking governmental programs to prop up their philanthropic efforts, particularly in context of financial stressors in trying to meet severe needs.  Some of that may have been pragmatic more than philosophic, particularly in consideration of the very overt religiosity that was expressed by those proto-founders.

So now there is a new call for OT leaders in Eastern Canada - and that call is in context of a new Social Justice that is rooted in a model of governmental control and redistribution of resources.  That call occurs in a whitewashing of our actual history that is rooted in philanthropy and Christian Ethics.

Understanding our history provides us a proper context for examining where we are.  Understanding our history also provides us with meaningful background information to evaluate the current value system and philosophic trajectory.

My how things have changed in 100 years.


(see embedded links)

Grenfell, W. (1910). A Man's Helpers. Toronto: Musson Book Co.

Grenfell, W. (1927). What Christ means to me. Boston: Houghton-Mifflin.

Harley and Schwartz (2013) Philip King Brown and Arequipa Sanatorium: Early occupational therapy as medical and social experiment.  American Journal of Occupational Therapy, 67, e11-e17.

Harnish,  B. (2011). Jane Addams's Social Gospel synthesis and the Catholic response: Competing views of charity and their implications.  The Independent Review, 16, 93-100.

Head, B. and Friedland, J. (2011, Jan/Feb). Jesse Luther: A pioneer of social justice.  OT Now, downloaded from

Rawls, J. (1971). A Theory of Justice. The Belknap Press of Harvard University Press

Rompkey, R. (2001).  Jessie Luther at the Grenfell Mission.  Montreal: McGill Queen's.

Townsend, E. A. (1993). Muriel Driver Memorial Lecture: Occupational therapy’s social vision. Canadian Journal of Occupational Therapy,  60, 174-184.

Townsend, E. (2015, February 8). Advancing occupational science and occupation-based practices globally - how are we building leadership for key posts. Message posted to!topic/occupational_science_intl/ajdBHCjjVk8

Thursday, January 22, 2015

Follow up on 'Ways you will be paid'

Follow up to PTE Speech in 2012: Ways you will be paid.

I said in that speech that "The people who need you the most might not be able to pay you the most."  I thought about that this morning, because several things that I did are not 'reimbursable.'

The idea of my talk to those students was to tell them that over the longer course of their careers that it is likely that they will make enough money to repay their student debt, but that it would be short-sighted to measure success in monetary terms because sometimes the ways you are paid can't be identified as a quantifiable amount in your Account Receivables, or it might not be noticed by the widget counters that reside in the Halls of Productivity, Outcomes, and Cost-Control.

This morning a mom called to cancel their appointment, and then asked sheepishly, "I have a question, and I hope that you don't think it is silly.  My son deleted his Minecraft world and do you have any idea how we might be able to get it back?  He is just beside himself and it is really a concern for us."

The reason why I loved this question is because somehow this parent received the message that I am in tune with children's interests, and she also received the message that I care about her child.  I don't consider her question silly at all; in fact, it might be the best question I have been asked in a really long time.

So I researched the Minecraft problem and provided a solution that I hope might work.  I spent an hour on the issue, because "Needs are an indispensable part of human nature, and imperatively demand satisfaction," and if she thought enough of me to ask that question then I have a responsibility to generate a top-quality response.  I also made a note to myself to check on the child's situational coping over this issue, because we have been working on coping skills in therapy.  There is no CPT code for this, but that is why I got to thinking about my PTE speech.

My second non-reimbursable task was writing a letter to a child's MD.  The parent brought the child to see me due to concerns with intolerance to clothing.  The mom carried the child into my office, and all the while the child was having an Epic Meltdown.  No developmental or sensory assessment was possible, and based on the whole interaction it was obvious that there were some acute contextual elements that were contributing to the Epic Meltdown.  After 30 minutes the parent was able to get the child back OUT the door, and the entire encounter that is not a billable encounter was a stressful event for both the parent and the child.  After they left I called the pediatrician and wrote a letter of my observations and recommendations.  I hope that they can help the family with those acute contextual problems, because they are clearly in distress.  There is no CPT code for this either, and that is why I got to thinking about my PTE speech for a second time today.

I write about this because I feel some frustration.  I am NOT frustrated about the parents or the children.  I am NOT frustrated with the lack of CPT codes or that these are not reimbursable activities.  I am frustrated because it bothers me to see our profession slip into the clutches of 'care' models that are all about accountability, documentation of outcomes, cost-savings, designated care pathways that are 'evidence based,' etc etc.  All of that is fine, and I don't really disagree with many of the conceptual values, but when we adopt those 'care' models we also generally lose our focus on the kind of caring that people needed in my office today.

Today I was not productive by the measure of my accountant or by Higher Powers that place quantifiable metrics on my activities.  But actually I was very productive by the measure of the people who needed help.

Like I told those PTE students, I have a Faith that the financial piece will all work out in the end.  And in the meantime, I keep reminding myself that "The people who need you the most might not be able to pay you the most.  Pay you the most money, that is."