Tuesday, February 24, 2015

The American Occupational Therapy Association: The new 'Concern Troll' in school-based mental health

Concern Troll: (noun) A person or persons who pretends to be 'concerned' about something and talks about it, all the while serving to actually disrupt the legitimate concerns and activities of people who are trying to address problems. Concern trolls are particularly skilled in derailing conversations, conflating issues, and leading people off track.

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AOTA recently released a new document on use of restraints and seclusion related to school based practice.  I will not link that document because I believe that it is fundamentally flawed and does not represent the thinking of many people who actually practice in school settings.  There is no value in spreading that faulty document, but I will describe the problems with a hope that more conversation will be generated about the issue broadly.

The paper has some positive aspects, including identification of the role of OT in helping teams understand and interpret personal and contextual factors that might lead to disruptive or dangerous behaviors.  OTs have good skills and abilities to participate on those teams.

However, the document takes a sharp turn off course.  The authors describe the negative problems with 'occupational deprivation' caused by restraints and seclusion practices and that OTs need to work on school teams to provide 'occupational enrichment' to counteract the alleged systemic or habitual use of restraints in schools.

I am uncertain if it is really appropriate to refer to therapeutic use of restraints in context of how scholars have defined 'occupational deprivation' in forensic or refugee or war contexts.  Restraint use in a treatment context usually has to do with preventing harm to self or others and is only used in a last-ditch context when all other methods have failed and only to prevent harm.

Certainly there are problems with the use of restraint but that has more to do with the de-professionalization of care teams and lack of oversight or sound policies in 'treatment' contexts than it does with forensics or willful removal of rights in a punishment or war or refugee context.  When there is conflation between the two it sounds as if OTs are confused that we are still in a pre-Moral Treatment period, which of course we are not.

When a restraint method is used the issue of 'occupational deprivation' is not a factor.  The only factor that I am aware of is to prevent harm or injury.  Restraint methods are time limited and there is no 'occupational deprivation' associated with their use.   Conflating time limited restraint methods to prevent  harm and injury with 'occupational deprivation' (whatever that is) is ridiculous.

Also, conflating special education placement itself as a form of 'occupational deprivation' is an extreme and unusual perspective that does not comport with reality.  This is perhaps the most odd belief expressed in that document.

This bizarre concern about 'occupational deprivation' is fueled by the 'Trauma-Informed Practices' movement.  The notion underlying this movement is that care providers need to be sensitized to the trauma that many people who have emotional and behavioral disorders have lived.  Then with this new-found sensitivity they can engage in non-specific practices to help people understand the root causes of their behaviors.  It is all about being more SENSITIVE and CARING.  An entire industry has cropped up on how to create a Trauma-Informed Care Team.

Instead of attending conferences and writing papers and conducting trainings I would like to see OTs actually working in behavioral/mental health programs themselves and doing something DIRECTLY to address these problems.

The entire 'trauma informed' movement is  the ultimate in hashtag advocacy.  We fail to understand that the real reason that care systems are sub-optimal is because professionals have abandoned those treatment settings and left them in the hands of marginally trained people.  Then we complain when the marginally trained people aren't functioning the way that we want them to.

Instead of working in those populations ourselves now we have a giant push to 'educate' people and to make sure that they 'assume' that everyone in these settings has experienced trauma, and to 'train' staff to approach things with an improved sensitivity.  Maybe if we all FEEL BADLY ENOUGH about the problem it will get better!

It is Moral Treatment Redux.  Just like the first Moral Treatment movement failed this one will too - because the real answer involves investment of resources so large that no one is really willing to make that commitment.  It only took a short time before the beautiful design plans of the 1850s reverted to stinking cesspools that were labeled 'SNAKE PITS.'  Then we had a generation of new hope in a civil rights movement that de-institutionalized everyone but failed to really meet other needs.  And here we are again with a whole new generation of feel-good advocacy that puts the responsibility on the 'other' care providers.  Professionals of ALL STRIPES have abandoned treatment of people who have chronic conditions and REPLACE CARE with FEELING BADLY as if that will serve to purify themselves of guilt with their faux CONCERN.

People who care go out and do something about problems.  LIKE ACTUAL TREATMENT.

They don't attend conferences so they can be SENSITIZED about HOW HORRIBLE THE WORLD IS TO PEOPLE and how to MAKE OTHER PEOPLE TAKE CARE OF THINGS.

It is all about Dirty Jobs, that TV show that so many people love to watch.  We have a fascination with the work, but no interest in doing anything about it other than deep-sitting on our couches in the comfort and safety of our living rooms and then exerting just enough effort to lift our finger to turn up the volume.

This is why I label this movement as 'Most likely to bore the pants off of anyone who really cares.'

So now we have found a NEW PROBLEM of restraint use and we will label it in our own made-up terms of 'occupational deprivation' and we will conflate restraint use with some horrible injustice that the world is perpetrating on people.  Because there is no real leadership on TREATMENT of people who have mental illness the AOTA response is to turn us all into CONCERN TROLLS and will have us all attend conferences and then present on 'Trauma Informed Care' so that 'those other people' who are tying up school children and throwing them into rubber padded rooms will do a better job.

I strongly suggest that if the AOTA wants to get back into the business of providing services to people who have mental health problems, that it actually start with providing services to people who have mental health problems.  This current track of coming up with 'new problems' and calling it 'occupational deprivation' and promoting 'trauma informed models' seems a little bizarre.

Can occupational therapists predict the future?

There is ongoing debate on the AOTA forums about move to an entry level doctorate.  Within that debate there is repeated discussion about the 'future.'  I am very interested in the concept that occupational therapists should attempt to 'focus more on what COULD and SHOULD be different for practitioners graduating in the future.'

Prognostication is an interesting endeavor, and I am wondering if this is something that most occupational therapists really have the skill set to accomplish.  I don't believe that there is evidence to support OTs having these skills.

R. Buckmister Fuller, who in my opinion was a tremendously gifted anticipatory design scientist, felt that he had an ability to prognosticate based on his model of integrative systems thinking and on his naval training in navigation and ballistics.  
In his book 'Operating Manual for Spaceship Earth' he explained how some people felt that he was 1000 years ahead of his time, which puzzled him because he did not understand how others thought they could understand events 1000 years into the future when he only felt confident about analyzing 25 year scientific, industrial, and innovation cycles.  As he got older, some people said that he was 'behind the times.'  An analysis of these varying assessments of his ability seems to be a good example that most people have absolutely no ability to prognosticate reliably or to assign time values to future events.

Nonetheless, this does not seem to stop people from thinking that they have the ability to prognosticate.

I thought it would be interesting to look at the accuracy of occupational therapy prognostications - so I would like to refer everyone to the special meeting of the Representative Assembly in 1978 that was held on 11/8 through 11/12 in Scottsdale Arizona.  The purpose of the meeting was to direct the course of the profession for the coming decades and to hear the thoughts of leaders of the profession at that time.  The thoughts of these leaders is encapsulated in a series of lectures that were published under the title Occupational Therapy: 2001 AD.

Several of the authors were so mired down in 1978 concerns that they could not really offer much specificity about the future.  At the time of the conference Wilma West and Alice Jantzen were talking about whether we would be a professional or a technical vocation.  This ended up being such an esoteric concern that by the time 2001 rolled around no one was really discussing it any longer.  

Nedra Gillette suggested that we would require post professional training in order to achieve 'professional' status, but it seems that professional status was conferred more by a robust certification process and state licensing than by conversion to graduate education, which didn't end up happening until 2007.  

Ruth Weimer thought we should develop knowledge in economics so that we could convince others of our value.  I don't know that we accomplished that; today OT persists in many environments by legal mandate and not because it is a 'valued service.'  Jerry Johnson focused mostly on the present failings of the Association and difficulties in responding to member needs.  

Elizabeth Yerxa focused on socialization requirements between what made for a caring and empathetic OT vs. what would be required to seize power and exert control in a professional context.  I think she failed to understand that the future would create a context whereby if someone raised this issue today that they would be accused of genderism.  Gail Fidler took Yerxa's comments and overtly discussed her perspectives on the fact that OT is a female dominated profession.  I can state with confidence that these kinds of conversations would not be openly appreciated in 2001.

Florence Cromwell believed that the proper place for OT would be in helping people with chronic illness.  It seems that she did not see the trends of OTs abandoning mental health, adults with developmental disabilities, and other populations of people with chronic health problems.

Mae Hightower-Vandamm's presentation stood out in that she took very bold positions on what she thought the future would hold.  She thought that AOTA would have 80,000 members in 2001.  She also thought that cities would not be able to handle conferences so there would be regional conference centers where there were no hotels but just modest rooming for attendees and that food would be available in a concentrated capsule form designed to be ingested with a liquid nutrient.  She actually wrote that.

She also believed that OTs would be integral to the unemployment system.  OTs would be available 24 hours a day, in shifts.  She was kind of repeatedly interested in closed circuit TV, thinking that it would be used for education as well as for certification.  Kind of like the Internet, I guess.  She was close on this one.

She thought that OT Aides in hospitals would be 'Quasar Men' and they would be programmed to do all craft preparation, monitor the clinic for safety, clean up, and transportation.

SUMMARY:

There is not much evidence to consider in analyzing OTs ability to predict future events.  In 1978 there was a concerted effort to plan for 2001, and important leaders at that time were overwhelmed with 1978 issues as opposed to what would be needed in order to move forward.  The primary issues at that time were concerns with professional vs. vocational training, inability to precisely articulate a scope of practice, and other sundry issues such as career laddering for OTAs, dominance of women within the profession, generalist v. specialty practice, and inefficiencies in professional training and in the Association itself.  Most of the OT leaders at that time were skilled in discussing present day concerns.  Most of those concerns were interesting, but few if any of them have ever been fully resolved.  Most of the OT leaders kind of avoided discussing the future even though that was the point of the conference.  Those who did discuss the future were generally off target.

Watching the current AOTA leadership seems similar.  They seem aware of problems (like the structure of the Association) but are not able to mobilize resources to change much.  They seem to be aware of the Affordable Care Act, but focus on primary care models that don't reflect any current realities of practice on a large scale.  They seem to value evidence based models, but can't grasp the reality that pediatric practice is rife with snake oil.  They understand that OTs abandoned mental health, but it is all a little johnny-come-lately.  They understand that there are opportunities for OTs in new areas of practice, but we have an academic faculty that is largely divorced from the clinics.  In sum there is a big focus on articulating current problems, but the solutions constantly fall short of fixing anything.  OTs seem to have skill in articulating present day problems.  OTs just are not skilled in prognosticating the future.

I believe that the status of the profession in 2014 is the same as it was in 1978 - the only difference being that there are different present day concerns on the table.  The French have a saying for this: Plus ca change; plus c'est la meme chose.  Translated, the more things change, the more they stay the same.

I am concerned that we are asking members to plan for the future.  Leaders don't seem to have good ability to plan for the future.  As an example, we are told that we need an entry level doctorate as a single point of entry for the profession.  A lot of ancillary issues about current problems are discussed, but there is no real evidence to support the recommendation.  I previously mentioned that OTs are skilled in chasing trends but not so much in leading change themselves.

For this reason I will place the prediction of this 'need' for entry level doctorates in the same category as the Quasar Man.  It is an interesting idea, loosely sensible on a superficial level, but lacking in any real substance of justification and practicality that is necessary to support its existence.

References:
AOTA (1979). Occupational Therapy: 2001 AD. Papers presented at the special session of the Representative Assembly, November, 1978.  Rockville, MD: AOTA.

Fuller, R.B. (1968). Operating manual for Spaceship Earth, Carbondale: Southern Illinois University Press.

Wednesday, February 11, 2015

Can use of an occupational justice model in an American context result in accusations of professional misconduct?

Can use of an occupational justice model in an American context result in accusations of professional misconduct?

Conceptual practice models are interrelated bodies of theory, research, and practice resources that are used by OTs to guide practice (Kielhofner, 2009). One such conceptual practice model is the Occupational Justice Model (Townsend, 1993; Townsend and Nillson, 2010).  According to these sources, the Occupational Justice Model is framed around the concept that injustice occurs due to inherent governance and social structures that allegedly restrict the occupational performance of some populations and individuals.

Concepts associated with occupational justice models have filtered into some official documents of the American Occupational Therapy Association.  For example, the AOTA 2010 Code of Ethics included a new principle of 'Social Justice' (AOTA, 2011).  That new principle required occupational therapy personnel "to provide services in a fair and equitable manner and to advocate for just and fair treatment ... and encourage employers and colleagues to abide by the highest standards of social justice and the ethical standards set forth by the occupational therapy profession."

The social justice requirement has been controversial.  The challenge with this requirement is that there has not been any corresponding statements that provided meaningful guidance on what practicing in a social justice context means for practitioners.  Disagreement about social justice terminology and whether this philosophy was congruent with OT Core Values has been a significant debate that has lasted over four years.

Occupational justice is also mentioned in the new (3rd) edition of the OT Practice Framework (AOTA, 2014).  This document states that children who have psychiatric disabilities placed in alternate schools face occupational injustice because they may have limited opportunities to participate in sports, music programs, and organized social programs (p. s9).  No specific references are provided for this claim, and this is not in accordance with my own lived experience as an occupational therapist, so I must assume that this reflects the observations of a therapist who last practiced many years ago, perhaps pre-dating 1973 when federal law prohibited such discrimination. 

Nonetheless, whoever wrote the Practice Framework also believes that such discrimination occurs in other settings as well.  Other examples provided (p. s9) are residential facilities that don't allow people to engage in meaningful role activities and poor communities that lack accessibility and resources.  Again, this is not in accordance with my lived experience as an occupational therapist in the United States, so I am thinking that whoever wrote this must have been reflecting on some mission trip to a former Soviet-bloc country's orphanage, or something.  I am very aware that conditions of such institutions are rather grim in some parts of the world.

The fact that the OT Practice Framework 3rd edition includes elements that are grossly out of step with reality of practice in the United States is something that probably requires some discussion and hopefully correction.  This is particularly true because this document is used so heavily in academic programs to teach students how to practice and is referenced in many other AOTA documents.

The AOTA Practice Framework 3rd edition states that OTs "work to support policies, actions, and laws that allow people to engage in occupations that provide purpose and meaning in their lives." (p. s9).  Outcomes of interventions for populations "may include health promotion, occupational justice and self-advocacy, and access to services." (p. s16).  Specifically, related to outcomes, the AOTA Practice Framework 3rd ed. references the work of Townsend and Wilcock (2004).

The Canadian Association of Occupational Therapy has published helpful information about how to practice from Townsend's occupational justice model (Wolf et al, 2010). In the article an example is given about occupational deprivation.  The example is a child who has developmental delay and limited access to toys because of poverty.  According to the article, "the injustice is predicated by a social system which does not provide enough funding to support children’s development."  The therapists actions as a result are to write letters to politicians, obtain grants, and other advocacy activities.

Surprisingly, the document does not state that the therapist actually addresses the motor delays.

The problem that I see with this practice model is that it does not reflect any reality that I have experienced in almost 30 years of practice.  Actually, most therapists I know would have given the child toys themselves, left toys for the family to use, or referred them to a toy lending library, or placed them on a list to receive charitable donations like from the US Marines Toys for Tots Foundation.

While doing all of this the therapist would be working with the child and family on the motor delays.

Maybe a therapist would develop a side interest in obtaining grant funding but that would be a long term project and certainly not tied to outcomes for any one specific child.  Using this occupational justice framework to address problems of occupational deprivation seems to be a disconnected and confused idea that does not reflect actual practice.

It is important to note that this article is written from the context of Canadian practice, about which I claim no expertise at all.  However, using this occupational justice model in a United States context could cause the well-intentioned therapist to be accused of professional misconduct.

Specifically, a therapist in the United States could be accused of failing to respect the procedural rules and laws associated with care of children that age.  Those procedural rules and laws do not support the advocacy activities of writing political letters as a part of OT practice.

Additionally, there could be accusation of failing to address those issues that ARE within the scope of practice, particularly the specific client factors (developmental delays) that the therapist found were severely delayed.

Unfortunately, the guidance provided by Wolf et al (2010) is that "occupational injustices like those faced by Sarah and her family cannot be resolved at an individual level" and that "occupational justice is achieved through a change in social attitudes which acknowledge the value of diversity and support the engagement of all persons in meaningful occupations." I am not sure if writing letters to politicians in Canada is a legitimate intervention method for occupational therapists.  American therapists attempting to get reimbursement for writing political letters that might have some long-term or downstream impact on the person who is supposed to be receiving help now would generally not be considered occupational therapy.

Therapists might engage in varying degrees of advocacy-related activities depending on their own philosophies and inclinations.  That is very different than using advocacy activities as intervention as this model proposes, particularly in context of using them and NOT providing actual occupational therapy to address those developmental delays.

American therapists using an occupational justice model could reasonably expect a threat of disciplinary action.  I am hopeful that by pointing out the dangers of an occupational justice model applied in an American context will cause the American Occupational Therapy Association to reconsider its reference to these models in its official documents.


References:

see embedded links

AOTA. [Slater, D.Y. (Ed.).] (2011) Reference guide to the occupational therapy code of ethics and ethics standards. Bethesda: AOTA Press.

AOTA (2014). Occupational Therapy Practice Framework: Domain and Process, 3rd ed. Bethesda: AOTA Press.

Kielhofner, G. (2009). Conceptual foundations of occupational therapy practice.  Philadelphia, PA: FA Davis.

Townsend E. (1993). Muriel Driver Memorial Lecture: Occupational therapy’s social vision. Canadian Journal of Occupational Therapy, 60, 174-84.

Townsend, E. and Nillson, I. (2010). Occupational justice: Bridging theory and practice. Scandinavian Journal of Occupational Therapy, 17, 57-63

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

Wolf, L. et. al. (2010). Applying an occupational justice framework.  OT Now,  12, 15-18.


Monday, February 09, 2015

From Social Gospel to the New Deal: A values juxtaposition that has been whitewashed by OTs

I was interested to see some comments from Dr. Elizabeth Townsend (2015) in an online forum asking "How are we building leadership for key posts at universities in support an [sic] occupation focus - both in the science and therapy of occupation?"  She asked this question in context of an open position at Dalhousie's School of Occupational Therapy in Halifax, Nova Scotia but was interested in a more general sense of how to build leadership outside of large metropolitan areas. 

This interested me because I have been studying recruitment and spread of occupation workers at the time of the founding of the occupational therapy profession.  I began to wonder if a study of this history could provide context for interpreting the current recruitment call.

An important early supporter of proto-occupational therapy was a man that is not often cited in American textbooks.  Sir Wilfred Thomason Grenfell is described as a "physician, medical missionary, social reformer, and author."  I encourage readers to visit this link and study the life of Grenfell who was quite an interesting person.  I have been reading all of Grenfell's books and have been particularly interested in what drew him to Newfoundland and Labrador to do his mission work.

In a previous blog post about the Core Values of the occupational therapy profession I stated 
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 ...

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.

Dr. Grenfell was similarly motivated and he discusses his religious conversion and values in his books (Grenfell, 1910; Grenfell, 1927).  He knew that he had to recruit others to help him with his work, and he was impressed with Jesse Luther, who was an early occupation worker often associated with Dr. Herbert Hall (Rompkey, 2011).  Luther's roots extend all the way back to Hull House, where her 'occupation work' actually pre-dated the work of Eleanor Clark Slagle (Rompkey, 2011). 

So I was reflecting on Grenfell and Luther when I read Dr. Townsend's call for recruiting into the far Eastern portion of Canada - and I thought of what motivated the first occupation workers to that region and how different that was from Dr. Townsend's interest in social justice (1993).

There is evidence of conflation between Christian philanthropy and 'social justice' in the occupational therapy literature (Harley and Schwartz, 2013; Head and Friedland, 2011).  It is important to consider that 'social justice' was not even conceptualized until after the New Deal that placed the government into a position of resource redistribution (Rawls, 1971).

This is what makes Dr. Townsend's call to Eastern Canada somewhat ironic in context of the history of the profession and in context of Grenfell and Luther's mission work there.

Grenfell, like many of his contemporaries at that time, were interested in solving social problems.  The Social Gospel movement was an application of Christian theology to social problems.  It is very unusual that this movement is completely left out of conversation about the founding values that motivated the philanthropic work of Jane Addams, Phillip King Brown, Wilfred Grenfell, Elwood Worcester, and so many others.

It is true that the Social Gospel Movement was not cohesive, with some branches promoting philanthropy and other branches promoting collectivism and labor movements. As governments became more involved in welfare acts, philanthropy took a back seat.  This is described in excellent detail in an analysis by Harnish (2011) who writes:
Charity has long been described as an expression of God’s love as opposed to a policy measure aimed at lowering the unemployment rate or the labor hours necessary to buy a loaf of bread. As an expression of God’s love, charity knows no boundaries; it goes to friends and enemies alike—quite a difference from redistribution measures, long known to be but another means of funneling cash and favors in order to secure political reelection. Further, charity is a religious virtue and an ethical statement. It claims to be capital “G” Good and a worthy choice for human action simply because it is a reflection of God’s fixed and eternal nature. This claim the Social Gospel rejected outright. The only place left to find a justification of its welfare-state measures was...the refuge of pragmatic successes.

There is evidence that Christian Ethics motivated the majority of proto-founders who were interested in the 'occupation cure.'  Some of that may have morphed into seeking governmental programs to prop up their philanthropic efforts, particularly in context of financial stressors in trying to meet severe needs.  Some of that may have been pragmatic more than philosophic, particularly in consideration of the very overt religiosity that was expressed by those proto-founders.

So now there is a new call for OT leaders in Eastern Canada - and that call is in context of a new Social Justice that is rooted in a model of governmental control and redistribution of resources.  That call occurs in a whitewashing of our actual history that is rooted in philanthropy and Christian Ethics.

Understanding our history provides us a proper context for examining where we are.  Understanding our history also provides us with meaningful background information to evaluate the current value system and philosophic trajectory.

My how things have changed in 100 years.


References:

(see embedded links)

Grenfell, W. (1910). A Man's Helpers. Toronto: Musson Book Co.

Grenfell, W. (1927). What Christ means to me. Boston: Houghton-Mifflin.

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.

Harnish,  B. (2011). Jane Addams's Social Gospel synthesis and the Catholic response: Competing views of charity and their implications.  The Independent Review, 16, 93-100.

Head, B. and Friedland, J. (2011, Jan/Feb). Jesse Luther: A pioneer of social justice.  OT Now, downloaded from http://www.caot.ca/otnow/jan11/luther.pdf

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

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

Townsend, E. A. (1993). Muriel Driver Memorial Lecture: Occupational therapy’s social vision. Canadian Journal of Occupational Therapy,  60, 174-184.

Townsend, E. (2015, February 8). Advancing occupational science and occupation-based practices globally - how are we building leadership for key posts. Message posted to https://groups.google.com/forum/#!topic/occupational_science_intl/ajdBHCjjVk8