The problems with polarity frames in occupational therapy theory

There is nothing quite like starting off a Monday morning with a good theory article.  I opened up my Twitter feed to find a link to Taff & Putnam's contribution entitled "Northern philosophies and professional neocolonialism in occupational therapy: A historical review and critique."

The authors "suggest with confidence that the current American philosophical landscape in 2021 is a mix of mostly analytic philosophy accompanied by a smaller measure of neopragmatism predisposed to a Continental mindset." (Taff & Putnam, 2022).  I am uncertain if this is a view shared by all, and to any degree that it is true, this perspective does not respect an entire heritage of thinking that has been adopted into the American perspective generally and by occupational therapy practitioners specifically.

The fact that many occupational therapy practitioners in the United States continue to frame their practice around core American values is a topic that is important to explore.  Claiming that a paradigm change is needed to address extra-contextual beliefs represents the logical fallacy of begging a question.  Is it possible that there is no paradigm crisis, at least from the perspective of American occupational therapy practitioners?  Change can be interpreted as problematic or evolutionary, depending on perspective.  Paradigms change over time to reflect new theories.  However, when new theories disrupt everything that is previously known or are inconsistent with practice this represents a paradigm crisis. Therefore, the term 'colonial' has to be approached cautiously and it has to be appreciated in a contextual manner. What exactly is 'colonial' about a perspective that is being practiced in a 'home' context? And what would the possible interest be in de-constructing that perspective that was designed for that context? 

Perhaps the most important question - who is the audience for an article in a journal in an Internet/global context? I am responding as an American occupational therapy practitioner.

What constitutes the ordinary meaning of occupational therapy for practitioners in the United States?  The answer to that question depends on whether or not the American context of the founding of the occupational therapy profession is primarily considered.  To use an ‘older’ reference that reflects occupational therapy heritage, perhaps critiques about American paradigms have not always remembered to pass that entire weft of American history through the warp of our current model and theory development.  This dynamic has implications for the practice of the profession in the United States. It is interesting to propose de-colonization, and that may be helpful for some contexts, but is it helpful for American practice where the concepts are being applied within those systems?

That occupational therapy in the United States adopted reductionistic models in its Second Paradigm is not being debated.  However, it was Mary Reilly's work along with her graduate students in the 1960s and 1970s, leading to Kielhofner's Model of Human Occupation, that rejected monolithic pragmatism and instead encouraged what is commonly referred to as Reilly's 'Not Only, But Also' (NOBA) approach (Alterio, 2019, p.80).  That approach was designed to respect the scientific advances of the 21st Century, but to also recognize the need to consider human agency (occupation) and its association with the values of the Arts and Crafts Movement (aesthetics, beauty, design, meaning, and purpose). Reilly proposed episteme and techne - and I am confused about why that is so frequently skipped over in these analyses. Truth and Knowledge should not be set in a zero-sum polarity - that is against American occupational therapy philosophy at its core - a philosophy that has always valued 'knowing that' as well as 'knowing how.' Ironically, occupational therapy practitioners often re-label that approach as 'pragmatic' or as 'making sense!'  What would Heidegger say of this 'sense-making!'

Still, does a dominant model of traditional pragmatism persist in Northern/Western practice - of course. Reimbursement systems remain oriented around that perspective, and one can make an argument that this creates problems even for practice within the United States.  However, there is ample space for other ways of knowing and they certainly do flourish (Clark, 1993).  To any degree that they don't, one might point directly at the Academy that is more concerned about colonialism than others who are practicing the profession daily. After all, the members of the Academy are the ones who control the profession's Northern/Western literature and journals. So, if perspectives or approaches are not being promoted - I say 'cura te ipsum!'  I don't see much of that in the high-impact-factor journals though, and so authors have to publish in Southern journals, or write blogs, I suppose.

I believe that the error in the authors' approach is twofold.  First, by labeling the an American approach as 'colonial' implies an intent that I don't believe exists, for the most part.  The criticism is not new - and it was started by Mocellin (1992, 1995, 1996) - but the problem with the criticism is that there is no acknowledgement that Northern/Western occupational therapy constructs were explicitly designed for the American context - so much so that Reilly even said that in her Slagle lecture (Reilly, 1962). The piling on over time (Iwama, 2006; Hammell, 2009, 2011; many others - and now Taff & Putnam, 2022) assumes colonial intent. I have argued that occupational therapy may not be a profession that easily bridges socio-political contexts (Alterio, 2019, p. 192).  Reilly explicitly said that occupational therapy was an American hypothesis - why do so many theoreticians just gloss over that?

Admittedly, there has been some intentional colonialism (described by Bowyer et al, 2008) and in general I think that was a bad idea. I am unaware of any existent pressure on international colleagues to adopt American textbooks, and if no other textbooks are available then they could be written - or even open-sourced. Then those international contexts could define practice in terms that are locally and contextually relevant - and if it turns out that the totality of occupational therapy practice does not appear unitary, or at least have enough common elements to be recognizable between localities, then I suppose we have an important conversation to engage.

I understand the pressure on Northern and Western authors though. I was told by a publisher to make my textbook internationally contextual, so that people would buy it globally. Privately, I thought that was a ridiculous request - but that is because I happen to have a deep understanding of the problems of what is perceived as and called "colonialism." Accordingly, I wrote my book the way I wanted, and inserted a chapter on globalization that called out the problem. 

The second error of the authors is that using terms like 'neoliberal' inserts a political motivation that I also don't believe exists and may be unnecessary and divisive. I am uncertain if the term is designed to be a slur or a descriptor based on the venom that often seems to accompany its use. Here we enter into a world of capitalistic-critique and get far afield of our purpose. I just don't see this as a productive conversation. Calling American practice neoliberal is like getting angry at the black cat for being black and a cat. Is all of medicine in the United States oriented around insurance systems that some love (to hate)? Of course, and if we deconstruct that system, or de-tangle from it, what are we expecting American students to do - practice in another country? There is nothing pragmatic in such an argument, but here I go using the 'P' word again.

I don't know of any American students (medical, allied health, etc) or practitioners who are unable to understand determinants of health and that care systems need to be constructed in ways that meet the needs of all who seek care. Is the American system perfect - no - and I don't see any model systems in other contexts either. So what is the point of the argument?

This is another opportunity to teach American students about our history - and the value of charity - and how that value informed the American founding. We do not all need to adopt social justice (redistributive) political models to function as care providers, and if the 'neoliberal' or 'capitalistic' health care system of the United States does not reflect the reality of how systems work in other contexts - then again, others should feel free to practice in accordance with their own context. I believe the common parlance among American students, who seem to understand that you should not force values down each other's throats, is 'You Do You.'

The framing of 'colonial' and 'neoliberal' intent creates a false polarity for the occupational therapy profession that I don't believe is helpful and in fact I don't think it is particularly accurate. Emerson & Lewis (2019) wrote an interesting book about the abolition of 'either/or' thinking - and in this context I would call the assumption of 'Northern/Western neoliberal colonial intent' a shining example of what these authors suggest avoiding. Again, the core message of Reilly's Third Paradigm resolution was NOBA - not only but also.  Techne and episteme.  Knowing how and knowing that.  On and on. Kielhofner provided  roadmap with the contextual application of GST and heterarchical thinking so we wouldn't leave out important understandings. If we go back and review all of this we may find that creating false polarities is not really needed, or particularly helpful.

References/Additional Reading:

Alterio, C.J. (2019). Clinically oriented theory for occupational therapy, Wolters Kluwer.

Bowyer, P., Belanger, R., Briand, C., de las Heras, C. G., Kinebanian, A., Launiainen, H., Marcoux, C., Mentrup, C., Morel-Bracq, M.C., Nakamura-Thomas, H., Pan, A.W., Tigchelaar, E., Yamada, T., Ziv, N., & Kielhofner, G. (2008). International  efforts to disseminate and develop the Model of Human Occupation. Occupational Therapy in Health Care, (22), 1-24. 

Clark, F. (1993). Occupation embedded in real life: Interweaving occupational science and occupational therapy. American Journal of Occupational Therapy, 47, 1067-1078.

Emerson, B. & Lewis, K. (2019). Navigating polarities. Paradoxical Press.

Hammell, K.W. (2009). Sacred texts: A sceptical exploration of the assumptions underpinning theories of occupation. Canadian Journal of Occupational Therapy, 76(1), 6-13. 

Hammell, K.W. (2011). Resisting theoretical imperialism in the disciplines of occupational science and occupational therapy. British Journal of Occupational Therapy, 74(1), 27-33. 

Iwama, M. (2013 June 18). Open Plenary Speech to the College of Occupational Therapists Annual Conference 2013.  [Video File] Retrieved from https://www.youtube.com/watch?v=67PqinQ7qNM 

Kielhofner, G. (1978). General systems theory: Implications for theory and action in occupational therapy. American Journal of Occupational Therapy, 32, 637-645.

Mocellin, G. (1992). An overview of occupational therapy in the context of the American influence on the profession, Parts 1 &2, British Journal of Occupational Therapy, 55(1), 7-12; 55(2), 55-60. 

Mocellin, G. (1995). Occupational therapy: A critical overview, Part 1. British Journal of Occupational Therapy, 58(12), 502-506. 

Mocellin, G. (1996). Occupational therapy: A critical overview, Part 2. British Journal of Occupational Therapy, 59(1), 11-16. 

Reilly, M.  (1962). Occupational therapy can be one of the great ideas of 20th Century medicine.  American Journal of Occupational Therapy, 16, 2-9. 

Taff, S.D. & Putnam, L. (2022). Northern philosophies and professional neocolonialism in occupational therapy: A historical review and critique. Brazilian Journal of Occupational Therapy, 30, e2986.