Glen Gillen; A Fork in the Road: An Occupational Hazard?. Am J Occup Ther 2013;67(6):641–652. https://doi.org/10.5014/ajot.2013.676002
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Overcoming the monster: Jack and the Beanstalk, Frankenstein, and Jaws
Rags to riches: Cinderella and Aladdin
The quest: Don Quixote and Raiders of the Lost Ark
Comedy: The Marriage of Figaro and Shakespeare’s comedies
Tragedy: The Picture of Dorian Gray and King Lear
Rebirth: A Christmas Carol and It’s a Wonderful Life
Voyage and return (the plot I focus on): Gulliver’s Travels, Robinson Crusoe, Alice in Wonderland, the Wizard of Oz and, in my opinion, our journey as an occupational therapy profession.
From normalcy to falling into the other world: Normalcy is our usual, customary, traditional, normal functioning as a profession. I define other worlds as not just our attempts to be influenced by, but our adoption of and substitution of, other professions’ approaches and techniques. The obvious hazard is professional role blurring and loss of professional identity.
Fascination with puzzling and unfamiliar things: Even in past Slagle lectures, we have called our own interventions “commonplace” (Reilly, 1962, p. 1) and “unsophisticated” (Hollis, 1979, p. 499). When I first began as a full-time academician, I was lamenting with a seasoned colleague about why our students are still reporting not seeing occupation practiced in the clinics. She responded by saying that occupation appears to not be sophisticated. She also added, “It’s not sexy!” If we feel that the tools of our trade are both commonplace and unsophisticated (and, I suppose, if we’re not feeling sexy), it makes sense that we would seek out seemingly more sophisticated techniques and approaches. However, it does not guarantee that these approaches are more effective or even in line with our profession’s philosophy. We begin to envy our colleagues in other professions, and further professional blurring continues.
Frustration: Although I am only in the clinic 1 day a week, most of my day is about problem solving and celebrating the small successes one would expect to see on an acute neurology unit. However, there are everyday frustrations in clinics across the country that we all know as well. Why is this not working? How can I make clients better, and how can I do this faster? Why are they trying to do what I do? Why doesn’t everyone know my role here?
Thrilling escape and return to normalcy: It might not be thrilling, but our return to normalcy is imperative. I am going to argue that to move forward, we may have to take a few steps back to get to where we want to be.
Increases gray matter in sensory and motor areas both ipsilateral and contralateral to the affected limb and to the bilateral hippocampi,
Strengthens motor cortical areas and associated descending cortical connections,
Increases contralesional and ipsilesional cortical activation on functional MRI, and
Increases areas of activation to the cerebellum and mid-brain (Young & Tolentino, 2011).
Verisimilitude, the degree to which the cognitive demands of the test theoretically resemble the cognitive demands in the everyday environment (“functional cognition”); identifies difficulty in performing real-world tasks
Veridicality, the degree to which existing tests are empirically related to measures of everyday functioning (requires a statistical analysis).
“Predictions based on neuropsychological test data tend to be more accurate if the particular tasks utilized during testing closely match or simulate the individual’s everyday and vocational demands” (Sbordone, 2001, p. 199).
“The ecological validity of neuropsychological testing can be extended by observing the patient’s approach to tasks in the assessment environment and by observing the patient in his or her normal activities” (Bennett, 2001, p. 237).
“The importance of reliable behavioural observations, made in more ecologically valid environments than purely the consulting room is stressed” (Manchester, Priestley, & Jackson, 2004, p. 1067).
How much time is spent on impairment-level and preparatory interventions that are not occupation based? Practitioners, I challenge you to consider your practice in terms of the actual percentage of time spent in occupation. I encourage you to reflect on this and, with your peers, implement a plan to consistently increase this percentage over the next months. By the way, I have no problem with preparatory activities. I do have a concern over how they may be being overused.
A related issue is whether we are using authentic occupations in the clinic or catalog-purchased contrived activities. Practitioners, this change needs to occur now. I will tell you this is not only doable, it is also less expensive! We have generated a body of research emphasizing the use of real, familiar, and age-appropriate objects and occupations.
We need to move away from “therapists doing to” and back to a model of “clients doing”—back to the actual practice and the actual doing we discussed in 1922 and that, again, are now being called cutting edge and contemporary. Everything old is new again.
Do we look like occupational therapists? If we visited each other’s clinics, how often would we see authentic occupations being used? We need to practice what we preach. If we do not, we are on unsteady ground to protect what we do. At the same time, we need to stop encroaching on our colleagues’ approaches and methods.
There is nothing wrong with being influenced by our colleagues in other professions. However, let us learn from our mistakes and, going forward, maintain our confidence that our approach is effective, artistic, scientific, reimbursable, and evidence based. Let us not repeat our mistakes of replacing our approach by adopting others’ techniques.
Let’s stop trying to convince ourselves and our colleagues that we can predict occupational performance from non–occupation-based assessments.
In terms of assessment, the time to embrace performance-based assessments is today, if not yesterday. As stated, these tools are already developed and available. Some argue that we do not have time to use them. I would argue back not only that they are time savers but that we do not have time not to use them to maintain our professional identity.
How much information should we include in entry-level texts and programs related to potentially outdated approaches to assessment and intervention that are not historically ours and have not shown the ability to predict or improve occupational performance? How much curriculum time and testing should we spend on this material?
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