Thursday, February 26, 2009

The equivocal value of (some) school-based occupational therapy

Occupational therapy, at its best, is a change-enabling service that helps people accomplish goals that are personally meaningful and relevant to how they occupy their time. For kids in school, this means being able to learn and socialize and develop skills for future citizenship.

Therapists routinely wring their hands over issues of eligibility criteria for said services and balance this out against spoken and unspoken procedural rules that are generally applicable only within their own school systems. The interesting aspect to this is that any given school based OT will then believe that the way THEIR school district operates must represent the way that ALL school districts operate (and for that matter, how they are SUPPOSED to operate). Those of us who have the opportunity to interact with dozens or scores of districts across wide geographic areas have wider exposure to the variety of ways that districts interpret presumably identical criteria and rules.

Twice this year I have thrown in the towel at CSE meetings and told the school-based therapist that I concur with their recommendation to discontinue therapy, even though the children arguably had needs that would make them eligible for services. I also followed up by stating that there is little point in arguing for a service when the service provider wants to discontinue a service. This has generated some puzzled looks from the districts who are generally more accustomed to some measure of protestation.

I'm not sure what is different this year in my approach. I am seeing little value in having a child pulled from a classroom (because that is a typical model) to practice some skill or subset of skills in isolation of every other need that is screaming to be met in the classroom. I see little value in trying to convince another professional of a child's needs. I see little value in trying to contact the OTRs who are supposedly supervising the COTAs who make these discharge recommendations - because by the time anyone finds the OTR the meeting is over. I see little value in continuing to suggest that there be some kind of consistent eligibility criteria - because the conversation just seems to get lost when a therapist is convinced that you can meaningfully track a child's progress through a triennial evaluation process. I just don't see the point in trying to educate people about this any longer - because I just can't do it myself.

So the new reality dictates that until situations change I will sometimes tell parents not to bother with school based OT - because sometimes the service has equivocal value. We are finding that we can accomplish more by working with the parents and teachers directly ourselves - even when we are off site. That is the current unfortunate reality.

Three step solution:

1. updated AOTA direction and guidance on philosophical and practice models for school-based OT services, including clear recommendations for OTR/COTA role delineation, general service eligibility parameters, and evidence-based practice guidelines

2. statewide (e.g. NYSOTA) roundtables and plenaries that review the recommendations and 'stamp' them as approved after additional modifications as needed to address state by state regulatory and procedural differences

3. local/regional study groups that meet to develop plans to implement the recommendations

Wednesday, February 25, 2009

Central convolutions to itch and scratch in sensory processing of pain

Convolutions have always been interesting to me - and that is the way that I have always tried to understand the complexities between itch and scratch. I think I slept through any references to Fourier analysis that I was ever exposed to though so I am kind of weak on applying a mathematical model to the problem - even though I think that is the best way to consider the relationship.

This is why I am an occupational therapist and tend to keep myself in application/behavioral analysis - because as soon as I dunk my head into the literature of molecular pain I start to get a little lost. I find some solace in the knowledge that even the molecular pain people are still figuring it out though.

Itch and pain are oddly connected. Histaminergic systems seem to be square mediators between these two sensations. In conversations with OTs I have heard people talk about local histamine release associated with brushing - but this always seemed (to me) like it was an overly simplistic way to explain the complexity of itch/pain sensation. The complex fact is that histaminergic systems operate both peripherally and centrally - and that always adds a layer of complexity to the problem that I haven't seen addressed until recently.

Anyway, I just got this email which reminded me of this whole issue:

Hello, I am an Occupational Therapist and I am doing research on vasoactive effects/histamine release related to sensory integration and your blog came up.... could you point me in the right direction in terms of studies or literature to review...


Now it just so happens that there is a new study that documents a CENTRAL effect of how scratching ameliorates itch sensations.

Basically, the idea is that scratching suppresses the emotional components associated with itching sensations by reducing brain activity in the anterior cingulate cortex, which when activated normally drives aversion to unpleasant sensory experiences. These changes were noted on fMRI.

I personally like this study because it provides a functional explanation behind some of the molecular pain conversations in the literature. This should be an interesting read when it is fully published and hopefully will add to our understanding of the complexities of itch/scratch processing and how it impacts "pain."



References:

Wake Forest University Baptist Medical Center (2008, February 1). Why Scratching Relieves An Itch. ScienceDaily. Retrieved February 25, 2009, from http://www.sciencedaily.com­ /releases/2008/01/080131121804.htm

Thursday, February 12, 2009

Thick descriptions of occupational therapy ADL intervention: A case study.

The context for this entry is that there has been some debating lately about what constitutes occupational therapy and if it can be represented by symbols or even words. So file this entry under: "An example of when the story probably works a little better than the image."

Caleb is thirteen years old and he lives in a shack on the east side of the city. His father abandoned the family long ago and his mother has been on disability payments for as long as she can remember. It's a little difficult understanding the full story because all of her teeth are missing and her articulation isn't particularly clear. That could be part of the reason why Caleb has speech delays - because the voice that he has heard since infancy, although loving, is like listening to marbles rolling over white noise.

Caleb has a moderate degree of mental retardation for which there is no specific cause. It could be genetics and it could be environmental but it is likely both. He relies on the school bus to get to his special education program - but now his transportation is in jeopardy. The problem is that the family bathtub is used to store newspapers, garbage, and his now-dead grandfather's bath transfer bench - so he doesn't have access to using it for hygiene purposes. Caleb also has some difficulties with encopresis and enuresis, which has recently caused upset on the bus because it is getting to the point where the other pre-teens are making fun of him and no one wants to sit near him while riding to school.

The bus company's solution to this is to 'write him up' which means that he is given a slip of paper that identifies the offending behavior and the potential consequences of not solving the problem. The slip of paper states that Caleb has a "Loud Body Odor" and other children are making fun of him. He will be not be allowed to ride the bus again if he does not correct this problem.

I pray to God frequently and today I can tell you that I thanked Him for the fact that Caleb can't read very well.

When we first met him the initial occupational therapy evaluation that was provided concluded that Caleb's fine motor skills were functional and that he did not qualify for school based services. The report stated that although there were some ADL concerns that these did not rise to the level of educational relevance. We wrote up a new evaluation that stated he required occupational therapy. No one questioned the new recommendation, and I remember feeling badly that these decisions that impact the lives of children are sometimes arrived at so whimsically.

The COTA working with Caleb brought in some of her husband's old clothes and gave them to Caleb. Although it amused her to see her husband's clothing on this child, at least Caleb had something clean to wear in case he had an 'accident' in school. We also got him some Axe deodorant and body spray because we thought it might help with some of the odor problem. Plus, kids think that Axe is cool. Once a week the COTA marches him down to the physical education locker rooms and has him take a shower. In between all of this Caleb is very gently coached and educated about personal hygiene and why it is important for a young man to begin taking care of his own body.

The COTA called me the other day, her voice choking a bit. She said that Caleb was walking down the hallway to the OT room and she was walking behind him - but he didn't know it. Caleb walked up to the OT door, wearing loosely frumpled clothing that used to belong to her husband, and his body odor and a slight hint of Axe trailed in the hallway behind him. But just as he got to the door, he reached around into his back pocket, took out a small plastic comb, and with an uncoordinated and misdirected swipe attempted to mash his hair down onto his head. He smiled, placed the comb back into his pocket, and pushed his way into the room.

Now I don't know where that comb came from - but when the COTA saw it she cried. I don't know if Caleb's progress will occur rapidly enough for the bus company. I don't know if the other children's teasing will subside. God knows we haven't even touched the issue of talking to the mom about using the bathtub at home yet.

But today Caleb tried to comb his own hair.

Wednesday, February 11, 2009

Issues with occupational science and the developing lexicon related to occupational or social justice.

The concept of occupational justice is in its infancy, still struggling with definition and identity. Although many of the concepts associated with occupational justice are not new, they are being evolved and reaffirmed, representing another step in the scientific (r)evolution of occupational therapy. Clarification of salient issues has to include definitions of assumptions, concepts, taxonomies, and subsequent research orientation; these are all critical for the evolution of concepts.

The primary challenge in developing a lexicon for occupational science is one of linguistics. Some linguists argue that a concept must be encodable in order for it to be stable. This is important so that the 'hearer' can understand and form a mental concept of the message. However, other linguists argue that there are more concepts than there are encodable forms. Additionally, it takes time for words to stabilize within language. This seems to be the state of affairs in occupational science, which is understandable given the nascent development of the field. Specifically, this is why there has been considerable debate and difference amongst scholars, even in providing basic definitions for the concept of ‘occupation.’ This is acceptable for scholarly discourse, but is not acceptable for conducting research or explaining occupation to the public, or for application to practice.

Prior to trying to frame the nature of occupation for research purposes, occupational scientists still need to clarify concepts amongst stakeholders within the evolving science. This is important because as Kuhn (1962, p.5) states, research is "a strenuous and devoted attempt to force nature into the conceptual boxes supplied by professional education." Unless the professional education is consistent and sound, the research that is conducted will be in danger of having serious flaws. This fact underscores the importance of having a well-developed lexicon; research will hold more value once definitions are broadly accepted.

The logical question that follows is this: are occupational therapists adequately prepared to develop the lexicon of this evolving science? The evidence to date shows that there will likely be periods of confusion as the profession begins to move toward a consensus opinion on the meaning and definition of its central concepts. Yerxa (1999) was concerned that “some might use such a lexicon to oversimplify and/or reduce rich, complex concepts…lead[ing] to premature closure of what should be a generative theory.”

Occupational science is identified as an interdisciplinary endeavor, and this creates inherent opportunities and dangers when inviting broad diversity of input into the creation of the science. In simplistic terms, occupational science is like a bandwagon: new ideas are generated and they ‘jump aboard’ the bandwagon where they are able to conduct tests of congruency against the developing set of ideas. Some of these ideas fit better than others.

In addition to the above problem, many occupational scientists were initially schooled as occupational therapists. Since most occupational therapists were educated within a medical model, how does this same group transfer its collective knowledge into post-positivistic models like occupational science? The creation of taxonomies by positivistic-thinking individuals can create a very shaky foundation for the entire science. In this regard, classification systems must be understood as being arbitrary conveniences that are subject to revision and debate. The developing taxonomies of occupational science should be considered a temporary and convenient filing system, not a set of fixed rules. This is particularly important until the evolving field develops enough points of triangulation to eliminate spurious ideas.

The logical corollary to this is that the lexicon developed by occupational scientists might not fit well within the constraints of practice models for occupational therapy. So, it is possible that occupational science may inform occupational therapy, but caution must be exercised before we can state that an occupational science lexicon will consistently make sense for practice.

As a discipline, occupational science is still in its infancy. The current professional discourse on definition of terminology serves as the necessary precursor to scholarly research, which can than be presented to the public. Occupational science is another step within a long revolution in the field of occupational therapy. Theory-testing will demonstrate its ultimate worth and determine its place within practice.

The most recent issue of the American Journal of Occupational Therapy (January February 2009) is the first special issue dedicated to “social justice and health disparities,” which are central constructs within occupational science. After reading the journal I was left wondering “how does this relate to how an occupational therapist engages in practice?”

I decided to conduct a small study using a convenience sample with an N of 1 (self). In other words, this is my opinion.

I spend a fair amount of time blogging about power inequities in systems and how they negatively impact people who have disabilities. A smattering of these entries can be found under ‘OT Stories’ and ‘Disability Rights’ in this blog. As this blog theoretically represents practice it seemed to be a reasonable data set from which to test the presence and applicability of the occupational and social justice concepts discussed in the journal.

While reading through these blog entries I found that I did not use words like “occupational injustice,” “occupational apartheid,” “occupational deprivation,” or “occupational marginalization” despite my strong familiarity with the concepts. Considering the recent attention to these concepts in the occupational therapy literature, as recently summarized by Braveman and Bass-Haugen (2009) I began wondering why these words haven’t been inculcated into my lexicon and practice.

As evidenced in the blog entries herein, my practice is strongly focused on navigating systems and functionally advocating for patients. Additionally, there is a strong focus on narrative construction of meaning with the individuals who are living a disability experience.

Specifically, I find that my own practice, as related in the narratives on this site, was highly influenced by Mattingly and her concepts related to narrative construction of meaning. In blog entries on this site therapeutic ‘storytelling’ is used as a primary technique that helps to guide the outcome of intervention – and it is also used to explain the intervention for the blog readers. Sometimes the storytelling is purposefully manipulated for the patient’s and reader’s benefit. This benefit and interaction has often been unwittingly embedded within the banal form of this blog.

Mattingly draws upon the Heideggerian expectation that current meaning is strongly dependent on a future conceptualization of hope. She provides detailed analyses of therapeutic interactions, providing examples of how therapists struggle against the notion that their patients who have disabilities might experience time as a brute sequence of events. She shows that therapists work with patients to develop a shared vision for the future and of life after recovery from illness or disease.

Mattingly explains that the process of narrative within the context of therapeutic exchange may be construed as imitating the patient’s life that is actually being lived, or it may be that the patient’s life is imitating the narrative that is being constructed between the therapist and patient. She also proposes a third interpretation, suggesting that narrative imitates experience because of the therapeutic ‘sense-making’ of the occupational therapist. All of these elements are embedded within this blog.

Another significant influence on my practice is the work of Jerome Bruner, who describes the concept of ‘folk psychology’ as a model of empiricism. Folk psychology is a system that people use to organize their experiences and to make sense of them. Folk psychology is based on narrative, which is a sequential, factually indifferent, navigational method that has dramatic quality and is accessible to anyone who has mastered the (shared) language. Bruner diverts criticisms that this is a relativistic model by suggesting that since language is a shared expression of culture, meaning-making takes on a larger sense than as simple individual interpretations of reality.

Bruner advances his own philosophy of experience that can be contrasted to Husserl’s phenomenology. Where Husserl proposes that all un-provable assumptions be discarded when describing what is given in experience, Bruner expresses that culture, as mediated through narrative discourse, is the foundation for interpretive meaning. Bruner’s interpretation of ‘zu den sachen selbst’ is that the ‘things’ that matter most are the communal cultural experiences that are acquired through language acquisition.

This blog, much like Bruner’s book, provides an autobiography as a sample illustration, demonstrating the strong linkages between personal experience, historicity, and cultural foundation.

This blog, which reflects my practice, follows a constructed design of storymaking, storytelling, and narrative folk psychology. The emphasis is on making and finding meaning, navigating systems, and is reflected in the plodding efforts and struggles of the people whose stories are contained herein.

This can be rather strongly contrasted to the concepts outlined by Braveman and Bass-Haugen (2009) and as reflected in many of the articles in the referenced AJOT. I have some rather strong concerns that the concepts associated with social or occupational justice might inadvertently contribute to ‘linguistic determinism’ and subsequent victimization.

This brings the conversation full circle back to issues related to lexicon. I don’t doubt that “occupational injustice,” “occupational apartheid,” “occupational deprivation,” or “occupational marginalization” exist – but when we frame the problems with this language it is possible that we are creating a new liberation politic, and that the advancement of the ‘cause’ becomes dependent on the continued subjugation of people’s ‘occupational rights.’

In other words, the terms may be helpful for explaining the sociology of power differentials, but they may not provide a functional springboard for providing an intervention. Here, Mattingly’s focus on hope and Bruner’s focus on meaning-making are a much more functional model for helping people move forward. If we spend too much time talking about “occupational injustice,” “occupational apartheid,” “occupational deprivation,” or “occupational marginalization” I am afraid that all we will create is a bunch of really angry people – or even worse – we run the risk of beginning to think that the proper point of intervention is in picket lines and protest rallies as described by Blakeney and Marshall (2009).

Albert Camus is often quoted as saying, “Don't walk in front of me; I may not follow. Don't walk behind me; I may not lead. Just walk beside me and be my friend” This is a model of shared narrative construction between therapist and patient that is used as a therapeutic tool for return to daily occupations (whatever the disability may be). This model of therapist-patient interaction is starkly contrasted to a fist-pumping anger-fest that is stoked by using an inflammatory lexicon of rights-denial.

The presence or absence of rights-denial is factual and independent of our opinions. What matters is how we help people get past those barriers. We are a pragmatic profession that helps people. We are not community activists and rabble rousers.

In summary, I am not sure who is going to pay for OTs to attend protest rallies about water quality in Kentucky. However, if lack of potable water causes disruption and stress in caregiving routines for parents of children who have disabilities I am relatively certain that there are ways to help them cope, adapt, and make meaning out of their experiences.

This difference in intervention alone can serve to represent the crux of the problem in how we make social or occupational justice fit into an occupational therapy practice model.

References:

Blakeney, A.B. and Marshall, A. (2009). Water quality, health, and human occupations. American Journal of Occupational Therapy, 63, 46-57.

Braveman, B. and Bass-Haugen, J.D. (2009). Social justice and health disparities: An evolving discourse in occupational therapy research and intervention. American Journal of Occupational Therapy, 63, 7-12.

Kuhn, T.S. The Structure of Scientific Revolutions, 3rd ed. Chicago: The University of Chicago Press

Yerxa, E. (1999). Occupational terminology interactive dialogue. Journal of Occupational Science, 6, 75-79.



Background reading:


Bruner, J. (1990). Act of meaning. Cambridge: Harvard University Press.

Mattingly, C. (1995). Healing dramas and clinical plots: The narrative structure of experience. Cambridge: Cambridge University Press.

Sperber, D. & Wilson, D. (1998). The mapping between the mental and the public lexicon, In Carruthers, P. & Boucher, J. (eds.) Thought and language. Cambridge: Cambridge University Press

Thursday, February 05, 2009

Reflections on the 'branding' of occupational therapy

Also file under: Nel mezzo del cammin di nostra vita mi retrovai per una selva oscura, che la diritta via era smarrita. (because when all else fails, read Dante).

With some pain, I have been watching the wheels fall off the branding bus over on the OT Connections site. AOTA kicked off a new branding campaign in the last year - starting with an unveiling during last year's annual conference and recently represented by the release of a rather odd poster that is being alternately described as wonderful or horrible, depending on your individual opinion.

In response to some of the questions and constructive criticism, AOTA President Penny Moyers writes:
When we read the literature about OT, it is not really about simple engagement back into doing. The essence is about meaning, quality of life, satisfaction, health and well being that comes from being able to participate in a life that is full of potential, regardless of the barriers. We no longer confine our intervention to those with obvious disabilities, we also work to prevent occupational problems and to promote health and participation with clients of all ages, who might not at the time of intervention have a current occupational performance issue. If ever the world needed a positive message given this economic decline, now is the time to deliver it! Living life to its Fullest can be achieved each day.

That's nice and all - but I think that it also represents a real problem and disconnect with those practitioners who are expressing a little concern about this 'brand.' In the world of everyday practice, therapists are trying to develop programs that meet the needs of people who have actual disabling conditions. They are working within established and not-so-established systems to find ways to support the continuation of their work. In simple terms, they are struggling with reimbursement and with barriers to service delivery in hospitals, schools, and communities.

Although I appreciate the lofty rhetoric and philosophic intentions of providing 'positive messages in our current economic decline' I am relatively certain that occupational therapy is not properly positioned or suited for addressing our current state of sociocultural and political decay- at least not in any pragmatic sense. I say this with all due respect to Mary Reilly, whose economic arguments I actually understand and appreciate - but please, let us avoid getting our heads lost in the clouds. There may be time for us to develop Utopian societies, but can we figure out how to deliver evidence based and effective services in school systems and nursing homes first?

I suppose that there is some irony in the OT Practice magazine dated 1/19/09 where our new 'brand' is presented for discussion. The cover of the magazine is about Occupational Therapy and Disaster Response. I'm not sure what the point of the article was - perhaps it was some rationale for us taking over FEMA. I'm not sure if it really matters because last time I checked there was no CPT code for disaster response and I don't know if Medicare identifies this as a restorative service. I need to learn more, obviously. Anyway I am thinking that Disaster Response might have been better applied to finding ways to respond to legitimate criticism about our new branding.

I don't believe that our profession is in crisis because everyday thousands and thousands of occupational therapists go to work and help real people with the real problems in their lives. Sometimes those problems are autism and sometimes they are carpal tunnel syndrome. Sometimes they are drug addictions and sometimes they are advanced cancer. Sometimes the solution is provided in the form of a direct therapy and sometimes it is provided in a piece of equipment or a new way for a family member to help accommodate a problem.

I think that our stakeholders know exactly what I am talking about - and they want us to do our jobs even better.

I am not so convinced that our membership leaders know exactly what I am talking about - at least not based on the responses to street-level practitioners concerns about the 'brand.'

I am all for lofty academic pursuits. I like them, actually. They serve a purpose - but right now the connection to practice is lost or hopelessly buried. I suppose we can continue with branding that can't be sold to our own membership. And then we can follow it up with AJOT issues packed full of more pie-in-the-sky conversations about social justice and self-flagellation over health disparities. But will there come a time when we can have some reasonable marriage between our philosophic base and what is actually going on in practice every day?

Memo to AOTA: If you want to know why membership is declining, look at your current 'brand.' Think about the 'A' in AOTA. It is not only supposed to mean 'A'cademic. It is also supposed to represent all the everyday working practitioners. Real life. Real practice. If the literature about OT is NOT including 'simple engagement back into doing' then you are forgetting something that is rather germane to our practice.

Stream of consciousness on being a Witness

This post deserves an update - because as I have stated these stories do not end. You may also want to reference this partially related rant for background.

I received a subpoena to appear in Family Court regarding the case linked to above and I sat, dutifully, waiting to be called in. I was a little surprised to receive the subpoena because my documentation excoriated the Child Protection system as much as it did the family. Still, if someone actually wanted to hear me tell a story I was more than willing to do the telling.

My faith in these court hearings is minimal - I have been to some and had the defense attorney make fools of CPS and been to others where the children were removed from the family home as was appropriate. The problem is that you never know what you are going to hear and see before they start.

Rules of evidence are tricky - and at the same time I appreciate their complexity. I really do hate the concept of an oppressive state that can remove your freedoms but at the same time I know that sometimes it is necessary. My last two rules of evidence issues have been frustrating - I think I referenced one in here about a child handing over a dime bag of pot to one of my therapists. When the police and CPS reports came across my desk they stated that the bag allegedly contained "leafy vegetable material." That was pretty funny - I mean, it made it sound like the therapist couldn't tell the difference between pot and a bag of Dole Classic Salad Blend. Whatever.

Anyway, I was going to be a witness again. I had not seen the child in about six months - the parents had threatened to move out of the county and around that time the kids were placed in a foster home and a center-based program - this effectively removed them from my caseload. As I waited I thought about what I observed and what I was concerned about - I wanted to be prepared for whatever questions I was going to be asked.

It is hard to sit in a Family Court waiting room. The environments tend to be a little sterile - mostly plain walls and mostly plain styled wooden chairs. There is always an opening in the wall with a sliding glass panel where you are supposed to check in. There is usually a bespectacled County worker who tends to avoid acknowledging people's presence at the window for the first few minutes that they are standing there. When they do acknowledge the person they tend to look over their glasses and down their noses. I wonder if they get training to all do it the same way.

When people get called in before the Judge the bespectacled worker screams the names really loudly: "JOHN DOE. AND JANE DOE. PLEASE ENTER THE COURTROOM. REMOVE YOUR COATS AND TURN OFF YOUR CELLPHONES BEFORE ENTERING THE COURT." I think that every person whose case is called hates the fact that their name is screamed out loud by Bespectacled Court Worker.

So there were people who had scheduled appearances before the case I was there to testify for. One young couple (JOHN DOE and JANE DOE) went in at the same time. JOHN had a lawyer and JANE didn't. After disappearing behind the Court doors for a few minutes JANE burst out of the room with tears in her eyes. A few minutes later JOHN came out with his lawyer - who asked him to check if JANE had gone. JOHN looked around the room and flippantly remarked, "I guess JANE flew the coop." JOHN did not have tears in his eyes.

I mention all this because I think it is important that the walls and furniture be somewhat stark and hard because there is just too much sadness and pathology in those waiting rooms, and it wouldn't be a good thing if any of it seeped into the walls or furniture.

Anyway, just before it was my turn to give testimony I was informed that a settlement had been reached. I guess that if the parents 'admit' to neglect then they don't need to have a hearing, and the children will just remain in foster care. At some future time there may be some other hearings related to permanency of the placement but I didn't really feel it was important to dig for details.

The concept of a 'settlement' was interesting to me - because it seems that there is really nothing to be settled other than the question of whether or not the kids were neglected. Maybe there is more to this than I am aware - and maybe they have some criminal culpability - but that is all conjecture on my part. I really don't know.

I felt bad for the parents today - because no matter how much they could have or should have conducted themselves more responsibly - they just seemed like meat for this grinder. They were undereducated, uninformed, and ill-equipped for parenting - and in some way that is kind of tragic. It's like not being able to escape from the rubble of your own collapsed circumstances.