Thursday, May 14, 2015

A critical juncture for the New York State Occupational Therapy Association

The New York State Occupational Therapy Association is planning to make significant changes to its bylaws and governance in the very near future.  Since so little information has been available on these changes I took the initiative to gather data so that occupational therapists in NY would have more information to assess these proposals.

I will begin my analysis with an apology, because it is my longstanding belief that to be an appropriate critic one needs to be a member of the group that is being held to scrutiny.  For purposes of transparency I will divulge that I ceased my NYSOTA membership approximately ten years ago in protest of inappropriate accounting practices.  However, I remained in close contact with many therapists around the State who continued their participation with the membership association.  Many of these members are currently upset about the proposed changes to governance.  Some don't want to make their protest public and have given me copious information to analyze about this topic.  I believe in transparency and openness that can lead to improvement, and that is why I am sharing the information that was given to me.

To begin with, it is important to know background demographics about occupational therapists in NY State.  According to the New York State Office of the Professions as of January 1, 2015 there were 12,254 occupational therapists and 3,912 occupational therapy assistants.  That is a total of 16,166 occupational therapy practitioners in NY State.

According to NYSOTA documents that I have reviewed, there are 548 occupational therapist members (4.5% of all NY OTs), 168 occupational therapy assistant members (4.3% of all NY OTAs), 1,308 student members, and 19 'other' members.  As students are not practicing professionals they should be excluded from any calculations.  So, there is a total of 716 practicing OT/OTA members (4.4% of all NY practitioners).

Social disengagement in traditional membership structures was brought to the forefront of attention in Putnam's classic work Bowling Alone.  The occupational therapy profession in NY State reflects this trend.  During the period of time from  2006 through 2014 NYSOTA OT/OTA membership declined 24%.  Most of that loss is declining OT membership; in fact, OTA membership increased over that time period.

The challenges associated with diminishing membership caused the American Occupational Therapy Association to attempt governance restructuring several years ago.  Those efforts failed when they were voted down by the Representative Assembly.  Unfortunately, records of those discussions have been purged from the AOTA website and can no longer be viewed there.  My recollection of those conversations are that many people were concerned that elimination of the RA and replacing it with another structure was considered inadequately 'representative' for members.  I always considered it unfortunate that AOTA leaders were not able to successfully explain to members why a different structure was needed, or to present a structure that was palatable.

Based on an analysis of the proposed changes to the NYSOTA bylaws it appears that a similar proposal for governance restructuring is being attempted.  Below are some highlighted and important changes:

Districts are being eliminated.  NYSOTA will be governed by 9 people.  Four will be officers elected by the members, four will be members-at-large elected by the members, and one will be appointed by the elected Board members.

This is a very unusual configuration because the distributed membership around the State is very uneven.  Additionally, allowing the vote of students who represent the largest membership block sets a problematic scenario where academics who know those students and are responsible for giving them grades have a lopsided advantage in elections.  Having one person randomly appointed to the Board is also unusual and leads to questions about why such a configuration would be suggested. Aside from geographic concerns, OTAs are also notably absent from Board representation.

2. Another immediate concern is a proposed change in the stated purpose of the association.  The current bylaws state that NYSOTA is "dedicated to the advancement of the occupational therapy profession and to the improvement of the quality of occupational therapy services."  The PROPOSED bylaws state that NYSOTA will be to "promote the OT profession within the State of NY, to promote and advance education, training, and research in the profession, and to engage in any other such activities determined to be advantageous to the Association and its members."  This is a dramatic and different role for the membership association and completely steers away from the previous purpose that explicitly sought to improve the quality of OT services.


There are additional troubling elements to this restructuring plan given the historical financial context of the membership association.  There were longstanding accounting difficulties dating back many years and at one point prior to 2006 caused the resignation of the NYSOTA attorney and several members of the Executive Board because of non-compliance with standard accounting practices.  Those concerns were never really explained to the membership and to my knowledge the resignation letters of the attorney and some members of the Executive Board were never shared with the membership.  This was a troubling lack of transparency.

I have been informed by several members that those accounting concerns were remedied by a consolidation of finances that now allows centralized auditing.  That consolidation has not gone without criticism from some districts and members.  A look at the recent balance sheet indicates some concerns.  According to available documents, net income has been in the red for seven of the last nine years.  In the last two years, net income has been near a $60,000 loss each year.  Expenses averaged approximately $100,000 per year from 2006 through 2012, but jumped up above $150,000 for each of the last two years.  Clearly, something is dramatically changing to cause such an increase in expenses in the last two years.  This significant increase is financially unhealthy, particularly given the historical instability of conference revenue which is being relied upon more and more on recent balance sheets.


The sum of this analysis is that NYSOTA is at a critical juncture.  A governance change that appears to be less representative than before is being proposed, but the previous structure was admittedly unwieldy.  The Board seems to be at war with some of its own districts, stating that at least three districts should have been dissolved according to provision of current bylaws.  That may be true (details are unknown to me at this time), but this is not a healthy situation.

Expenses are rapidly increasing, dues paying membership is rapidly decreasing, and (free) student members inflate the membership rolls.  The very purpose of the association is being re-defined.

My recommendation to the NYSOTA BoD is to slow track their proposed changes and explore new methodologies for inclusive planning to meet this acute crisis.  The fact that several sources from different districts are leaking out documents to me should be an indicator of the heightened dissatisfaction from the dwindling membership that remains.  I expect some criticism for putting this information out for people to see, but my motivation is to create a context where members will be involved, represented, and able to participate in some consensus decision making.  NYSOTA has not been healthy for many years, and a change is needed that will involve a much greater level of participation from ALL OTs in NY State - members or not.

Right now, that is apparently not happening.

As I have previously done, I willingly offer my time and abilities to help solve these very challenging problems.

Friday, May 08, 2015

Social justice in occupational therapy: Where to from here?

After a multi-year debate there was some small capitulation regarding the social justice language in the AOTA Code of Ethics.  The previous section labeled 'Principle 4: Social Justice' was removed and replaced with a more generic section on 'Justice' that focuses on procedural aspects of the Justice construct.  A passing reference to a social justice construct was included in the Preamble.

It is difficult to know if it is even fair to say 'capitulation' because we have not had precise commentary from the Ethics Commission on those changes.  What we have are the comments of the EC Chair Dr. Lea Brandt who stated

It is correct that in the section on Core Values there is still terminology referring to social injustice.   This reflects the membership feedback which called for inclusion of the concept of social justice while tempering that perspective with a group of members who requested to have the term removed.  The term “Social Justice” was removed from the Principles and Standards of Conduct section which outlines the enforceable areas of practice, but was retained in the aspiration section of the Code.  
 In short, standards which contained language that could appear ambiguous to some or more challenging to enforce were removed or modified; however aspirational language related to social justice concepts was relocated to the Preamble section accommodating the large number of requests to strengthen and include this language consistent with the profession’s Centennial Vision.  The intent in doing this was to develop a Code which includes further clarification of the potential interface between the professional Code of Ethics and state licensure laws and the roles and responsibilities of each.

One of the primary arguments about a social justice requirement was that it could not be enforced.  The EC attempted to separate enforceable principles from non-enforceable values but actually created an illogical division that has concepts listed in both.  Obviously, enforceable and non-enforceable are mutually exclusive divisions and that makes the current Code very confusing.

For example, Justice is listed in both divisions.  How can Justice be both an enforceable principle and a non-enforceable Core Value?  An excellent analysis of this illogical classification scheme was posted by Alex Duran and can be viewed here.

I understand the intent to separate Non-Enforceable (aspirational) v. Enforceable ethics, but it appears to have been done poorly.  Perhaps a model that attempts a more clear distinction between the two categories would be the APA Code of Ethics.  The APA Code does not seem to re-label and confuse the two categories.  Rather, the Enforceable Ethics (Standards) are rather specific and relate to very concrete practice and research oriented concerns.

The APA Ethics Director stated "The distinction between aspirational and enforceable is central to the code's structure and differentiates between the ideals and goals to which psychologists aspire and the rules by which psychologists must abide. When adjudicatory bodies blur this distinction, psychologists may inappropriately be held responsible and possibly disciplined for not fulfilling the profession's ideals and striving toward its highest goals."

As the AOTA Code of Ethics is unfortunately embedded in the license law of several states by reference, it is critical that the Code is clear and coherent.  In this there has been a clear failure.

So although there have been improvements with the removal of some of the Social Justice language, large problems have been created with an illogical division of enforceable principles and non-enforceable values.  With functional classification schemes readily available (APA), it is disappointing that this kind of error was made.


What remains problematic in this entire ethical debate is that there continues to be a disconnect for many American therapists about what the social justice construct actually represents and what it means when it is adopted as a value.  There are some agenda-driven therapists who are fully aware of the implications of their advocacy for a social justice concept but there are also large numbers of people who go along with it because it 'sounds' good.  I am not certain that much has changed since 2011 when the debate started on OT Connections - at that time many people were arguing that social justice was not a political construct and they thought it just meant that we should try to help poor people.  Of course the issue is not the objective (trying to improve the lives of people) but the problem is with the methodology (redistribution and governmental control).

It is my wish that American therapists would watch or read the news of the 2015 British elections and see the unfortunate result of a health system that has become hopelessly intertwined with politics.  The commentary from UK colleagues and even the COT is telling and demonstrates the angst and concern that is created because the conservative party performed much better in elections than was initially predicted.


As an interesting and related point of reading, I encourage occupational therapists who are still confused about what the social justice construct represents to read Adam Swift and David Brighouse's recent 'scholarship' on the topic.  They are promoting the concept that "familial relationship goods" are unfairly distributed because some families are able to confer advantages based on values, relationships, opportunities, etc.  This hit the lay press last week associated with Swift's appearance on a radio show where he was discussing the 'unfair advantage' that was conferred by some families reading bedtime stories to their children - so of course the extension of this bizarre thinking is that reading bedtime stories should not be allowed.  It is fortunate that the lay press grabbed a hold of the odd 'ban on bedtime stories' because sometimes it takes just such a soundbite to bring the agenda and dangerous thinking to the fore.

I don't expect that Swift and Brighouse actually want to control people's bedtime story routines with their children, but this type of thinking and 'moralizing' helps to prop up the notion that the State has to be an arbiter of fairness and distribution because there is no other mechanism to ensure equal distribution of "familial relationship goods."

I wish that this soundbite was available during the debates on social justice in the Code of Ethics.  I would love occupational therapists to explain how they are supposed to "abide by the highest standards of Social Justice" (as was required in the 2010 Code of Ethics) when Social Justice crusaders state that we need to make the distribution of familial relationship goods "fair" for everyone.

I already blogged about this in context of Melissa Harris Perry's objectionable statement that children don't belong to their parents and need to be raised by a collective community.  This remains an issue for the Ethics Commission to address, because it is very difficult to understand how Dr. Brandt can continue to state that such collectivism is a Core Value of the occupational therapy profession when so much evidence points to the contrary notion that the profession has always emphasized autonomy and individual responsibility.

My opinion is that this Social Justice conversation should continue as long as there are elements in the (USA) profession who mistakenly believe that it is a Core Value.

And now we have the introduction of a new unfortunate confusion about what is an enforceable principle and what is a non-enforceable Core Value.  There is work still to be done.

Thursday, April 23, 2015

When it becomes more important to state 'why' you do something

If you ask 100 occupational therapists what they do you will get 100 different answers, because the nature of the profession is to help people do the things that are important to them.  Every patient has their own priorities, and that makes all the stories different.

Instead of focusing on the 'what' I like to focus on the 'why.'  When I need to be reminded 'why' I do what I do I like to drag this story out.

I knew a young family and they were unable to conceive.  After spending many thousands of dollars they made some arrangement with a young teenage mom so that they could adopt her baby (just about to be born).

So they go to get the baby and sign all the papers and get on the plane.  The baby was only a couple days old. On the way back home the baby goes into cardiac arrest and the new mom (a trained health care professional) gives this new baby rescue breathing and chest compressions. They are admitted directly into the intensive care unit when they get off the plane.

It turns out that the baby had several STDs: syphilis, gonorrhea, chlamydia, plus other bad infections including CMV - any of which could be deadly in a newborn. If that wasn't enough the baby had a poorly developed liver and developed a condition called necrotizing enterocolitis - they had to take out most of her small intestine as it had died inside her. They also put in a feeding tube and a tracheostomy (the baby's lungs were underdeveloped too and she couldn't breathe except with a ventilator). The baby also had a colostomy bag.

So the next eight months were a constant vigil in the ICU for these parents and their family. The feeding tube could never work properly so they had to provide liquid nutrition directly into an artery - a process called hyperalimentation. It is effective for the short term but ultimately will burn out your liver, and that is what happened to the baby. She became so jaundiced and sick that as a last ditch try they flew her to another city that had a great transplant program and prayed for a miracle. Unfortunately, the child's mesenteric artery which supplies the liver was also malformed and so she was not a candidate for any transplant. They sent her back to the hometown hospital.

Now I imagine that everyday these parents faced a fork in the road and could choose to either keep forging ahead or they could throw up their hands and give up. I am not sure if anyone could blame them if they did that - after all, they did not bargain for this situation: months in an ICU with a sick child that is not biologically theirs, and running up hundreds of thousands of dollars in medical bills (of course insurance companies at that time balked at coverage given the adoption and that this was 'pre-existing'). But the parents never quit anyway. They kept with it, every day, every night. Sleeping in chairs in the ICU. The baby had some moments of real quality - she was not neurologically impaired and so with regards to her cognition she was a normal 8 month old baby.

In the end, it was apparent that the baby was in pain, close to death, thrashing inconsolably, and jaundiced the color of yellow-green mustard.  The parents made an unthinkable decision and chose to end her life by withdrawing the ventilator support. The baby was alert and cognizant of her surroundings, which made the decision to withdraw support so much more complex. I can't understand the depth of love it took to do this for their child. Their child - not really theirs. But theirs nonetheless.

The baby died in her real mom's arms one night. After so many months in the ICU and with every day an act of love I think that these parents deserved to be called the baby's "real" parents, regardless of the biology.

This is not a story about heroic doctors.  It is not a story about caring nurses or diligent occupational therapists.  Most of the real stories and the daily events that are out there are about the people we care for.

I provide occupational therapy because every parent has an unbelievable mission to help their own child, and when things go wrong OTs help them do things that matter to them.  It is not so important 'what' you do because those stories will change with every patient and every family.

What matters is 'why' you do it.  I do it because it is all about human need and the value of normal occupation like the dreams and hopes of a family, even in the face of impossible situations.

This is a story that I use for the purpose of focus.

Thursday, April 16, 2015

On persevering in leadership and its relevance to free speech

An interesting quote was attributed today to Amy Lamb, the President-Elect of the American Occupational Therapy Association.  Here is the quote as it appeared on Twitter:

I initially consider that the timing of such a statement that "No means not now" could possibly be related to the recent decision by the US Senate to refuse to support the Cardin-Vitter amendment that would repeal the Medicare outpatient therapy cap.  Therapy leaders have been trying for many years to get the cap repealed and it was a stinging defeat.

I asked for additional context and clarity about the quote and was informed that it was generally stated as an important leadership principle.

The reason why this caught my attention is because of my own experience with the way that the occupational therapy profession deals with divergent opinions.

In 2013 I attempted to reach out to a former Ethics Commission Chair to discuss ongoing concerns with the Social Justice construct.  That Chair was not interested in any conversation, and instead of receiving a note from that person I received a letter from an AOTA attorney that stated, "I understand your perspective on the Social Justice provision of the Ethics Code, and would note that it is settled business at this time."  From the tone of that letter, the philosophy in play was clearly that 'No means no.'  In fairness, that attorney also stated that there might be opportunities to discuss matters when the Code was re-written (in 2015), but that turned out to be a false promise because there was virtually no dialogue allowed with the Ethics Commission members during the current revision period.  In fact, that lack of dialogue and unwillingness to engage the membership contributed to rather serious errors that have been pointed out regarding the Code that was just approved by the RA.

Another example was in conversation with another OT leader about a banal debate in 2014 regarding patient vs. client terminology.  Specifically, I was stating that a lack of philosophic consistency is present in our terminology and ends up getting reflected in our meandering and inconsistent focus on our definition of practice.  In that conversation I was told that "I would describe the “name” issue as essentially resolved in OT and a non-issue."  Again, since the conversation was not of interest to the leader, it was clear that 'No means no.'

These two examples demonstrate clearly that divergent opinions are not always welcome and that sometimes there is a disinterest in even hearing other people's opinions.  When people tell you that something is 'settled' or 'already decided' that is a rhetorical method that cuts off conversation.

In a rather stunning juxtaposition of the 'No means no' methodology there has been evidence of conduct that indicates that 'No means no' only when it is expedient to the beliefs of those in charge.  Specifically,  the OTA Ad Hoc Entry Level group conducted a study that clearly demonstrated the membership's disinterest in moving the OTAs to a bachelor-level degree, but then still advanced a motion to explore how to be successful if a change is ever desired.  There have been several statements by leaders about the entry level OTD issue that show a similar lack of interest in member input - 'The decision has already been made' and 'The entry level OTD is happening like it or not.'  These kinds of statements clearly show that 'No means no' only when applied in certain directions.

So the public statement that acknowledges the value of persevering is something new and I am hopeful that this philosophy will be applied evenly, particularly when members speak out about important matters.  This becomes important because of the new Code of Ethics that states that 'negative online comments' may constitute an ethics breach if someone believes that those comments serve to stifle conversation.  Obviously, persevering and lobbying a position to one person could be considered 'badgering' by someone who holds an opposing view.  This is a very dangerous provision in the new Code of Ethics that could be used to limit the participation of members.  Someone could simply state that another person's opinions are 'badgering' and 'limiting the speech of others.'  Such a provision is a serious threat to free speech.

This is why it was so interesting to see the statement about persevering in leadership.  I am very hopeful that this statement will be universally applied and that this might signal a new day for the way that occupational therapists deal with conflicting professional opinions on the important matters of the profession.

If 'no' actually means 'not now,' and if persevering is a value, then people should be encouraged to persevere in their opinions and lobbying whether or not anything has been 'settled.'  That is the ultimate value of free speech.

Friday, April 03, 2015

Continued evidence of confusing Christian charity with Social Justice

In the Open Journal of Occupational Therapy this month there is an opinion paper written by Barbara Hemphill entitled Social Justice as a Moral Imperative.  The position presented is that Social Justice belongs in the AOTA Code of Ethics, that it is embedded in the tradition of the OT profession, and that it is not a political matter.

There continues to be confusion and conflation between the concepts of Christian charity and Social Justice.  The author states that Social Justice is not political, but this is refuted by literature review.  The originators of this movement in the OT profession have overtly stated that social justice is political (Wilcock, 1998; Townsend, 1993).  This is an inarguable fact.  

I have already written rather extensively on the topic of whether or not Social Justice was a Core Value of the occupational therapy profession.  I don't have too much to add to that original essay and would point to it as my response to the author's assertions on this topic.

One additional point that requires rebuttal is the statement about the parable of the Good Samaritan.  The author states that this parable is an example of Social Justice.  Here we are able to understand the author's characterization, because the statement is attributed to Jim Wallis, who is a very controversial and left wing Christian activist.  Reverend Wallis is editor of Sojourner's magazine, which has received millions of dollars in funding from George Soros' Open Society Institute.  Reverend Wallis regularly espouses an extremely politically liberal viewpoint.  Referencing a politically partisan individual undermines the author's assertion that Social Justice is apolitical.

The specific reference that is used about the Good Samaritan is Jim Wallis' recently published book, "On God's Side: What religion forgets and politics hasn't learned about serving the common good."  With this kind of reference it is difficult to claim that the definition of social justice has nothing to do with politics.

Aside from that, the author seems to misunderstand both the parable and the implications of social justice.  Social justice requires resource (re)distribution in order to assure equity of outcomes.  However, the Good Samaritan did good deeds by his own charity.  When the man was robbed, the Good Samaritan used his own resources based on his own choices.  He did not run to catch up to the priest or Levite that had already passed the man on the road.  He did not make them hand over their wealth to give to the man who was robbed!  If he did, THAT would have been an expression of social justice.

Instead, he took care of the man himself. That is Christian charity.

Social Justice is political and does not belong in the OT Code of Ethics.  It is important to carefully look at the references used by those who are making claims that it is not political.


embedded links above, and

 Hemphill, B. (2015). Social Justice as a moral imperative, The Open Journal of Occupational Therapy, 3(2).  Available at

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

Wallis, J. (2013).  On God's Side: What religion forgets and politics hasn't learned about serving the common good. Grand Rapid, MI: Brazos Press.

Wilcock, A.A. (1998). An occupational perspective of health.  Thorofare, NJ: Slack, Inc.

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