Wednesday, July 31, 2013

Historical roots of occupational therapy: It is easy to forget


To paraphrase J.R.R. Tolkien...

History became legend, legend became myth – and some things that should not have been forgotten … were lost.

In Glen Gillen's Slagle lecture at the 2013 AOTA conference he stated "We need to reclaim what we do..."  This is not the first time that there has been a call back to our roots - we periodically re-visit this theme in occupational therapy.  In order for us to develop a plan to 'reclaim what we do' we need to KNOW what we did.  And why we did it.  And what set us on the path to begin with.

In a previous entry in this series I showed how Dr. Licht went searching for some of that history.  After receiving a response from Mayor Copeland, Dr. Licht felt like he had struck a gold mine of historical information that he did not previously have:




















Also, as Dr. Licht had receipt of contact information for Isabel (Newton) Barton, he quickly sent her out a letter as well, eager to learn as much as he could about that early history. 

























I have no record of other correspondence between Dr. Licht and Mrs. Barton, so it is difficult to know how Mrs. Barton came to write her own article in 1968 or indeed how she came to attend the 50 year celebration of the profession's founding in Clifton Springs and dedication of the plaque in front of Consolation House.  I don't know if she was prompted to re-engage by Dr. Licht's correspondence or if she was contacted separately by others; that story may be buried in files at AOTF and someone else may have that answer.  

According to Mrs. Barton (1968), "With the death of George Edward Barton in 1923 came the end of activity in occupational therapy at Consolation House."  It is difficult to know how involved she was with occupational therapy following his death, although some of these threads will be explored in future entries.  

Death creates an emptiness - and that emptiness is either a gaping wound or just an absence, depending on your perspective.  In emptiness we lose details, and our memories fill in information of what we have heard, and that is influenced by what we have thought.  This is how quickly  we lose our history - and then our history can become legend as the story gets changed in the re-telling.

Mayor Copeland quickly corrects his previous correspondence and indicates that George Barton actually was NOT affiliated with the Clifton Springs Sanitarium, but as we now know, his efforts to establish Consolation House were entirely his own and were not at all related to the nearby Sanitarium:

























So in the years following George Barton's death, it is not clear that information about him was widely disseminated or documented.  Of course Mrs. Barton held most of that information, but other details were held by community leaders and former contemporaries - but it is evident that information becomes blurred in the re-telling and in fact partially forgotten.  This is how we approached the 50th anniversary of the founding of occupational therapy and it was at that time that we were beginning to lose the details.

The efforts of many people in 1967 and 1968 led to another re-telling of the Consolation House story and a documentation of what was becoming lost.  These documents are evidence of that process of re-discovery.

As we approach our Centennial as a profession and as we again look toward our roots so that we can 're-claim what we do,' I hope this will serve as an even more complete re-telling of the George Barton story.  In 50 more years, I hope that we will not be accused of almost forgetting.




References:


Barton, I.G. (1968). Consolation House, Fifty Years Ago.  American Journal of Occupational Therapy, 22(4), 340-345.

Gillen, G. (2013). A Fork in the Road: An Occupational Hazard? [Eleanor Clark Slagle Lecture, 2013], presented at the 2013 AOTA national conference, San Diego, CA.

Wednesday, July 24, 2013

Social Justice: What would Dr. Kielhofner say?

This post is a follow up to my post earlier this month about the use of a public health model for occupational therapy.  The issue of public health models is directly linked to the issue of inclusion of Social Justice in the AOTA Code of Ethics which states (in part):

SOCIAL JUSTICE

Principle 4. Occupational therapy personnel shall provide services in a fair and equitable manner.
Social justice, also called distributive justice, refers to the fair, equitable, and appropriate distribution of resources. The principle of social justice refers broadly to the distribution of all rights and responsibilities in society (Beauchamp & Childress, 2009). In general, the principle of social justice supports the concept of achieving justice in every aspect of society rather than merely the administration of law. The general idea is that individuals and groups should receive fair treatment and an impartial share of the benefits of society. Occupational therapy personnel have a vested interest in addressing unjust inequities that limit opportunities for participation in society (Braveman & Bass-Haugen, 2009). While opinions differ regarding the most ethical approach to addressing distribution of health care resources and reduction of health disparities, the issue of social justice continues to focus on limiting the impact of social inequality on health outcomes. 

This ethical requirement has birthed a 2.5 year 600+ post monstrosity of a conversation on the OT Connections website, and the debate seems far from over.  A core issue remains: how exactly are we to operationalize this social justice requirement?  How is an occupational therapist supposed to follow the general idea that recipients of service receive fair treatment and an impartial share of the benefits of society?

In order to understand how we may have arrived at this point I went back and scanned my journals for evidence of beginning conversations about this topic.  It is true that international occupational therapy scholars have been dabbling in public health models and social justice concepts for quite some time, but I wanted to find a point in time when we took a turn down this road in the American occupational therapy literature.

One of the earliest articles that I found that began to dance around this issue was Kielhofner (2005) Rethinking disability and what to do about it: Disability studies and its implications for occupational therapy.  I found the article to be extraordinarily even-handed in acknowledging that the occupational therapy field could probably learn something from the field of disability studies, particularly related to our understanding of disability and how we should position ourselves to respond to it.  However, Kielhofner also identified many inherent conflicts between the disability studies philosophy as opposed to the dominant culture's perspective on disability, what people actually wanted at different points in their injury/illness/disability experiences, and how all this relates to models of occupational therapy practice.

Another interesting article in this particular journal was written by Paul-Ward, Kielhofner, Braveman, and Levin (2005) Resident and staff perceptions of barriers to independence and employment in supportive living settings for persons with AIDS.  This article draws sharp distinctions between resident perceptions of barriers (being more systems-oriented) and staff perceptions of barriers (being a combination of systems and personal/client factors).  The authors suggest that there are no clear answers about how to resolve these differences, although they state that some integrated understanding of disability studies within a Model of Human Occupation (MOHO) context might be fruitful.  Again, this article seems to be rather even handed.

In my understanding of MOHO, there is little need to integrate some new model because MOHO itself is based on a broad General Systems Theory framework where these broad considerations are supposed to be already happening.

The issues raised by those who adopt a Disability Studies perspective are very closely aligned to the social justice model in that the focus of problem identification is inequity and oppression by powerful system forces and less attention is paid to personal or client factors.  These initial articles acknowledged disability studies concerns, but something happened along the way to finding and articulating a practice model.  Rather than integrating this information into OT practice models, some academicians took a road of adopting the Disabilities studies models - and turned them into conversations about occupational (social) justice, occupational deprivation, and so on.  These conversations have not served practice well.

The question left in the wake of this move toward public health/social justice/disability studies models is 'how does this translate for practice?'  The 'Social Justice' AJOT edited by Braveman and Bass-Haugen (2009) doesn't seem to provide clear enough guidance on how everyday clinicians are supposed to integrate a social justice requirement into practice.

I have already roundly criticized the Blakeney and Marshall (2009) article on water quality and how OTs should consider social action at rallies and boycotts as part of their practice.  Current readers are still referred to that discussion for background.  Rather, I would like to focus on the article by Paul-Ward (2009) Social and occupational justice barriers in the transition from foster care to independent adulthood.  The reason why this article is interesting is because the author previously co-wrote the article with Kielhhofner and Braveman and Levin that seemed rather even-handed as described above.

The 2009 Paul-Ward article has a different tone than the 2005 article.  In the more recent article the very notable emphasis is on problems within the systems designed to provide care and transition services to children in foster care and it is not on the personal/client factors of the children or their families.  The article states

Using a social and occupational justice lens to analyze the barriers to successful transition out of the foster care system, it becomes clear that many of the challenges that these youth face result from the bureaucratic system in which they are placed... independent living services...are underused, especially because they are not designed to be meaningful for teenagers...foster care agencies typically do not have access to the type of facilities necessary for the implementation of hands-on learning experiences...the preliminary findings from this study highlight the need for radical changes in the overall structure of the foster care system... stakeholders in the foster care system need to set aside agency and personal agendas to design a system of care that views all children as fully participating members of their communities and provides them with equal opportunities to achieve self-identified goals...the preliminary findings from the study described here provide a strong example of the social and occupational justice issues that must be addressed.

This is such a curious article because for all the platitudes about how the system is not designed to meet the needs of children, there is an absolute shortage of specificity on what the clinician is specifically supposed to do while using this suggested social and occupational justice lens!  First of all, I want to acknowledge that the broken disaster of foster care is absolutely not lost on me and in fact I have studied this extensively.  I have worked directly in these systems for many years.

The article raises many odd points.  As an exemplar, the author states that children in the foster care systems received training for banking and money management but that most participants did not even have a bank account.  I am not certain what OTs are supposed to do about this precisely - many children who are in this population are from very poor demographic groups and they are also over-represented by minorities.  The author states that the children don't trust the banking systems and they did not view the money management information as meaningful, mostly based on cultural differences.  It is absolutely factual that minority and low income demographic groups are un-banked and under-banked at levels approaching the 50-60% level (FDIC, 2012).  In fact, use of alternate financial services (both legal and quasi-legal) is the norm in many of these neighborhoods that I have worked in.  So what exactly are OTs supposed to do about this using our social and occupational justice lens?  Are we supposed to convince an entire culture that they should trust banks?  Should we Occupy Wall Street?  Should we throw in the towel and instead of a money management curriculum we should teach children Pawn Shop Strategies 101?  This is where the article falls flat on its face: after giving us a lens that helps us become outraged about the oppressive banking system that children in foster care don't trust and are not interested in there are absolutely no suggestions about what the next steps should be.

Our old treatment models were just fine.  MOHO itself was just fine.  It helps clinicians frame the problem, the broad general systems theory orientation allows clinicians to understand the big picture, and treatment is directed accordingly to help the person develop skills - and even learn to examine their own values and volitional system that brings them into conflict with the dominant culture.  However, client autonomy kicks right in and the model supports this - it is not our right to force people somewhere they don't want to go.  It is our responsibility to show them their options.  It is their right to choose.

Reed (1984) wrote the classic book Models of Practice in Occupational Therapy.  Although the models listed in the book are moderately dated, the framework she outlined for evaluating models remains highly useful.  In fact, USEFULNESS and PRACTICALITY (p.31) are important concepts that she used to 'rate' the different practice models.

Social justice itself is not a practice model.  It is so poorly described and so frequently misunderstood that at best we can describe it as a concept that academicians are trying to infuse into practice models.  The problem is that there is nothing there to guide practice.  It is not practical and it is not useful.  When we examine the articles in the literature we are told to join protest rallies about water quality, or we are told to become upset because children in foster care don't like the oppressive banking system.  When we ask the Ethics Commission we are told  in their advisory opinion that social justice means we should consider offering services for free.  It is a confused mess of a concept that has no practicality, no usefulness, and it has walked us away entirely from our previously very useful practice models.

So what happened to Kielhofner's measured interest and encouragement to think about keeping our minds open to issues raised by disability studies?  In the years following this initial suggestion we had academicians insert the social justice concept into our Code of Ethics, there have been attempts to re-frame our profession in public health terms, and we have seen encouragement to abandon our traditional models.  There are no social justice practice models to follow - just a strange bandwagon that has caused academics to encourage us to take wild forays into sustainability, politics, climate change, complaints about banking systems and protests against water quality in Kentucky and many other very odd topics.

I think we have taken a wrong turn, and we need to turn back.  I encourage my colleagues in academia to go back and study the Kielhofner article and see how it was a suggestion for measured inclusion so we can be more sensitive.  I don't believe that it was supposed to be a roadmap off a cliff.

As there are folks who will read this who are more attuned to Dr. Kielhofner's thinking than I am, I look forward to their comments on this paper and correcting any misperceptions I might have about his 2005 article.


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.

Federal Deposit Insurance Corporation (2012). 2011 FDIC National Survey of Unbanked and Underbanked Households.   Retrieved July 24, 2013 from http://www.fdic.gov/householdsurvey/

Kielhofner, G. (2005) Rethinking disability and what to do about it: disability studies and its implications for occupational therapy. American Journal of Occupational Therapy, 59, 487-96.

Paul-Ward, A. (2009). Social and occupational justice barriers in the transition from foster care to independent adulthood.  American Journal of Occupational Therapy, 63, 81-88.

Paul-Ward, A., Kielhofner, G., Braveman, B., Levin, M. (2005). Resident and staff perceptions of barriers to independence and employment in supportive living settings for persons with AIDS. The American Journal of Occupational Therapy, 59, 540-545.

Reed, K.L. (1984). Models of practice in occupational therapy.  Baltimore, MD: Williams and Wilkins.

Tuesday, July 23, 2013

Historical roots of occupational therapy: A beginning explanation for the inquiry.

In the previous installment I talked about the curious letter from Dr. Licht to Dr. Copeland, who was the Mayor of Clifton Springs, NY.  It was curious because Dr. Licht was so closely connected to Dr. Dunton, who was a Founder himself and attended the initial meeting at Consolation House.

Looking back at the 50th year celebration of AOTA, we can see that Isabel (Newton) Barton, the wife of George Barton, was alive when Dr. Licht made his initial inquiry in 1967.  She even wrote an article that appeared in AJOT in 1968 about her memories of Consolation House.  This exemplifies the (probable) difficulty of information sharing in a pre-Internet context.  It is difficult to understand any other reason why any 'disconnect' might exist and why Dr. Licht did not contact Mrs. Barton directly from the start.


Mrs. Barton's 1968 article is interesting - and primarily reflects a personal recollection of the particulars of Consolation House.  It is dripping full of context and context imbues meaning into form. Still, these words were written and 50 years later when someone attempts to learn more about the occupational therapy profession's founders there is only general description.  What happens to all of the context that Mrs. Barton shared when we read a sentence in a textbook that 'George Barton, an architect, was one of the founders of the occupational therapy profession????'

I believe that we should have a deeper covenant with our history.  I thoroughly enjoyed Kay Schwartz's (2009) Slagle lecture that breathed some life into the founders, but I am wondering if there is still more for us to consider, or if there is some way to make the history even more meaningful.

It is understandable how in a pre-Internet context we didn't have the resources or abilities to share and it is understandable how we can begin to 'lose' the context of our history - but now we have a new opportunity and perhaps obligation to share the things that we know.  I am hopeful that sharing this information and some reflections will serve others as we examine our history in context of 100 years of existence as a profession.

Words can be evocative, but perhaps presentation can also help to serve that purpose.  Some people state that there is a difference when a book is read as opposed to when the place described in the book is actually visited.  How can we make history meaningful so that it becomes interesting to people who may benefit from the fruits it holds in its branches?  What can we learn about our profession when we study the life of the man who was the first to give it the name "occupational therapy."

This is a primary question I pondered as I planned this series.  While eyebrow deep in study about George Barton I came across a Robert Frost poem titled 'After Apple Picking' :

My long two-pointed ladder's sticking through a tree
Toward heaven still,
And there's a barrel that I didn't fill
Beside it, and there may be two or three
Apples I didn't pick upon some bough.
But I am done with apple-picking now.
Essence of winter sleep is on the night,
The scent of apples: I am drowsing off.
I cannot rub the strangeness from my sight
I got from looking through a pane of glass
I skimmed this morning from the drinking trough
And held against the world of hoary grass.
It melted, and I let it fall and break.
But I was well
Upon my way to sleep before it fell,
And I could tell
What form my dreaming was about to take.
Magnified apples appear and disappear,
Stem end and blossom end,
And every fleck of russet showing clear.
My instep arch not only keeps the ache,
It keeps the pressure of a ladder-round.
I feel the ladder sway as the boughs bend.
And I keep hearing from the cellar bin
The rumbling sound
Of load on load of apples coming in.
For I have had too much
Of apple-picking: I am overtired
Of the great harvest I myself desired.
There were ten thousand thousand fruit to touch,
Cherish in hand, lift down, and not let fall.
For all
That struck the earth,
No matter if not bruised or spiked with stubble,
Went surely to the cider-apple heap
As of no worth.
One can see what will trouble
This sleep of mine, whatever sleep it is.
Were he not gone,
The woodchuck could say whether it's like his
Long sleep, as I describe its coming on,
Or just some human sleep.


What I hope my future installments will show is how we can consider George Barton's life as a parallel to the apple-picker.  I hope that it can be a fair and correct comparison.  There was a richness to his life that the statement about him being an architect simply does not reflect.  That richness can be considered in the apples that he picked, those that he left upon the tree, those that fell to the earth, and those that made it into barrels - full or not.

As I learned more and more about George Barton I felt like I was walking through the scene that Robert Frost described, looking around me at all the work related to his efforts.

That richness is not only important from a historical contemplation of being 'accurate' or 'fully descriptive' but I believe that it reflects the meaning and depth of the occupational therapy profession itself.  In the case of George Barton, the philosophy that informed a man also informed an entire profession - and this is something we should all consider when we stop to wonder 'why' occupational therapists do the things that they do.



References:

Barton, I.G. (1968). Consolation House, Fifty Years Ago.  American Journal of Occupational Therapy, 22(4), 340-345.

Frost, R. (1915). After Apple Picking.  Retrieved July 23, 2013 from http://www.poetryfoundation.org/poem/173523

Schwartz, K. B. (2009). Reclaiming our heritage: Connecting the Founding Vision to the Centennial Vision [Eleanor Clarke Slagle lecture]. American Journal of Occupational Therapy, 63, 681–690.

Sunday, July 21, 2013

Historical roots of occupational therapy: Introduction to a series

edit: For those looking for the full series of posts on this topic, please click on the 'History' button on the 'Labels' or use this link.
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I have been sitting on some historical source material for quite some time.  I have been studying the material extensively, trying to decide the best way to share the information, and at times just putting it all aside out of frustration.

When students learn about the founding of the occupational therapy profession they tend to read simple information in textbooks and it is somewhat devoid of context.  History without context provides opportunity for misinterpretation, and this is something that I believe is important to try to avoid. 

I am not a historian and I am not a biographer and I think this is why I have struggled with how to best present the information.  My motivation was to share this before AOTA's Centennial.  We are well in advance of 2017 and so I hope that beginning to share this information now will help others who are interested in historical reflections as we approach the 100th birthday of the occupational therapy profession.

I have decided to simply share this all in blog format and to do it serially over time. 

This information will tell a story, and I will try to keep my own opinions to a minimum and allow the players to tell their own tales.  When I insert my own opinion I will try to make it very obvious, as opposed to simply editorializing or presenting interpretation as fact.

An interesting place to start examining the historical roots of the profession is in a surprising place - but I will start at that point in time that occupational therapy was celebrating the occupational therapy profession's 50th birthday.  It all started with a blind shot in the dark, a letter written by Dr. Sidney Licht, who was the President of the American Congress of Rehabilitation Medicine and the Editor of Physical Medicine Library.

Before he edited Physical Medicine Library Dr. Licht co-wrote Occupational Therapy, Principles and Practice (1950) with Dr. William Rush Dunton, who was one of the profession's founders.  It is interesting that although he co-wrote this book and was such a notable leader in the profession for many years, it seems evident that a little bit of our history may have been lost or at least not easy to access.  Here is a picture of the envelope written by Dr. Licht as he was reaching out for some information about the founding of the profession:



Envelope of letter written by Dr. Sidney Licht.

As an interesting aside, you will note that there is no ZIP code - the ZIP code system did not start until the early 1960s and many people resisted using the system.  It wasn't until the 1970s that most people felt comfortable using the ZIP code system!

So the year was 1967 and it was occupational therapy's 50th anniversary and Dr. Licht was scheduled to deliver a speech in Boston for the annual conference in October.  He had knowledge that there was a "Consolation House" but was looking for more information.  Here is a copy of the letter he wrote to the mayor of Clifton Springs:





Letter written from Dr. Sidney Licht to Mayor of Clifton Springs, NY



This letter is amazing to me, mostly because in context of 2013 we are in such a different place with regard to being able to access information.  Here we have a strong supporter of occupational therapy who has written books and articles and was even associated with a Founder of the profession, but he did not have the information that he needed for his talk and so he wrote an absolutely blind letter in the hopes of connecting with someone who could provide the information that he needed.  This can be contrasted to how we operate today and how accessible information is.  However, ease of access does not equate to accuracy of information - and I think there is something to be said about dealing with source materials like Dr. Licht did in this letter.

Here is the reply that he received from Dr. Glenn Copeland, who was the Mayor of Clifton Springs where Consolation House is located:


You will have to click on this letter to see it full size and proper resolution.

Dr. Licht reached out and found a great source - and that is where we will pick up the next installment.  So this is the beginning of this historical series.  We are at a time approaching the centennial celebration of occupational therapy, and this installment starts us off with a peek into ANOTHER time that we celebrated a huge milestone and were attempting to 'discover' and 'uncover' and perhaps 'remember' our historical roots.

What will follow is a re-tracing of our footsteps for that 50th year celebration and a re-examination of the role of Consolation House and George Barton related to the founding of the occupational therapy profession.

Friday, July 19, 2013

More on the NYS 'negotiated' rates and what it might mean for the future of the early intervention program

There was some very important information in the Early Intervention Billing FAQ that was distributed via email today:

Q: ­If a provider accepts a lower rate for a payment from an insurance company, the municipality will bear a larger portion of the expense, correct?

A: If a provider accepts a negotiated rate of payment and that payment from the insurer is made in an amount less than the State-approved early intervention rate for the service provided, the ISFA will process payments for the balance due the provider from the escrow account using municipal funds at State established rates for the EIP. Billing providers will receive the full EIP rate for delivered services. If the provider does not accept the negotiated rate, and the insurer subsequently denies the claim for reasons such as out of network provider, then the entire payment will be made from the escrow account.

We have established a policy to refuse the 'negotiated' rate of payment for home based early intervention services UNLESS it is equivalent to the established rates for the EIP.  Most early intervention providers are not aware that standard commercial reimbursement rates have been established based on a Medicare standard that assumes that the visit is occurring in a clinic setting.  Therefore, we are expecting that most of the 'negotiated rates' will be based on pre-existing clinic-based reimbursement schedules.

To date we have not been approached by ANY commercial insurance entity to NEGOTIATE a rate for home based early intervention services.  Therefore, we are operating under the assumption that reimbursements will occur under the existing schedule (which actually does not even account for home based visits). 

We encourage the NYS Early Intervention Program to cease using the misnomer 'NEGOTIATED RATE' unless there is evidence that negotiation has occurred.

The reason why this is important is because of what we posted several weeks ago - please reference the blog post at http://abctherapeutics.blogspot.com/2013/06/remember-what-was-in-2013-2014-nys.html

In summary, again, NYS had every intention of leaving reimbursements up to a negotiated decision between providers and insurers.  The plan was that providers will accept this rate as PAYMENT IN FULL and WOULD NOT SEEK ADDITIONAL REIMBURSEMENT FROM THE FAMILY OR THE MUNICIPALITY.  Please read the Governor's proposal.

Anyone who accepts the insurance company 'negotiated' rate will set themselves up for having to accept that rate if the Governor's proposal as previously advanced ever makes it into law.  In the future, there will be no escrow, and that 'negotiated' rate will be 'PAYMENT IN FULL."

Most insurance reimbursements for clinic based therapy services are at approximately 70% of the early intervention home based rate.  The home based rate is higher, as it should be, to account for travel and other costs associated with providing therapy outside of a clinical/office context.

Accepting 70% as a 'negotiated rate' today will leave the program in a state of absolute decimation if the Governor's proposals are ever made into law.  There will be NO providers willing to provide home based services at that low rate and the system will collapse into a model where only clinic-based services are affordable to provide.

Do not expect that insurance companies will suddenly decide of their own volition to raise their reimbursement rates just because the State pulls out of the system.  It WILL NOT HAPPEN and providers will receive less pay and leave the system and families will go without these services.

This is so clearly obvious and there is no doubt in my mind that lawmakers and administrators understand this dynamic precisely.  Please read the Governor's proposals and develop an understanding of the impact of simply accepting this so-called 'negotiated rate.'

I call upon the Bureau of Early Intervention and the Governor's office to simply COME CLEAN regarding their intentions.  If it is the intention to dismantle the program by driving reimbursements down to the point where there will be no more home based providers - then just say it.  Being dishonest will hurt many families as they end up being in a reactive mode when therapists are not available.  Being honest will allow other systems to step in and make up for what NYS is no longer able to afford, and will allow families to make decisions in a more proactive manner and within new service delivery models.

Although I would not expect it, the Governor could alternately provide some assurance that NY State will support a 'minimum rate' and not attempt another sneaky parachute jump out of fiscal responsibility for the program.  That would leave the integrity of the home based model as it is, would allow providers the freedom to safely 'accept' whatever rates the insurance companies paid, and there would be assurance that the municipality would pick up the rest.

At this point I trust nothing.  The concept of cost-sharing between the insurance companies and the municipality is reasonable and very fair from a policy perspective.  Governor Cuomo tried to pull a fast one and bail out of responsibility altogether - and this should be enough evidence of how little he cares for this program on any level.

Tuesday, July 16, 2013

'Occupation' or 'function' as best descriptors for OT practice?

It is too hot to go outside and do anything and I had to shut down my office as we lost power in a (presumed) brownout so I came to my home office and have been trolling around the Internet all afternoon.  That rarely ends productively, but I was really happy to run across some comments from today's #occhat where there was a debate about use of terminology in the profession.

I want to strongly encourage people to go read the Letter from the Editor in the Spring 2013 Open Journal of Occupational Therapy written by Diane Powers Dirette. In this letter she discusses issues related to terminology in the field related to use of the words 'occupation' and 'function.'

Powers Dirette states that historically OTs have used the word 'function' but this word was replaced with the word 'occupation' in the mid-1990s.  Perhaps not coincidentally, this is the time period when we saw the creation of 'occupational science' as an academic discipline, something I recently discussed in my 'Fourth of July' message.  Powers Dirette states that as the occupational therapy profession embraced a new term, other professions were quick to use the word 'function' in describing their services.  I was very interested and surprised at her report that "An ArticleFirst search for the keyword “function” for the year 2012 results in 3,105 articles. Only seven of those articles are from OT sources, and those seven are from the British Journal of Occupational Therapy."

A search of the word "occupation" in the same time period yielded 88 articles, of which it is reported that only ONE as it is defined in our profession, and all the others referring to "work or the taking over of land or space."

That sure is surprising to me.  I am not personally very familiar with the ArticleFirst database so I don't know if that has anything to do with the search results.  I tried to use a similar search strategy in Ebscohost and using the Medline and CINAHL databases specifically but was overwhelmed with the number of articles - it would take a rather substantial effort to sift through the results of that search within the Medline or CINAHL databases.

The premise that Powers Dirette raises is still interesting though, particularly because there was some rather lively debate on the OT Connections site back in 2009 related to the AOTA 'branding' campaign.  At that time the new OT 'brand' was rolled out with the tagline 'Living Life to Its Fullest' and there was some measure of disagreement if this was the proper way to describe the essential nature of our services.

At that time I made these comments about the concept of 'branding:'

Brands are symbols and experiences used for recognition - and as such the poster that was unveiled was a collection of symbols and (presumably) representative consumers who were 'happy' with their OT experience/interactions.  Images are unpredictably evocative and I think you have already received a wide sampling of responses to the images.  Some like them - others don't.  Perhaps that isn't the bottom line problem.

I hear people saying that although the poster might convey a feeling that is positive, it still leaves people with a sense of "OK, I feel good, but what do I feel good about?  Do I feel good about a Blackberry?  Or will that glass of water be refreshing?  Or am I glad that I have a full tank of gas?"

So if the purpose of branding is to generate recognition based on symbols or collected feelings/experiences, one of the problems here is that there may be only a weak connection between these images and occupational therapy - and it that sense, at this stage, it 'feels' a little lacking.

First stage or not, as occupational therapists we all know about the importance of understanding within context.  Context, in this instance, supplies fuel to the initial fiery response of "What does that poster mean anyway!"  There are some contextual accelerating factors to keep in mind.

1. If we are embarking on a branding campaign, it seems reasonable to believe that we should have a common 'product' upon which we can agree to develop symbols, etc. around.  Do we have such a common product?

2. Questions about the commonality of our 'product' are significant.  Some have commented about their perspective that the Practice Framework doesn't translate to practice.  Others have commented about 'elephants' in the room regarding intervention modalities.  Others have commented on the concept of "who wants to define 'full' for another human being??'  Others have commented that maybe OT is less about 'feeling good' and more about 'hard work and achievement.'

I have blogged about apparent disconnects between our professional journal and everyday practice.  This was underscored in President Moyer's comments that OT literature "is not really about simple engagement back into doing."  What are practitioners left to think OT is when the AJOT is full of articles about water quality and factors associated with obesity - and the OT Practice is about Disaster Relief - and the President is asking us if our universities and state associations are doing enough to combat hunger?  All of these issues are important, and require attention, and in all reality do impact people's occupations... but everyday practitioners may be finding it difficult to relate to this 'brand' of OT that seems to be slightly off focus from what most people are actually experiencing in their OT careers each day.

So we can pick any of these as a jumping off point - there is so much rich data in those comments that I think we could start anywhere.

None of this means that we need to change anything with the branding campaign necessarily.  However, it doesn't make sense to have a branding campaign unless we are all standing on the same ship that we are trying to brand.  Developing that sense of commonality and having conversations about some of these concerns might go a long way in building consensus and support around a branding strategy.

The process for the re-branding campaign reportedly included a guided process by 'BreakWhiteLight' which was the public relations firm that AOTA contracted with.  It was reported that they surveyed a large number of OT leaders, practitioners, and other constituents and by the debates that ensued on the OT Connections site I believe that AOTA leadership was taken a little off guard by the negative response to the branding campaign by some members.  It is difficult to provide all of the direct references on these debates because of the organization of the OT Connections site, but if you go to that site and type in 'branding' in the search box you will be able to view quite a bit of representative conversation in blogs, discussion posts, etc.

All of this is relevant because I expect that after several years of a branding campaign where we are supposed to be rallying practitioners around common definitions of 'what we do' that it seems that we are just not 'there' yet.  That is a problem.

The reason why I went back and quoted myself about the branding issue is because the problem that I pointed to back in 2009 is something that we apparently need to continue to attend to, particularly if the Powers Dirette argument that we are not self-defining in a clear fashion is true and has merit.  The question remains: Do we have a common product?  Is it occupation - or is it function???  Or something else???

Whatever our product is, I am not certain that we have done enough to capture and communicate 'what we do' correctly.  Powers Dirette states that a review of 'OT definitions' on hospital websites indicates that more are using the word 'function' as compared to 'occupation' in a rather lopsided distribution.  The AOTA branding campaign has not served any purpose of promoting 'occupation' which has been so heavily favored in our academic literature and conferences.  She states, "there is a disconnection between the published literature from the academic arenas and the language used in clinical practice."  That is a rather powerful statement to make.  Powers Dirette goes on to advocate for the use of the word 'function' as it represents 'plain language' that is easily understood by the public.  She states that the word 'occupation' is professional jargon that is not particularly clear to consumers.

In fairness, it is important to note that it does not seem that the branding campaign was intended to promote a single word as a descriptor, but it was supposed to rally us around a concept.  Did we choose the correct concept?

So here we have a reflection point:  Does Powers Dirette make a legitimate argument?  Has our branding campaign been effective or ineffective?   Do we need to make course adjustments?

I want to thank Powers Dirette for an excellent Letter for us all to consider, and also thank the #occhat folks for bringing it to broader attention.  I hope that this blog entry will also spur some additional conversation about the issue.



References:

Powers Dirette, Diane Ph.D., OTL (2013) "Letter from the Editor: Let’s Talk about Function," The Open Journal of Occupational Therapy: Vol. 1: Iss. 3, Article 1. Available at: http://scholarworks.wmich.edu/ojot/vol1/iss3/1

Monday, July 15, 2013

Emails about early intervention while I was on vacation!

I was on vacation last week and had MANY emails about early intervention and billing in my inbox.  The most interesting one was from Chris Weis who states that he is a product manager for some billing software that is sold by the interim State Fiscal Agent for the NYS Early Intervention program.  It was my favorite email so I thought I would share my response that I copied to the EIP as well.  His initial email is in blockquote below.

For background, I will again mention that I think transparency is important and that is why I post this information.  This blog is not chock full of great ideas about treatment activities that kids love.  We provide that elsewhere on our Facebook and Pinterest sites - but this blog format is for communicating serious things.  This information is not for the faint of heart.  It is not intended to celebrate the wonderful job that providers do with children - but it does show how the system is currently threatened - and many families may not be aware.  Since these programs are municipally funded it is imperative that we all have awareness.

There is an underbelly to health care - and this is what it looks like.  This represents and demonstrates issues of how the NYS Early Intervention System has been disrupted with recent legislative and administrative rulemaking changes. 


______________________________________________________


Dear Mr. Weis,

I am very confused about why I am getting an email that seems to advertise your products.  Words like "a robust user-designed system that manages all facets of agencies and schools such as yourselves working with programs including EI, CPSE and CSE" would not need to be included if you were only wanting to share procedural information on billing through the EI program and acting as the interim State Fiscal Agent for the program.

As we receive MANY emails about the early intervention program each week, and as it has been challenging to sift through this very complex set of new requirements and processes, having email that seems to be simply advertising your products was very confusing.

It seems unlikely that it is appropriate to be using a list of BEI-approved service providers and agencies to troll for new business - if that is what is happening - it is rather confusing.  I have cc: the Early Intervention Program on this so they can comment in case they can help clear this up.

I am sure they have a lot that they could comment on.  Based on reports and posting from the United New York Early Intervention Providers Group on their Facebook page, they are stating that Brad Hutton the EI Director will consider writing letters of financial hardship for those providers who are still awaiting payments.  I attempted to verify this with the Bureau of EI directly and they transferred me to a line that they said they were told to direct people to who have such questions.  Surprisingly, it went to voicemail where they suggested that you just ask your questions in email.  It would seem to be such an important issue that they could answer directly, but these are odd times, so who knows?

I've been thinking that since the New York State Bureau of Early Intervention is being so helpful to service providers maybe we can order your products, and then have Mr. Hutton write you a letter to explain why we can't pay for it?

I understand that you sent information about YOUR ROBUST USER DESIGNED SYSTEM  how to manage these new systems because you have our best interests in mind.  Thank you very much for your consideration, and if by any small chance this was an attempt to procure new business can you please remove my email from your SPAM advertising lists and keep any communications to us related to your function as the interim State Fiscal Agent for the early intervention program?

And since I may have your attention I will just mention - any extra resources that your company could direct toward facilitating payments to providers and agencies would also be appreciated.  There is a whole lot of ugly out in the community right now when it comes to people needing payments for services they provided many months ago. 

I am just some random blog writing guy in Western NY, and people are emailing and calling my office asking me what they should do.  I try to direct people to the proper resources, but you know, what can I tell them when I know that they will just be sent to voicemail or that if they sign up for email lists that they might get spam advertising?

Thank you for your consideration.

Christopher J. Alterio, Dr.OT, OTR
ABC Therapeutics
11390 Transit Road
East Amherst, NY  14051
(716) 580-3040
(716) 580-3042 (fax)
chris@abctherapeutics.com

ABC Therapeutics Website!
ABC Therapeutics Blog!
Like ABC Therapeutics on Facebook!



From: "Weis, Chris" <cweis@JMcGuinness.com>
Sent: Thursday, July 11, 2013 5:00 PM
To:
Subject: FW: EIBilling.com / Claims Integration Procedures
-->
Hello,

My name is Chris Weis and I am the product manager for the County-Linked Agency Information Management System (CLAIMS), a robust user-designed system that manages all facets of agencies and schools such as yourselves working with programs including EI, CPSE and CSE.

Recently we sent out the attached pdf file to all providers who are using our software as guidance as to what we, the CLAIMS team, recommend they do each day when they log into the www.xxxxxxxxxx.com.  (edited, CJA).

We think that you could find most of the information useful, whether you use our software or not and so that is why we are forwarding this to you.  The only column that might be a little confusing is the “In CLAIMS…” column.  Specifically, this refers to the CLAIMS software that our clients use to manage their business, but you might still be able to adapt it to fit your system for the billing, payment downloads, tracking and such.

Chris Weis
Product Manager, CLAIMS
James McGuinness and Associates


Thursday, July 04, 2013

A Fourth of July message for the occupational therapy profession


I write this second installment regarding public health in an attempt to document the pathway that the occupational therapy profession has taken with regard to its perspective on client autonomy, client-centered occupational therapy practice, and now calls to move toward public health models of intervention.

An analysis of this topic can correctly start all the way back to the founding of the profession - including conversations about the musings of George Barton as he convalesced from tuberculosis - but for purposes of controlling the length and depth of the analysis I feel comfortable restricting the conversation to what I will label as the modern period, beginning in the 1960s.  It is during the 1960s that important leaders and theorists promoted a return to the philosophical roots of the profession and a re-focus on occupation and habits which functionally reflects a respect for our philosophical core.

There is too much volume of material to be absolutely complete so I will pick pertinent issues that I hope will fairly illustrate and document the footsteps.

A modern analysis can begin with acknowledging Mary Reilly's Slagle lecture.  Everyone knows the famous quote from that lecture so I won't use it because I think that we have become numbed by seeing it so much.  Instead I want to bring attention to what she says AFTER that quote.  She states that the central idea of occupational therapy falls into a class of ideas that is so great that it advances civilizations.  She states that the core construct of occupational therapy is "that man, through the use of his hands, can creatively deploy his thinking, feelings and purposes to make himself at home in the world and to make the world his home."

What would make Mary Reilly believe that this concept is so great that it could advance a civilization? I believe that at the core of this concept she understood that there was the deepest respect for the autonomy of human beings.  This concept of autonomy did advance a civilization; I am posting this analysis on July 4th for a reason.

Autonomy can never be pure or absolute for many moral and ethical reasons that are constantly debated.  Still, the core idea of respect for autonomy in itself is an extraordinarily powerful construct to base a profession around.  Mary Reilly wanted the profession to test her hypothesis about the action orientation and autonomy of humans.

In 1966 Elizabeth Yerxa's Slagle lecture was entitled "Authentic Occupational Therapy" and she highlighted the concept of autonomy throughout the lecture.  She stated "Authentic occupational therapy is based upon a commitment to the client’s realization of his own particular meaning. The authentic occupational therapist recognizes that although initial dependency might require a temporary suspension of the patient’s right to choice, the therapeutic experience is primarily an opportunity for self-actualization. Therefore, the occupational therapist does not force his value system upon the client. But rather, through using his skills and knowledge, exposes the client to a range of possibilities which constitute his external reality. The client is the one who makes the choice."

Again, absolute autonomy from a technical standpoint is very challenging, but the point here is that Yerxa also expressed deep respect for the concept.  Here is another quote from her lecture that is worth considering: "This active role of the occupational therapist in helping the client delineate his choices takes more knowledge, skill and sensitivity plus more faith in the individual than an authoritarian role of “you must do this because it is good for you."

Here is a final quote from Yerxa about the nature of man: "We are viewing the client, not as an object or thing to be manipulated, controlled or made to conform but as a unique individual whose very humanness entitles him to choices in determining his own destiny. For if the client interprets himself as a thing (one thing among others in the world) he might sacrifice his selfhood and neither recognize nor realize his potentials."

Reilly and Yerxa took what I believe to relatively unequivocal stands on the nature of human agency and autonomy.  These beliefs fueled theory development through the 1980s with Kielhofner's Model of Human Occupation and also subsequently informed creation and growth of 'occupational science' as an academic discipline in the 1990s.   Yerxa's ideas in particular also contributed to the entire notion of 'client centered practice' that was introduced by Mary Law in her book on the topic.

There were early debates about whether or not there were dangers in creating occupational science as a separate academic discipline.  Particularly, Ann Cronin Mosey wrote a very controversial proposal to separate occupational science from occupational therapy entirely.   Mosey was concerned about several issues, including the possibility that occupational science would generate basic research that did not speak to the applied research needs of clinical practice.  This proposal was subsequently countered by Clark, et.al. and here it is interesting to take careful note of some statements made in defense of their position.  Clark, et. al rebutted the notion that basic and applied research had to be defined in absolute dichotomy, which is a point that generated a lot more debate on continuous vs. dichotomous research models.  I think that the conversation got so confusing that some people tuned out at that point.  However, review of some of their defense in context of our current standing with regard to the drift away from the philosophical core of the profession is interesting.  They wrote: "We feel that Mosey exaggerated greatly when she speculated that such outcomes as occupational therapists confusion over the identity of their own discipline or the pursuit of poorly focused research would result if occupational therapy and occupational science were not completely divorced."

Following the Mosey and Clark, et.al. debate there was no division between occupational science and occupational therapy.  Instead, we almost immediately began to see different messages coming out of the occupational therapy literature and from academics.  One very clear example that served to portend the future was an article by Townsend, Langille, and Ripley in 1993 that began taking steps back away from the notion of client centered practice.   I have pointed criticism about this article, but I believe that the author's argument about the challenges of client centered practice can be summed up in the simple statement of, "This is too hard to do!"  With the level of detailed analysis applied to the specific case and the use of ethnographic analysis to try to frame their problem, I can't help wonder that if just a fraction of that same effort was directed toward trying to generate solutions that there would have been no need for the article.  So, with one fell swoop, we began to see the decimation of the client centered concept.  This quote from the article is interesting: "Given the drive by people with disabilities to become more empowered in their everyday lives, does it make sense for occupational therapy to work for institutional change or to abandon client-centered practice as too idealistic and too unrealistic in the real world?"

In the mid-1990s as this was being played out and we have to consider the impact of the Internet and globalization of the profession.   Occupational science became a world-wide academic discipline, and we saw heavy influence from international scholars such as Elizabeth Townsend and Ann Wilcock.  Suddenly we were contending with concepts of occupational justice, sustainability, climate change, and broad public health.  The academics of the profession changed dramatically as we absorbed all of this and pushed the profession into the masters and now the doctoral level of training.


In my opinion, this globalization generated a new wave of occupational therapy academic thinking that has since provided us with a vision of occupational therapy practice that is very unlike and often at direct odds with our philosophical core that respects autonomy and human agency.  The occupational therapy profession has taken a sharp turn off course.  I will readily admit that this is an American perspective and opinion, but it is not intended as protectionism as it is based on an analysis of our philosophical core and on the statements of some of our most important theorists.

It is very interesting to analyze Clark et.al.'s article in context of present-day practitioner statements about the equivocal value of some research published in the American Journal of Occupational Therapy, the statements made to AOTA in their business meetings that the annual conference does not have enough practical information for clinicians, that the AOTA itself is over-represented by academicians and students (who are often mandated to join by their academic programs), that there is vocal opposition to such issues as inclusion of social justice in the AOTA Code of Ethics, and most recently the concern about adoption of public health models that are not aligned with the philosophical core of the profession and respect for autonomy and human agency.  Perhaps Mosey had a point after all?  Has occupational science, as a global academic discipline, steered us off course?

Clark addressed the basic vs. applied science debate in her 2013 Ann Cronin Mosey Lecture and defended occupational science as now being a 'translational' science of everyday living - but at the same time acknowledged that not everyone agreed with her and that the plurality that is now occupational science represents a wide range of thinking.  I believe that is an understatement, because even if Dr. Clark is attempting to keep her occupational science work practical - we can easily follow the footsteps of this entire process and see that occupational science has taken us away from our philosophical core - particular in the influence from international scholars.

So now we are deep into debates about social justice and public health - concepts deeply embedded within the international occupational science literature.  Public health, just like social justice, is based on the notion of egalitarianism.  Application and respect of autonomy is often very challenging within the public health context.  Buchanan wrote an article that all OTs who are quick to jump to a public health model should read.  The article outlines (in a fairly even handed fashion) the intertwining concerns with autonomy and paternalism as it relates to  activities conducted within a public health context.  Buchanan provides an excellent reminder of the apparently forgotten idea that the best strategies to promote health occur through the autonomous and informed decisions of people in action.

That notion of autonomy is an original American ideal.  Globalization has taken us sharply off course of our original principles.

Autonomy and human agency were ideals that Mary Reilly said could move a civilization and on a smaller scale could move a profession.

We have such a rich theory base, but it is being abandoned for something else.  This theory base has been discarded by proponents of social justice and public health, because apparently to wave this flag of autonomy and free agency is just 'too hard.'  It is apparently easier for some to create a dogmatic and oppressive authority over others and to tell them what is good for them.  It is apparently easier to try to be a planet-saving freedom fighter based on someone's paternalistic ideals of what that means and how it should be constituted.

We have failed to prove Mary Reilly's hypothesis.  What could have been the greatest idea in 20th century medicine is currently being sold out to a global model of paternalism and egalitarian justice.

Maybe there are people who would label this progress.  I label this abandonment of principle, despite the efforts of some academicians to keep the discipline pragmatic and relevant.



References and background reading:

Buchanan, D.R. (2008). Autonomy, paternalism, and justice: Ethical priorities in public health. American Journal of Public Health, 98, 15-20.

Clark, F. (2013). NYU Steinhardt Department of Occupational Therapy 2013 Anne Cronin Mosey Lectureship.  Accessed July 4, 2013 from http://vimeo.com/62729507 

Clark, F. A., Zemke, R., Frank, G., Parham, D., Neville-Jan, A. M., Hedricks, C., Carlson, M. E., Fazio, L., and Abreu, B. (1993). Dangers inherent in the partition of occupational therapy and occupational science [The issue is]. American Journal of Occupational Therapy, 47, 184-186.


Kielhofner, G. (2008). Model of human occupation: Theory and application (4th ed.). Philadelphia: Lippincott, Williams & Wilkins.

Law, Mary (1998). Client Centered Occupational Therapy.  Thorofare: Slack, Inc.


Mosey, A.C. (1992). The Partition of occupational science and occupational therapy. [The issue is]. American Journal of Occupational Therapy, 46, 851-853.


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.

 Yerxa, E. J. (1985). Authentic occupational therapy: 1966 Eleanor Clarke Slagle Lecture. in AOTA (Ed.), A Professional Legacy: The Eleanor Clarke Slagle Lectures in Occupational Therapy, 1955-1984, (pp. 155-174). Rockville: AOTA.

Wednesday, July 03, 2013

Will a public health model make occupational therapy more relevant?


I just finished watching the COT 2013 Annual Conference plenary by Michael Iwama.  You can listen to his lecture by clicking here.  Hopefully we will have accompanying slides in the near future.  I was very anxious to listen to this presentation after watching the Twitter feed coming from the conference that included statements about our 'preoccupation with the individual' and that our 'practice has stalled' and that we were at a crossroads where we had an opportunity to take on a new role in a broader public health initiative.

I was a little concerned about some of these statements and was not sure that I agreed.  I am in the beginning stages of my own Twitter-acceptance and was not sure if those conference tweets fairly represented the presentation.  I am happy to report that the quotes and concepts that people were tweeting from the conference were actually quite accurate and representative of the presentation.

I encourage people to listen to the whole presentation, but if you can't I will summarize it as briefly as I can in outline format:

I. Question: Is occupational therapy functioning near our capabilities and are we a relevant profession?
II. Current problem: We function from the perspective of individual embodiment, from the medical model, and our practice is shaped more by policies and remuneration than by good theory.
III. Statement: We have had good theory development (OB/MOHO/OS)
IV. Analysis: We are  hampered by our frameworks, we are not relevant, and we are not responsive enough to needs.
V. Reasons: We are stuck in understanding problems from what Durkheim's described as the cult of the individual.
VI. We need to focus on meta-environmental factors that shape people's life-course such as:
       - social factors - we need to adopt postmodern and relativistic perspectives
       - economic factors - we have to understand that globalization (Monsanto/Exxon/etc) impacts us
       - environmental factors - we have to understand how climate change, catastrophe, and oil dependence impacts us
       - technology advances - our use of technology and communication impacts us.
VII.  The public health model is our new choice so we can be relevant.  The community is our patient and changing society is our goal.
VIII. How can OT contribute to public health?  We should DO OT on the field of public health.
IX. Health disparities in affluent societies are unconscionable.  WHERE IS OT?
X. Role-emergent OT practice is a new path to relevance.  We do good work on the medical path and we still need to be there, but will we walk this new path?

The presentation was a little thin on examples, and Dr. Iwama expressed that he would need more than the time allotted to more completely express what clinicians and researchers and administrators need to do.  I am hopeful that we will learn more about specific public health interventions in the future.

The central question of relevance is what I would like to explore first and will be the focus of this particular post.  Is it possible that I am not relevant, or that my practice is not relevant - and I just have not noticed?

Relevance is an interesting concept.  The question of relevance is a question if something is practical, or if it is at all material to the problems at hand.  The charge of irrelevance or of being less relevant than what should be is a rather serious charge and is worthy of exploration.

In a free market, relevance can be measured by existence - because if something is irrelevant than certainly it will not persist unless it is propped up by something else.  Alternately, if something is not as relevant as it could be than it is likely that it would not flourish or that if it did manage to exist it would be weak or perhaps sickly and something else could be seen as being much more healthy.  We can use these metrics to determine if occupational therapy has any relevance.

I am not sure how to apply some measurement to the entire field of occupational therapy so I will apply Fuller's Guinea Pig B methodology to the problem.

My occupational therapy clinic, which is quite humble, has persisted as my primary means of economic sustenance in a free market context for thirteen years.  It has not been propped up by anything other than the fact that people walk into my front door and transact business with me.  I provide an occupational therapy service and then I receive some money.  In order to be practical I need to listen to the people who come into the front door and I need to meet some need of theirs that is valuable enough to them that they would engage a transaction.  In a broader sense, 13 years of continuous operation is a metric I use to conclude that people have perceived the transactions as relevant - meaning that I provided something practical that was material to their problems at hand.

What have those transactions consisted of?  Here Guinea Pig B methodology is helpful because I can very explicitly report what I do and I can do so with absolutely no reporting error.  I can report that I have provided individual occupational therapy services to people of all ages who have needs ranging from developmental disabilities, learning problems, accidents or injuries, emotional problems, and many other conditions that could probably be labeled within a 'pathological' or 'medical' context.  I can report with absolutely no error that the focus of those occupational therapy services has been related to the impact of those conditions on the occupational problems of concern to the individuals and their families.

I have reported relevance from an economic argument of continuity of existence in a free market context, but there have been other points of evidence about relevance along the way.  Here are a couple I can think of off the top of my head just from this week:

1. We received an envelope in the mail yesterday from the parent of a child who had very constricted tolerance for foods.  After a short course of therapy the child made great progress and was discharged.  On the envelope the parent wrote: "We miss seeing you so much but we are doing GREAT!"  I interpret this message written on the envelope as a sign of relevance, because if we were not relevant the parent might have written "Take this money that I owe you and shove it - this was all a ripoff and not helpful at all!"  I think that the fact that the parent was happy to publicize her gratitude and well wishes on the front of the envelope is a rather powerful message about her perception of our relevance.

2. Today a parent told me, "I really think that Jasmine will be ready for school in September.  I did not think that before, but you have helped us so much."  Jasmine's progress in therapy has even surprised me it has been so dramatic - and I actually credit the parents for most of the work because THEY are the ones who were so willing to follow through on recommendations and were so diligent in changing  routines at home.  When I analyze the situation I understand that it was the partnership that made all the difference, and I know that my recommendations were relevant to their needs - the proof is as plain as that child's kindergarten readiness.  Very powerful evidence.

Interestingly, I believe that these examples indicate that we were responsive to the needs of the people who were asking for services, EVEN THOUGH the families self-defined their problems from the perspective of the 'cult of the individual.' 

There does not seem to be any evidence that we were hampered by policies or remuneration.

These families did not define their problems in any post-modern terms and they did not ask me to deconstruct their lived experience.  As a former participant in occupational therapy doctoral studies I am fully competent in the academic playground of hermeneutic analysis and narrative interpretation but really all these parents wanted was for their children to eat healthy foods and to be ready for kindergarten.  They parent of the child with feeding problems was not overtly concerned about globalization and whether or not Monsanto was genetically modifying their wheat.  I don't recall any conversations about climate change.  I tried to attend to their needs, to be RELEVANT, and I just didn't notice any of these meta-environmental themes expressed as being of primary concern.

If I think about it, I would have to state that the intervention was relevant and it was responsive to their needs.

This leads to some questions.  If it seems evident that the intervention was relevant and responsive to their needs, why do academics in the occupational therapy profession worry so much that occupational therapy is not relevant and responsive to people's needs?

Some of my favorite occupational therapy 'textbooks' are those written by Cheryl Mattingly.  If I am remembering correctly, she is an anthropologist by training.  In her books she explores in great detail how occupational therapists meet the needs of their patients, in both explicit and implicit ways.  Maybe some of the academicians should read Mattingly's books again - and maybe they should come visit my humble little clinic for a little dose of Guinea Pig B evidence.

I would like to challenge occupational therapy academicians to provide some evidence that occupational therapists are failing to meet the needs of their patients and are not relevant.  It would seem to be important to provide some evidence to support this theory before we embark on some whimsical traipse into a public health experiment.

Perhaps, somewhere, there are people who are quite angry at their occupational therapists because the OT was focused on something silly like teaching them how to get dressed after they had a hip replacement, when the real issue at hand was whether or not getting a hip replacement at all was fair given all the health disparities on the planet and also whether or not recommending adaptive equipment was just propping up the medical-industrial complex and driving up health care costs unnecessarily.  Maybe the patient really wanted the OT to partner with them on a letter writing campaign to their politicians to protest the lack of social justice that contributes to these problems?

I hope this will serve as a springboard into a long conversation about whether or not occupational therapy as currently constituted is relevant enough and meets the expressed needs of those seeking services.