Wednesday, May 07, 2014

Emmanuelism provided the Core Values to the developing occupational therapy profession

As part of a multi-year research effort into the nature of Social Justice I have been participating in an lengthy conversation about this topic on the OT Connections forum, which is an official message board for the American Occupational Therapy Association.

From the beginning of the discussion some have claimed that Social Justice is a Core Value in occupational therapy.  This has been a difficult claim to validate, because there does not seem to be a a standard definition of 'Core Value' just as there does not seem to be agreement on the definition of Social Justice itself.
"In 2003, members of the AOTA Representative Assembly Coordinating Committee recognized that the philosophical and historical roots of occupational therapy were not known to all occupational therapy professionals. In response, the 2003 RA adopted a motion to form the Ad Hoc Committee on Historical Foundations, which was chaired by Kathlyn Reed and included Suzanne Peloquin and Christine Peters. The subsequent series of articles, published in OT Practice magazine, illustrate how events and societal values of a given time period influenced the role and practice of occupational therapy."

 Unfortunately, Social Justice is not mentioned in Dr. Reed's 'Values and Beliefs' series, and Justice itself is barely mentioned in these documents.  I believe that the reason Dr. Reed did not find a focus on justice is because there was no focus on justice.  Simply stated, this was not a driving philosophical point for the profession.

A bioethicist on the AOTA Ethics Commission has stated "My recollection of our discussions during my tenure on the Ethics Commission, is that the concept of social justice was incorporated secondary to the vast literature within our profession and articulating healthcare discussions which identify social justice as central to the profession’s core values."

The obvious question is that if Social Justice is not a Core Value as identified in the AOTA Values and Belief Series, then how did the Ethics Commission believe that there was a "vast literature" that said social justice was a Core Value?  This is very curious.

Social justice is a newer term that was just added to the 2010 AOTA Code of Ethics:

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 and 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 insociety (Braveman and 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.

Many of the principles previously identified as 'Beneficence' in the 2005 code were simply re-labeled and placed under Social Justice in the 2010 code.  What was removed from the definition of Social Justice was the obvious reference to political rights, as identified by Beauchamp and Childress. Additionally, there is a failure to identify that Social Justice is chiefly a political term, and has been identified repeatedly as an expression of liberal entitlement along with a morality that requires some people to pay for those things that other people think they should have.

As is eloquently expressed in the video linked here Social Justice becomes a mixed sense of entitlement based on a variety of factors - right to just about anything, as long as it is desirable.  Given that living conditions at the time of the OT founding were so challenged (poverty, chronic illness, rise of industrialism, World War I, loss of agrarian life, and so on) there was a lot of understandable desire for improvement.

There were many 'social movements' occurring at this time to counteract the changes people were experiencing during this 'Gilded Age.'  Most of these movements were taken up by the social elites and were based on charity, philanthropy, and Christian Ethics (as expressed philosophically via Pope Leo's Rerum Novarum and popularized through specific religious efforts like the Emmanuel Movement and the lay efforts of the Arts and Crafts Movement).

A lot of change was desired.  A lot of effort was undertaken to effect those changes.  However, these efforts were not undertaken in a Rawlsian definition of Distributive Social Justice.  They were undertaken in a Christian Ethic that guided charitable deeds.

So when Jane Addams started her settlement house work it was not based off of governmental largesse and re-distribution of resources.  It happened because of philanthropic efforts.  It was not until her program became DEPENDENT on governmental distribution that Hull House ultimately was destroyed.

When Elwood Worcester set up treatment programs for people who had tuberculosis in the slums of Boston, it was not based off of governmental largesse and re-distribution of resources.  It happened because of philanthropic efforts.

When Jessie Luther made the long trip North to Newfoundland it was not based off of governmental largesse and re-distribution of resources.  It happened because of philanthropic efforts.

When Phillip King Brown traveled to San Francisco and did his work in the Arequipa Sanitorium and helped to rebuild the city after the Great Earthquake it was not based off of governmental largesse and re-distribution of resources.  It happened because of philanthropic efforts.

Why is it that occupational therapists have come to believe that social (distributive) justice is a correct way of understanding the philosophy and ethic behind these efforts?  They make this mistake because they MISLABEL ANYTHING THAT IS DESIRABLE AND GOOD AS SOCIAL JUSTICE.

As an exemplar, I encourage everyone to go read Harley and Schwartz (2013) Philip King Brown and Arequipa Sanatorium: Early Occupational Therapy as Medical and Social Experiment.  American Journal of Occupational Therapy, 67, e11-e17.

The premise of this article is that Philip King Brown established social justice as a core value in occupational therapy when he founded a tuberculosis sanitarium in 1911.  The authors claim " It is noteworthy that he was a pioneer in advocating for occupational justice 100 years before the term was introduced into the occupational therapy lexicon."

Just at face value, isn't it a little odd that someone can pioneer something 100 years before there is even a word to describe it?

Although it is true that men and women had very divergent 'cure pathways' for tuberculosis in the early 1900s, this had more to do with social status, expectations regarding role behavior, and perceptions on what was respectful of different gender roles at that time.  These differences between men and women's cure pathways is explored in great depth in Sheila Rothman's (1994) book: Shadow of Death: Tuberculosis and the Social Experience of Illness in American History. New York: Basic Books.

That Philip King Brown founded a tuberculosis hospital for women in California in 1911 had more to do with exigent realities of women's health following the Great California Earthquake then it did in trying to resolve some fundamentally unjust context where 'chasing the cure' was biased in favor of men.  Here we see the bending of history to suit a current Social Justice narrative - where the premise of those favoring Social Justice models believing that building a sanitarium for women MUST OF COURSE be due to the need to correct some Social Injustice against women.

Of course, "occupation work" as it was called back then was not even codified into the discrete profession of occupational therapy, Philip Brown King was a medical doctor and not even a direct 'Occupation Worker," and the founding of the profession did not even occur until 6 years after the sanitarium was built.  It seems to be a stretch to say that the generic "occupation work" within this particular institution had anything at all to do with specific occupational therapy much less some newborn concept of Social Justice that we wouldn't even know how to label until Rawls came up with his definition 60 years later.

I am NOT criticizing the significant efforts and humanitarian work of Dr. Philip King Brown.  I am just questioning that it was all done to serve a Social Justice narrative that didn't yet exist and for a profession that was not yet even named.  The reality is that the methods used at Arequipa were no different than those used at any other progressive Sanitarium of that day that had adopted a 'work cure.'

The authors of this article also state, "To our knowledge, Brown is the only one of the founding generation of occupational therapists to explicitly champion the cause of social justice by creating a program specifically for the underserved."  There are several logical flaws with this statement.  First of all, Brown was not an occupational therapist or even an occupation worker.  He was a doctor who was in charge of the sanitarium.  Second, it is unfortunate that the authors did not find any of the dozens of sanitariums that were set up and established specifically for the 'underserved.'  A prime example of one such sanitarium was The Pickford Sanitarium which was founded much earlier than Arequipa and was devoted to the care of African American people who had tuberculosis.  Of course there is also Jessie Luther's efforts, mentioned above.

And of course there was also the work of Elwood Worcester and the Emmanuelists in Boston, also mentioned above.  And there was Dr. Henry Foster who founded Clifton Springs Sanitarium and Dr. James Mumford and his efforts to bring Emmanuelist philosophy to the Clifton Springs Sanitarium - and I hope that most people know what that led to! (Adams, 1985).

There were many others.

The development of these tuberculosis sanitariums and the spread of 'occupation work' was not because of an unjust distribution of care resources.  They were developed based on the humanitarian desire of people to help other people.  Attempting to frame the humanitarian motivations into some re-configured social justice narrative is factually incorrect.

The Social Justice philosophy does not fit the reality of what caused these Sanitariums to be founded.  They were not founded because of some sense of unjust distribution of care.  They were founded because of the severe problems that tuberculosis caused to society, the threat that the disease posed to every single person, the need to redirect the energies of a disabled and "invalid" generation back into productivity, and of course (perhaps most importantly) the humanitarian desire to help other people.

The analysis in the Arequipa article is an example of how history is bent to serve the political narrative of the Social Justice Experiment.

What is left out of the analysis is that Dr. Philip King Brown was visited by Elwood Worcester in January and February  of 1909 (Worcester, 1932).  Dr. Brown and Worcester both hailed from Boston and were good friends, and in fact the work cure that was promoted by Brown was a direct copy of the Emmanuelists.  This is further documented in the subsequent San Francisco visits of Dr. Richard Cabot in 1912 (Quiroga, 1995) who was also a proponent of the work cure.  

It is not mere coincidence that Dr. Brown was visited by Worcester himself who founded the Emmanuel Movement and Dr. Cabot who was among the first MDs in Worcester's circle who was promoting this method.

The Emmanuel method was not based on any conception of Social Justice.  There is so much rich documentation of what it DID stand for that to make any claim other than that Dr. Brown was an Emmanuelist is simply a matter of historical distortion to fit a political narrative.

In order to understand the VERY DIRECT impact that the Emmanuelists had on occupational therapy we do not need to create a fictional social justice narrative.  Why don't we just read the words of George Barton, one of the actual founders of the OT profession?  He was 'cured' by Worcester himself, assisted by James Mumford (Worcester, 1932).  Let's look at what Barton wrote in his often conveniently ignored treatise "Re-education: An analysis of the institutional system of the United States" (Barton, 1917).  Here is a choice quotation from Barton - an occupational therapy founder, and Emmanuel practitioner:
"And if it seems cruel to the charitably disposed mind to let a man go hungry under any circumstances, it should be borne in mind that St. Paul said, "And if any would not work, neither should he eat";  that Adam was told that by the sweat of his face he should earn his bread; and that, according to the Commandment, it is six times more important to work than to keep the Sabbath. The vagabond would no longer find it necessary to attract the roundsman's attention by throwing a brick through the window of some respectable taxpayer; for, by declaring himself dependent at any police station, he could be sent to that shop where he was best fitted to work, and where, by his own efforts, he could be fed and lodged until his little earnings had amounted to enough to give him a fresh start."

I am curious as to why we ignore the Emmanuel Movement as much as we do - it is sometimes named but few will dare to discuss its roots - which are deeply religious and based on the idea that medicine did not have the answer to these vexing problems and that a NEW MODEL was needed that combined medical and social and spiritual components.  Rather than being an argument for social justice and distribution to correct inequity, it seems that this is a very different kind of philosophy regarding responsibility and self reliance - and surrounded by Christian values of charity.  That might be too painful for some people to tolerate, and I am curious if this is why we have to re-create a fictional Social Justice narrative.

Here is another Barton quote:
"There is necessarily a limit to the amount which the normal man can do for his unfortunate brother. There is necessarily a limit to the number of members of a community who can remain in idleness, no matter how distressing their condition. More than that — to support in idleness, even though in distress or pain, if not the worst, is not the best means of assisting the unfortunate. "

Again, that hardly seems to support the notion of distribution based on inequity.  Rather, this is a philosophy of responsibility and self reliance.

Here is another Barton quote:
"Indeed, so thoroughly have our so-called charitable impulses undermined the self-respect of the people that a new medical term has been introduced in Europe to cover those cases who, through fear of not being supported for nothing, refuse to endeavor to return to work. This condition is known as "pension hysteria."

I don't even know how you can bend a social justice framework around that!

And finally, we have George Barton stating what drove all of his efforts:
"Or even the author who, during the ten or twelve years of hospital and convalescent life necessary for the overcoming of four attacks of tuberculosis, four surgical operations, including an exploratory laparotomy and an amputation, morphinism, hysteria, gangrene, and paralysis, has studied the relation of the sick man to society, and who now offers this little book as one of the results of his disability."

The Core Values of occupational therapy are based in Emmanuelism.  They are NOT based in Social Justice, or anything that anyone wants to try to bend in order to fit a Social Justice model.

Today Social Justice is a predominantly leftist term and is a political philosophy used to promote liberal policies.  Attempting to claim the charitable efforts of philanthropists in the Gilded Age as evidence of 'Social Justice Pioneers' is incorrect.

Occupational therapists should not be ashamed of the philanthropic notions that were present as the humanitarian spark for our profession, and they most certainly should not attempt to revise history to make it sound like OTs have always been for redistributing resources because of inequity.  These founders voluntarily 'redistributed' because of their Christian Ethics and philanthropy - not because the government made them and because everyone was supposed to be 'equal.'


Adams, R.A. (1985). The Emmanuel Movement: An antecedent to occupational therapy.  (Unpublished Masters Thesis), Rush University, Chicago.

Barton, G.E. (1917).  Re-education: An analysis of the institutional system of the United States.  Boston: Houghton Mifflin Co.

Beauchamp, T. L., and Childress, J. F. (2009). Principles of biomedical ethics(6th ed.). New York: Oxford University Press.

Harley and Schwartz (2013) Philip King Brown and Arequipa Sanatorium: Early Occupational Therapy as Medical and Social Experiment.  American Journal of Occupational Therapy, 67, e11-e17.

Quiroga, V. (1995). Occupational therapy: The first 30 years.  Bethesda, MD: AOTA Press.

Rompkey, R. (2001).  Jessie Luther at the Grenfell Mission.  Montreal: McGill Queen's. 

Rawls, J. (1971). A Theory of Justice. The Belknap Press of Harvard University Press

Rothman, S. (1994). Shadow of Death: Tuberculosis and the Social Experience of Illness in American History. New York: Basic Books.

Worcester, E. (1932). Life's adventures: The story of a varied career.  New York: Scribner's Sons.

Saturday, May 03, 2014

Academia knows best: Mandating doctoral education for entry level occupational therapy practice.

The American Occupational Therapy Association Board of Directors has issued a position statement that future occupational therapists will need to be doctorally prepared for entry-level practice by 2025.  They have arrived at this recommendation after undergoing an insular process that neglected to engage broad stakeholder participation.

I understand that this is a weighty charge, so I will outline the evidence as clearly as possible.

The AOTA Board informed their decision on two workgroups: one an Ad Hoc Board Committee on the Future of OT Education chaired by Dr. Thomas Fisher and the other an internal subcommittee of the Board itself that reviewed the Ad Hoc Committee's findings.

The Ad Hoc Committee was comprised of occupational therapists who also served as Deans, Provosts, or other high ranking University officials as well as the AOTA Director of Accreditation and Academic Affairs.  Task groups were developed to address specific questions.  Specifically, one task group called the "Maturing of the Profession" task group made the specific recommendation for mandatory doctoral level education.  This group consisted of a physical therapy educator/Dean and four occupational therapy academics who all held high ranking University positions.

It is not known who comprised the sub group of the AOTA Board of Directors that looked at the Ad Hoc groups findings.  However, the AOTA Board of Directors is known to be heavily weighted with those who work in academic settings.  Among those who are not currently in academia, most either hold dual academic appointments, have held academic appointments in the past,  or are in senior administrative positions in their work settings.

The fundamental problem with the composition of these committees and task groups is that they are making recommendations that stretch outside the confines of academia.  The recommendation for mandatory doctoral level training is not an academic recommendation.  It is a practice recommendation.

The absence of practitioner or employer or regulatory voices in these task groups is a glaring omission.   The Committees and Task Groups have been meeting over some time, and the results of their work has not even been broadly shared with the occupational therapy community until the release of this recommendation.

I am aware that during the April 23-24, 2013 Program Directors meeting a 'Top 10 FAQ' on entry level OTD education was circulated.  In June 2013 I requested a copy of Dr. Fisher's report but never received an answer to my request.  I am also aware of others who requested a full copy of the report in November 2013 and were never provided a copy.

In addition to restricting the groups to academic voices and opinions, there was an unwillingness to even share information about the work of these groups with the membership.  The reports that are now available only appear after all of the work is completed and after the AOTA Board of Directors already made their recommendation.

There is also the fortuitous timing of an article in AJOT from a group of academics who are supporting the change to mandatory doctoral level education.  The AJOT opinion piece (Case-Smith, et al, 2014) also fails to address pertinent concerns including:

1. What are the ROI impacts for students when we require increasing levels of education with static and shrinking levels of reimbursement?

2. What are the impacts of 'shutting out' students from higher ed by requiring doctoral level training?  What affordability factors are present?
3. Do affordability factors disproportionately impact minorities and what impact does this have on initiatives to promote a more diverse workforce?

4. What is the impact of a move to a doctoral level while at the same time decreasing access to community college/OTA levels by proposing OTA move to a baccalaureate level?
 5. What is the potential impact of this kind of a proposed change on the cusp on increasing demand for OT services (aging of population, etc.)?

Fisher and Crabtree (2009) brush away these types of questions saying they are 'concerns' but not 'barriers.'  The problem is that I have not seen any evidence that we are doing anything meaningful about the concerns. A survey of OT Program Directors conducted in 2004 and published by Griffiths and Padilla (2006) indicated that Program Directors held opinions in support of OTD education, despite objections from other stakeholders. That is a familiar theme.

How does the proposal square with what little evidence has been collected re: readiness and competence for practice? Mitchell and Yu (2011) conducted a study comparing BS and MS students on a test of critical reasoning, and in their results the students with the BS level actually scored higher than their MS students.  The study has limitations, including convenience sampling of one school and non-parallel admission practices, but these findings should be raising a few more eyebrows.

In a study of perceptions of 600 practitioners, Dickerson (2009) found that the majority of respondents did not approve of moving to the doctorate for entry-level practice.  Plain and simple - they did not see the point.  In a smaller study conducted by Smith (2007), there was not a strong opinion whether there is an advantage to a clinical doctorate degree, and only 22% agreed or strongly agreed that they would be interested in pursuing a postprofessional OTD.  Apparently these practitioners also do not see the point.

One might hope that intervening studies that quantify opposition to the proposal would have been considered by Case Smith et. al., but they remain impervious to the evidence even though there is notable and contradictory opinion.  The fact that these studies are excluded from the Case-Smith analysis is itself an example of academic cherry-picking, and automatically disqualifies their opinion because in fact they are not acknowledging all sides of this issue.  

Leaders of AOTA have a long history of doing what they want and remaining impervious to the evidence.  I will remind everyone that at the American Occupational Therapy Association's Annual Conference in 1999, the Representative Assembly passed Resolution J, mandating post-baccalaureate education for entry into the profession.  Following Resolution J, ACOTE formed a committee to look into the issues. The ESRC (Educational Standards Review Committee) identified some significant concerns about any move toward accrediting doctoral level programs. It seems that someone didn’t care what ESRC had to say because a different committee was formed (the ACOTE OTD Standards Committee) to develop standards for doctoral degrees despite what ESRC reported.  This started the ball rolling, and was prima facie evidence of how AOTA/ACOTE handles these issues.  It seems that history is about to repeat itself and again - once decided - things will go the way that AOTA wants them to go no matter who says what.

As a technical matter, AOTA can only provide an 'opinion' because ACOTE is theoretically a separate entity, but that is like saying the sock puppet is not controlled by the hand it sits on.  That is another whole topic.

So although I don't doubt that this change will happen anyway, I can't in good conscience close my eyes to the fact that many people oppose this, that there is very little evidence supporting this change, and that the issues that have been identified as 'barriers' have not been addressed at all.  Therefore, I predict that moving to doctoral level education without addressing the opinions of stakeholders and without considering the broader impacts on the workforce will contribute to unintended consequences that in the long run will harm the profession and more importantly harm the people who need the profession's services.

It is true that now there is an outlined process where stakeholder opinion will be solicited, but this is just the veneer of integrity.  This is just a superficial listening tour because the recommendation has already been made.  So what is the point?

My personal opinion: I am undecided, but leaning toward the opinion that mandatory doctoral training is at  best unnecessary and at worst could be harmful.  

But it sure would have been nice to solicit opinions before the horse got this far out of the barn. 


AOTA position statements and reports, linked above.

Case-Smith, (2014). The Issue is... The professional occupational therapy doctoral degree: Why do it?  American Journal of Occupational Therapy, 68, e55-e60.

Dickerson, A., & Trujillo, L. (2009). Practitioners' perceptions of the occupational therapy clinical doctorate. Journal Of Allied Health, 38(2), e47-e53.

Fisher, T. F., & Crabtree, J. L. (2009). The Issue Is—Generational cohort theory: Have we overlooked an important aspect ofthe entry-level occupational therapy doctorate debate? American Journal of Occupational Therapy, 63, 656–660.

Griffiths, Y., & Padilla, R. (2006). National status of the entry-level doctorate in occupational therapy (OTD). The American Journal Of Occupational Therapy: Official Publication Of The American Occupational Therapy Association, 60(5), 540-550.

Mitchell, A. W., & Xu, Y. J. (2011). Critical reasoning scores of entering bachelor’s and master’s students in an occupational therapy program. American Journal of Occupational Therapy, 65, e86-e94.

Smith, D. (2007). Perceptions by practicing occupational therapists of the clinical doctorate in occupational therapy. Journal Of Allied Health, 36(3), 137-140.