Wednesday, March 30, 2016

From elite social clubs to personal atonement: The history of the formation of Consolation House.

Private and elite clubs were vehicles of socialization and business transaction during the Gilded Age.  Clubs were often restricted in membership and members were highly scrutinized before being offered the opportunity to join. 

The Tavern Club in Boston is one example of an elite social club.  It was established in 1884 and was a gathering place where the members were focused on fine dining, lectures, and the arts.  Notable members included Charles Eliot Norton, William Dean Howells, and Henry Cabot Lodge.  Herndon (1892) described the club as "an organization of good fellows, mostly artists, musicians, and lawyers, who breakfast and dine together with more or less regularity in their snug and artistically fashioned club-house on Boylston Place, just off the busy thoroughfare of Boylston Street by the Commons."  The entrance dues in 1892 was a $50.00 fee.  The approximate 'economic status' of that amount in 2015 terms is $11,100.00, which provides some current-day comparison to understand the social prominence associated with the Tavern Club.

Hornblower (2000) provides additional perspective on the nature and function of Boston social clubs, including the Tavern Club.  He reports in tongue in cheek fashion

"The Tavern (1884) is said to be so exclusive that the man who proposed forming the club, a teacher of Italian descent, was denied admission. Sort of... The club was founded to promote “literature, drama and the arts.” Today it more or less pursues that mission...In the late ’80s, the Tavern was perhaps the most vocal opponent to sexual integration. One production, included a song entitled, “We love the ladies.” Its final refrain: “But we’d rather have the place in embers/ Than see them as regular members.”'

In 1988 the Supreme Court ruled in NEW YORK STATE CLUB ASSOCIATION, INC., v. CITY OF NEW YORK et al. that such private clubs were forbidden to discriminate based on race, creed, sex, and other grounds.  Opinions about the social value of clubs has changed and fewer people place value and importance on membership.  This is very different than how those clubs were viewed during the Gilded Age.

George Edward Barton served on the Elections Committee of this exclusive club from 1901-1903

This fact becomes relevant because it provides useful background information when attempting to understand Barton's methodologies for creating the National Society for the Promotion of Occupational Therapy (NSPOT), which later was renamed the American Occupational Therapy Association.

Many occupational therapists consider the NSPOT meeting in Clifton Springs, NY as the 'founding' of the profession.   It is important to consider that the NSPOT meeting was a function of a larger enterprise that eventually became known as the Consolation House Convalescent Club (CHCC).  The NSPOT meeting occurred during the middle of Barton's occupational therapy work on March 15, 1917.

Consolation House was opened on March 7, 1914 and marked the beginning of Barton's activities that ultimately led to the incorporation of the CHCC on April 1, 1922.  The purpose of the Club was to provide a location where people who were disabled could rehabilitate themselves and develop skills for economic self-sufficiency.  Every article or product made by a disabled person was to be stamped with the image of a phoenix which was the official emblem of Consolation House.  The motto "Beauty for Ashes" was also supposed to be stamped on the product so that anyone making a purchase would know that "this article was made by a sick man who is doing his very best to support himself."

Barton's earlier experience among the most elite members of society served as the basis for his creation of a new kind of club.  The use of a Club as a means of social expression was normative in his perspective.  However, due to his illness, Barton believed that he had lost everything.  He stated to Elwood Worcester (1932), 
"What is the use of talking to me?  My life is utterly ruined, my health, my power of movement, my beautiful profession, my wife and child, my home, my capacity for earning money are taken from me.  All that is left for me is to sit in this chair, a beggar, a pauper and to suffer like hell..."

Barton's choice of the Phoenix represented his belief that something new could be born out of such loss.   His choice of the naming of Consolation House and the motto "Beauty for ashes" also reflects his spiritual conversion at the assistance of Worcester. 

Worcester was not a social elite - he was a preacher in Boston - but many of those club members came to his church.  He provided Barton with the relevant scripture that would send him on his way to recovery and also lead him to his new occupational therapy mission.

Isaiah 61:3 states
To appoint unto them that mourn in Zion, to give unto them beauty for ashes, the oil of joy for mourning, the garment of praise for the spirit of heaviness; that they might be called trees of righteousness, the planting of the LORD, that he might be glorified.

The methodology for mourning in biblical times was to sit among ashes and to rend your clothing.  The message in this passage from Isaiah is that people can be comforted.  And consoled.   And happy again.  Barton existentially depended on such an atonement, reformation, and rebirth.  Barton's actions need to be considered within the context of his personal life story.  When some historians lacked that information, his behaviors were labeled as 'zealous' and 'sometimes irrational' and he was described as a 'difficult person' who lacked 'interpersonal skills' (Quiroga, 1995).

These characterizations of Barton are incorrect.  He was just a man who held a particular station in life and perceived that he had lost everything.  He used the tools he knew best to create a solution for himself, and that solution ended up contributing to the creation of the occupational therapy profession.

As reported in the Clifton Springs Press, one of the founding directors of the Consolation House Convalescent Club was Elwood Worcester, the minister who brought the Emmanuel Method to Barton as he convalesced in Clifton Springs, NY.

When you consider the historical context and motivations of George Barton, it becomes quite evident that Consolation House was aptly named.  He was a man who believed that he had a mission, and fulfilling that mission was an expression of hope for his own recovery as well as the recovery of other people similarly situated.


embedded links, and...

Herndon, R. (1892). Boston of today: A glance at its history and characteristics. Boston: Post Publishing Company.  Retrieved from

Hornblower, S. (2000, April 27). Fifteen minutes: The old boy's clubs.   The Harvard Crimson.  Retrieved from

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

Worcester, E. (1932). Life's Adventure: The Story of a Varied Career.  New York: Charles Scribner's Sons.

Tuesday, March 22, 2016

Check your patron

Reciprocity.  It is customary in ethics to discuss the connection between purpose and values in terms of reciprocity.  The body of knowledge in any discipline - that is, the reflective concepts and the action of technology - is derived from its reciprocal relationship to the purpose of its services... Searching for patronage and constructing a new support system is a dangerous venture for any discipline.

...The shift to a client system represents, perhaps, a desperate strategy to survive under the awesome pressure of the self-interest of medicine.  - Reilly, (1984).

Last year I noted that an article published in the American Journal of Occupational Therapy furthers the politicization of the professional association by endorsing very partisan approaches to health care (aka 'Triple Aim' model).  The chronic difficulty with labeling something as 'partisan' is that there will always be that segment of the population that agrees with that approach and does not see it as 'partisan.'  I take the risk in labeling anyway and hope to show why there is reason to pause and carefully consider these approaches.

The authors of the article (Leland, 2015) align the concept of 'value' with the IHI 'Triple Aim' that includes "improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations." (Berwick, Nolan, and Whittington, 2008).

Occupational therapists should ask themselves and their professional association when it became their duty to control for the amount of cost that the government is incurring in health care.  Responsible therapists should always be economically prudent and should be properly cognizant of the costs associated with their services, but is it the job of occupational therapists to meet the economic goals of a governmental patron?

If the purpose of occupational therapy is overtly stated as 'reducing the per capita costs of care for populations' then how does that position us ethically when it comes time to deliver care?

Simply put, the government defines 'value' in terms of dollars spent.  Most occupational therapists define 'value' in terms of people helped.  Those are not mutually exclusive objectives, but aligning your professional purpose with cost-saving methodologies changes your entire ethical system.

Where can we find 'value' propositions where occupational therapists have unexpectedly aligned themselves with government patrons?  Look at the slogan from the College of Occupational Therapists in the UK:

The important consideration here is that most occupational therapy services in the UK are delivered within the context of a single-payor government-run health care system.  That is not the case (yet) in the United States, although it is the particular objective of many partisans who are interested in fully socializing our health care payment system.

Who, exactly, does occupational therapy serve in this context?  The patient?  Or the government-patron?  Take a look at this other twitter-post from COT and decide:

/Edit: 3/23/16: Here is another depiction from the COT on what OT is supposed to accomplish:

Note that there is nothing in the messaging about improving function or quality of life for the patient.  Perhaps that is implied?  Who is the COT marketing to?  Are they marketing to the government patron so they know that length of stay can be decreased?  The COT provides a reference for this ability to reduce length of stay (Barnett, 2015), but it seems to be a rather stunning claim that needs further scrutiny.  Most OTs would argue that they could contribute to decreasing length of stay but I don't know anyone who would make a claim like this - it would be interesting to know how the researchers came to this statement.


From a US perspective, this is a confused approach that places therapists into what I call 'morally untenable zones of practice.'  Ethically, how is a therapist supposed to meet the occupational needs of their patients while at the same time meeting the economic objectives of their government patrons?

I understand that it sounds very noble to hear about 'care of populations' but this kind of orientation is actually very foreign to most OTs practicing in the US.  Do US practitioners think that they should have 'Saving Money' in their tagline?  Or that they should go out on ambulance rides and find ways to prevent hospital admissions?

I have great respect for all of my international OT colleagues and the systems that they function within but there is a deep and pernicious problem with accepting the methodologies of other countries and assuming that they are aligned with practice in another country.  Some occupational therapists have complained about 'colonial' attitudes of Western theories. (Hammell, 2011).  Certainly this concern travels bidirectionally.

The straw-man argument that is often used when I bring up this issue is "How can you possibly not be concerned about costs of care and improving quality?"  But remember - we should always be concerned about costs and we should always be concerned about quality (when it is properly defined) but that does not mean that we have to become stooges for a single-payor health care system and do their bidding to save money.  That is not the 'great idea' of occupational therapy (Reilly, 1985).

Simply put, you can walk and chew gum at the same time, but you can't do so when the government is defining 'quality' in your practice and basing it on economic terms.

I am concerned that some American occupational therapy leaders are not thinking deeply enough about the models that they are asking us all to support.  In another recent issue of AJOT we had more endorsement of population-based models (Braveman, 2015).  The author promotes further re-definition of the occupational therapy profession and states that we should "identify specific competencies related to population health and public health and include them clearly in the Framework."

Braveman proposes an expanded role for practitioners that includes policy work for non-profit organizations or in federal health agencies.  Certainly, occupational therapists can function within these roles but it is rather important to distinguish between the things that one might do with  occupational therapy training vs. what constitutes occupational therapy practice.  Suggesting that OTs work in these roles is fine, but suggesting that the PRACTICE Framework be changed is another matter entirely.  A different set of ethics is required when working with patients vs. working in the interest of public health.  One approach values autonomy and individual choice.  The other focuses on the good of the broad public (including its economic good).

In a previous blog post I laid out an explanation that population health models are focused on broad community needs and frame concerns in broad population statistics.  Occupational therapists have been carefully warned that public health models are incompatible with occupational therapy (Reed, 1984).  Specifically, Reed suggests that "occupational therapists must be careful to differentiate between the public health model and the health education and wellness model."  Unfortunately, occupational therapists are now confusing these models and in fact are even naming public health as a goal of occupational therapy.  Braveman asks, "How can we demonstrate occupational therapy's distinct value in improving the individual experience of care, improving the health of populations, and reducing the per capita cost of care?"

The answer to this question is that we can do it by socializing our health care system, aligning our purpose with the goals of the government-as-payor, and abandon our social compact to provide care to people.

That is incompatible with the current American system, and occupational therapists practicing in the United States are right to question if this is the correct direction for the profession in the United States.


Barnett, D. (2015) From ‘assess to discharge’ to ‘discharge to assess’. What a difference a year makes! In: College of  Occupational Therapists (2015)  College of Occupational Therapists 39th annual conference and exhibition, plus Specialist  Section Work annual conference, 30th June–2nd July 2015 , Brighton Centre, Brighton, Sussex: book of abstracts. London:  College of Occupational Therapists. 25.

Berwick, D. M., Nolan, T. W., and Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27, 759–769.

Braveman, B. (2015).  Population health and occupational therapy.  American Journal of Occupational Therapy, 70, 1-6.

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

Leland, N.E.; Crum, K.; Phipps, S.; Roberts, P. and Gage, B. (2014).   Advancing the value and quality of occupational therapy in health service delivery. American Journal of Occupational Therapy, 69, 6901090010p1-6901090010p7. doi: 10.5014/ajot.2015.691001.

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. 

Reilly, M. (1984). The importance of the client vs. patient issue for occupational therapy. American Journal of Occupational Therapy, 38(6), 404-406.

Thursday, March 17, 2016

Update on occupational therapy and case management

One year ago I posted about the American Occupational Therapy Association process of an Ad Hoc committee to delineate the role in case management for occupational therapy in primary care and mental health.

My concern at that time centered around two primary points:

1. Case management is not a recognized domain of concern of occupational therapy practice.

2. There is a difference between 'things that can be done with OT skills' vs. 'what constitutes OT practice.'  I believe that occupational therapists should be delimiting practice and clarifying professional roles, not blurring them.

My objections have nothing at all to do with case management, which I consider a worthwhile and valuable endeavor.  It is my opinion that these are worthwhile and valuable endeavors for others and should not be something that OTs concern themselves with excessively.  The concern has a lot to do with resource allocation.

Despite this type of feedback that was given to the RA, the Ad Hoc Committee was created anyway.  Today I was given a copy of the committee's report to the RA by some colleagues who were aware that I had concerns about this issue last year.  Getting this report also coincides with my reading of the lead article in the March/April 2016 American Journal of Occupational Therapy entitled: Role of occupational therapy in case management and care coordination for clients with complex conditions.

I don't expect that it is any coincidence that such an article would be published just as the RA is considering the report about the topic and new motions on case management.  Clearly there are forces at work to push the case management agenda for the profession.

Unfortunately for the cause, the report to the RA reveals major problems for those who would like to think that OTs can act in a case management capacity.  Here are some rather stunning details in the report:

1. Of employers surveyed 98% LIMITED the case management role to nurses and social workers.  The vast majority of primary and medical employers required that the position be filled by a nurse only.

2. Of insurance plans surveyed in 14 states, 98% DID NOT allow occupational therapists to fulfill the role of a case manager.  Again, the majority stated that a nursing degree was required.

3. The committee survey attempted to find OT practitioners working as case managers only FOUR could be located in the entire United States.  Adding to the SEVEN members of the Ad Hoc Committee that is only ELEVEN OTs in the United States working in this capacity.

4. Not all state license and practice acts identify case management as a legitimate role for occupational therapists.

Despite the overwhelming lack of justification for any consideration whatsoever, the Ad Hoc group proposes several motions including AOTA lobbying license boards to recognize case management courses for OT continuing education credit, for AOTA to develop an official document on the role of OT in case management, and the creation of an online special interest section for professional networking of OTs working in this area.

The lead paper in the AJOT this month presents a similarly surprising argument given the overwhelming lack of supporting evidence.  Claiming that the Affordable Care Act is a "game changer both for the insurance industry and for health care providers" the authors state that "one group of providers that can be more than they are now is occupational therapy practitioners." (Robinson, Fisher, & Broussard, 2016).  It is very unclear why these authors think that OTs need to be more than what they are now, or what evidence exists outside of their own perceptions that such changes are needed.  They seem to lean heavily on the premise that occupational therapists should (for some inexplicable reason) be responsible for contributing to the highly partisan and controversial Triple Aim philosophy, which has been discussed here previously.

Why would a lead article in AJOT that offers nothing but the opinion of the authors as evidence be accepted as a legitimate argument to change the role and scope of the occupational therapy profession?  And why would such a paper be published just as some Ad Hoc committee makes recommendations to pour scarce resources into a project that benefits ELEVEN occupational therapists in the entire United States?

To be fair, not a lot of resources would be required to enact these proposals, but what justification exists for allocating any at all?

Isn't an Ad Hoc committee and a lead article in the professional journal and the volunteer efforts of RA members who are now forced to spend time on this issue enough to meet the needs of eleven occupational therapists in the United States?  Or do we really need to now spend money on more meetings and more papers and more conversation?

Spending time on case management roles for OT is wasteful.  These efforts have no practical relevance to the profession. There are certainly more pressing issues for members of the association to attend to.


AOTA Representative Assembly (2016, January 8). Report of the Ad Hoc Committee on the Role of OT as Case Managers, Bethesda, MD: Author.

Robinson, M., Fisher, T.F., & Broussard, K. (2016). Role of occupational therapy in case management and care coordination for clients with complex conditions. American Journal of Occupational Therapy, 70, 7002090010.

Monday, March 14, 2016

Why Dads are so lucky.

I pulled this out of a fifteen year old journal tonight and decided to post it.  My daughter will be 21 years old next week so I thought I would remind her of a story.

I need to explain a couple seemingly disconnected points.

Casey (my youngest daughter) will write novels or be an artist someday - I am sure.  She writes constantly, and she is only in kindergarten.  I find scraps of paper all over the house, and she will take books from my library and sit down to spend hours copying the words.  She is like a little monk scribe, preserving the world's knowledge before the Dark Ages.

It is so funny to see what she copies.  The other day I found a couple pages about an annual spaghetti dinner, complete with driving directions.  I also found a page about renal physiology from a medical text.  Of course she has no idea what she is writing, but it is just the act of copying that she seems to love so much.

She surprises me sometimes, and is able to form sentences and draw pictures.  I found her "diary" the other day - but I have to explain the other point first...

I got a haircut a couple weeks back and it was a radical departure for me: most of my long hair was hacked off, and it was scary for Casey to see.  "Where are all your curls, Daddy?" she wanted to know.  And she was so concerned, "If your hair is gone, what is going to keep your brains in??"  She wouldn't leave me that night, and fell asleep right next to my head - guarding my precious brains to make sure nothing bad would happen.   I love the way young children think and have such a shaky concept of how human bodies work.  But I failed to understand what she was really telling me.

So I found a notebook with writing and pictures in it, and she told me it was her diary.  She doesn't copy in it, she told me.  It is only for what she thinks up in her own head.  I was intrigued; after all, she is only 6 years old.

My heart broke and healed and was warmed all at the same time when I opened to her most recent page.  It has a picture of a person, who she tells me is her.  The person has "thought clouds" as she calls them above their head - there are two of them (these are the little bubbles leading up to a cloud, indicating that the person is thinking.  She must have learned to do this from one of her sisters).

Anyway, in one thought cloud there is a picture of a happy and smiling face.  In the other one there is a picture of another face.  You can see that it had a sad mouth on it, but that she erased it (poorly) and put a happy face over the top of it.

Along the side it says, "I love you."

So I asked her what it was a picture of and she said, "I was just thinking and I felt kind of sad, but I felt kind of happy too.  And then I decided that I only wanted to feel happy, so I changed it to a happy face."

Also written on the page are 6 simple words: "My Dad is get a haircut."  In the most beautiful 6 year old printing I think I have ever seen.

Poor Casey was so bothered by my changed appearance but loves me so much and never wanted to show her sadness over the change.  And it was not just that she didn't want to show her sadness - it was more than that.  She wanted to show her love.  Despite something that was hard for her, and obviously made her sad - she found a way to show love.  That is the kind of love that persists - even when you lose your hair and your brains are at risk.

That is why I think Dads are so lucky.

Thursday, March 03, 2016

How some OTs are responding to criticism

Sometimes images can convey an action or feeling better than words, so I offer this as representation of the occupational therapy profession's response to the Washingtonian article that some in the profession believed was overly critical:

Like the Spartans, many occupational therapists responded to the message in the article by killing the messenger.  That might not be the best idea.

I made the following comments in the article but since I am not assured that those comments will persist I thought I would document them here.

Some OTs are concerned that the article is unfair and undermines the legitimacy of OT in general and their work in particular.  First of all, a magazine article can't undermine the legitimacy of anything. It is a piece of journalism. As such it has some reporting elements and invariably there are some differing opinions injected. Those opinions exist outside of the magazine article. The article does not undermine legitimacy; the opinions do. Therefore, it is important to look at the opinions that are reflected in the article.

Some defenders made comments that promoting normal development is a good thing to do, particularly since so many children have experiences that are not encouraging school readiness skills.  There was discussion about how the current culture and parenting practices are not always beneficial for children.  In the comments one therapist asked several questions related to "When is it bad to..." and those were all great questions because the answer to all of them is never. It is never bad to promote a child's development - but that is not the opinion here that is problematic. The opinion is a matter of whether or not it is ethically correct to promote and recommend therapy for every level of small deviation from normal that might exist.

So although it is never bad to promote a child's development, the real issue is whether or not it needs to happen in context of a skilled occupational therapy encounter.

Here it is important to take square aim at the American Occupational Therapy Association that promulgates policies and positions that countervail existing practice realities. Current practice realities include the fact that services are reimbursed with municipal money and that it is not in society's best interest to provide a therapeutic service to any child 'just because they might benefit.' Occupational therapists are routinely instructed by their professional association that they should promote wellness and that medical models should be questioned and that new models of prevention by providing 'population based services' should be adopted by all. Those are well intentioned but very misguided instructions.

Now those are all fine ideals and I understand the very good intentions behind those concepts but that is not how the world of municipal funding works and that is not how the world of private insurance works. Those ideas are also incongruent with how services are delivered in early intervention programs and school systems. These systems are not designed to provide services to anyone who might benefit.

So the problem here is not that an article is undermining the legitimacy of OT. The problem is that there are some OTs are providing services that might be unnecessary given the realities stated. They get ideas about providing those services because of misguided but well intentioned association-level dialogue. I notice that an AOTA pediatric representative commented and referenced the Practice Framework. I encourage my colleagues to take a deeper look and examine the expansion of the definition of OT that has occurred over the last three versions of that Practice Framework in the last 12 years. The definition of OT has expanded from being a service for people who have disabilities and it now states that OT is a service that promotes wellness for entire populations.  I documented and discussed this issue extensively in a previous blog post.

Some occupational therapists are abandoning their professional purpose and breaking the social contract of providing services to children who have disabilities and instead they are promoting this notion that 'everyone can benefit.' It might be true that people can benefit but that is not how the system works and that is not what society wants to pay for.

That is why we see articles like this.


In addition to problems with expanded definitions of practice that don't jibe with reimbursement reality there is also the problem that some therapists are providing services that are not evidence based and not reimbursed by regular insurance.   

This is a re-occurring narrative.  This is not the first such article that describes parents being charged thousands of dollars for evaluations and therapies that insurance will not reimburse. The prices quoted in this article are in line with what others have reported in many other venues and they are in line with what happens from some providers in my own community. Some unscrupulous OTs are charging these rates that are double, triple, quadruple, and even more than what any private insurance would pay for the service.

Furthermore, these services are charged for therapies that sometimes have very poor evidence to back them up. That does not mean that this represents ALL occupational therapy but this is a reality and we don't correct the problem by refusing to acknowledge it.

The problem does not solely exist in private practice. This time last year there was collective outrage about a NY Times article that discussed the skyrocketing rates of service provision in public schools. We can have interesting debate about the nature of modern parenting, the shifting culture and lack of outdoor play spaces and opportunities, the changing criteria for autism, and the rates of medication for young children - all of these are factors - but in my opinion responsible professionals should work to educate families about how they can personally work to mitigate these negative influences. Not every child needs to be placed on a therapy program.

My suggestion is "Occupational therapy: Heal Thyself." All the good that is done by so many responsible and ethical occupational therapists is quickly undone by your colleagues who are quick to swipe some concerned parent's credit card or by your colleagues in the school engaging in pseudoscientific quackery instead of evidence based practice or by your colleagues who have abandoned the original purpose of occupational therapy in pursuit of a new wellness service for the whole population.

I ask my colleagues to please stop killing messengers.