Pushing back against a 'Fourth Paradigm' in the occupational therapy profession

Occupational therapists have a century long tradition of identity confusion and that has been complicated by incrementalism in how the profession defines its scope of practice.  A significant victory against incrementalism was realized in the 2014 Fall Representative Assembly Meeting when the Philosophy of Education document that was proposed was not supported, but an amended document passed that removed references to the 'occupational needs of institutions.'  The amended document now reads:

"Occupational therapy (OT) education prepares occupational therapy practitioners to address the occupational needs of individuals, groups, communities, and populations"

The motion was to replace the word "institutions" with the word "groups" as individuals, groups, communities and populations have human occupational needs as OTs know and understand them, and it makes the language of the new document consistent with the Occupational Therapy Performance Framework (3rd edition).  This motion passed the RA on a vote of  38 Aye, 11 Nay, and 1 Abstention.

Concern expressed by delegates was that occupational therapists worked in the contexts of institutions but not directly on or with institutions.  That may seem like parsing words but there is a critical distinction.  Arguments focused on the fact that occupational therapists work with people who have occupational needs, and that stating we worked with institutions was potentially confusing to external stakeholders.  There was some opposition who wanted an expanded definition of OT that did not make distinctions between 'therapy' and 'things that a therapist might do but that don't constitute 'therapy.'

The attempt to modify the definition of OT is part of a recent string of attempts to change the nature of occupational therapy practice.  As previously noted, this trend began with the international influence of occupational therapy scholars (Townsend, Langille, and Ripley, 2003) who began thinking that it would be more valuable to intervene at the levels of systems instead of at the level of individual (or groups) of people.  This was followed by a more explicit exploration of social justice as occupational therapy (Townsend and Wilcock, 2004).  These ideas were subsumed wholly into the thinking of many American scholars, who in turn began infusing these concepts into AOTA official documents, including the Code of Ethics and Practice Framework.

Over time there has been significant pushback against including these models as evidenced by the motions to remove Social Justice from the Code of Ethics and this recent effort to stop the incremental redefinition of the scope of occupational therapy practice.  At the core of these objections is a tacit appreciation for our 'Third Paradigm' as expressed by Kielhofner (2009).  That 'Third Paradigm' refocused the field on occupation as a means and ends of the therapy process, and actually includes a strong consideration of contextual elements.  However, it did not intend to make the contextual elements the focus of therapy - which is what happens in a social justice framework where we are said to be focusing on 'systems' or 'institutions' in our work.

That focus on systems and institutions is what I call the 'Fourth Paradigm' - but it is being rejected by many therapists in the United States.

The primary reason why the 'Fourth Paradigm' is rejected is because it places health care professionals into the realm of economics and public health.  The 'Fourth Paradigm' takes our focus away from the individual.  Of course there is a need to address larger issues, and certainly within a General Systems framework we are aware of those other contextual levels -  but we do not re-define a profession and abandon our core philosophy in pursuit of those contextual methods.

Occupational therapy is not alone in its flirtation with making contextual elements a focus of practice.  An example of loss of focus would be Toronto physician Gary Bloch who is interested in the impacts of poverty on health.  He perceives the physician role as "prescribing income" and he does so by encouraging his patients to access governmental welfare benefits and advocating for more governmental funding to solve poverty problems.  I am sure that he has good intentions, but he has forgotten his medical mission and replaced it with the mission of a social worker and community activist. 

This is the kind of loss of focus that occurs when we consider institutions as our point of intervention, or social justice as our health care mission.  As additional consideration is the immorality of forced redistribution of other people's resources.  It is curious that Dr. Bloch does not discuss how he offers some of his own wealth or whether he would promote alternate economic policies that would provide jobs and shrink the dependence on governmental systems.  One can hardly imagine how as health care professionals it has become our New Ethic to promote lifelong welfare-state dependency.  That kind of philosophy of promoting social justice through Rawlsian redistribution and welfare dependency hardly seems compatible with Reilly's (1961) core premise that "man has a need to master his environment, to alter and improve it."

Occupational therapy scholars pursue the 'Fourth Paradigm' perhaps out of frustration with the slow pace of clinical change (Molineaux, 2004).  I am not as disheartened, and I think that the Third Paradigm continues to gain ground.  It is notable that important paradigm shifts in the profession have always been driven out of the clinic environment.  The First Paradigm was born out of the efforts of Barton, Tracy, Slagle, and others who were working with people.  The Second Paradigm was born out of the efforts of Brunnstrom, Bobath, Rood and many other clinicians who worked with people.  The Third Paradigm was born out of the efforts of Reilly and all of her students - steeped deeply in actual practice with people and then refined in academic study.  This is precisely why proponents of a 'Fourth Paradigm' are falling flat with the field - they do not represent the values or realities of street level practitioners.  That is not to say that the Academy has never or will never be an important driver of practice models - but unless those models gain traction in the real world experiences of clinicians who are working everyday they are likely to falter. 

That is particularly true of 'Fourth Paradigm' models that are congruent with the values of socialized medical systems - which is precisely what we do not have in the United States - and if the current political context is any suggestion, we will see continued pushback from the public because that is not the way that they want their health care system constructed or run.  This has been the fundamental misunderstanding of the American Academy when it readily adopted the values and beliefs of international scholars that are working in culturally and politically divergent contexts.

There always has been and will continue to be a role for occupational therapists to exercise their knowledge and skills in service of systems or institutions.  But that should always be called CONSULTATION and it should not be conflated with PRACTICE - which means PRACTICE in the interest of actual human beings in a direct manner.


Kielhofner, G. (2009). Conceptual Foundations of Occupational Therapy Practice.  Philadelphia: F.A. Davis.

Molineux, M. (2004). Occupation in occupational therapy: A labour in vain? In M. Molineux (Ed). Occupation for occupational therapists, Oxford: Blackwell Publishing.

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.

Townsend, E., Langille, L., Ripley, D. (2003). Professional tensions in client-centered practice: Using institutional ethnography to generate understanding and transformation. American Journal of Occupational Therapy, 57, 17–28

Townsend, E. and Wilcock, A. (2004).  Occupational justice and client centered practice: A dialogue in progress.  Canadian Journal of Occupational Therapy, 71, 75-87.


Chris, Thanks for fighting the good fight regarding this issue, and congratulations on having made a difference. I am pleased to see OT Connections serve as a vehicle for the kind of debate you are calling for and hope that other such debates on important issues in our profession can take a similar course.

Ted Peterson, DrOT

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