Updated: Nov 8, 2020
A couple of weeks ago I attended a networking meeting run by a local university. As part of the event, a few of the lecturers did a presentation on various occupational therapy models. It was an interesting feeling 'going back' to uni, and having a refresher course on things that had been hammered into me while I was there! I felt pretty confident that what was being talked about had become an automatic part of my practice. I left the presentation feeling pretty sure that what I had learnt years ago at uni was still being applied in my day to day practice.
Then I met one of the lecturers and got chatting with her about the struggle to find appropriate placements for her students, as a fair few private occupational therapists are not focusing on occupation, rather they are too deficient focused and are using non evidence based therapies. After hearing all her concerns, I suddenly felt that maybe I wasn't applying occupational therapy principles as well as I thought I was. I was guilty of doing some of the things she had issue with! I know that the 'ideal' isn't always completely relevant or particularly applicable for real life. In the workplace, you come across situations that uni simply can't prepare you for. You develop your own style and repertoire of knowledge and skills. Sometimes all you have is your clinical judgement to make decisions, because everyone is an individual, and no one size fits all. But the core concepts that you are taught, that makes your profession what it is, they don't change. Sure there might be advances, new research, new ways of doing something. You might trial something that hasn't yet been validated by research or studies. But at the end of the day, teachers still teach, engineers still engineer, and occupational therapists focus on occupation. I was confronted with the challenging thought of "Am I even doing this right?"
My colleague and I walked away from the meeting discussing our practice, and analysed if what we were doing was goal oriented, strengths based and occupationally focused. We decided it was, yet I continued to go over and over everything I have ever done, said or wrote. And then I begun wondering, why was I struggling so much to understand what was 'right' in my own profession?
After much reflection, I think that it's because occupational therapy has been diluted. That sounds really harsh, but as I started talking to and reading blogs from therapists, students, educators and parents I realised I wasn’t the first to come to this conclusion. Why do I think our profession has been diluted? I think in part it’s because occupational therapists can work in such different ways, and across vastly different settings. We often work in multi- or trans-disciplinary teams, so the lines between our profession and others can be blurred. If you go to a job search website, you'll see adverts for a Physiotherapist/Exercise Physiologist/Occupational Therapist as if we are interchangeable or one and the same. I have met occupational therapists who vehemently advocate for completely different therapies, often contradicting one another. There is no wonder that parents, families or individuals are confused about what constitutes occupational therapy, when as a profession we can struggle to agree.
Leaving university, I felt are so sure of what occupational therapy is. We were taught to focus on occupation, to use it as a therapeutic tool, as a means to an ends. We were taught to advocate for and find meaning and purpose and to use a "top down" approach. But out in the workplace, it can be really hard to hold onto this. It can be easy to start looking at personal impairments rather than overall functioning. We get asked to help a child self regulate, or hold a pencil correctly, or to have better attention. It's our job to dig deeper, to find out the "why". Why does a child need to self regulate? What is the end goal? Self regulation itself isn't a goal, but self regulating in order to engage in a meaningful and purposeful activity is. It's easy to slip into the habit of focusing on trying to address individual differences rather than focusing on making changes to the environment and occupation. When listening to the models being presented, I thought to myself "I do that. I think that". But when I talked to someone who really did do and think those things, I realised I use a watered down version. That sometimes I did try to 'fix' the hand strength of a child in order for them to hand write, using an activity that had no meaning or relevance to the individual. That I have focused on improving an individuals attention, instead of focusing on adapting the environment and activities given to support what they can do. That I have used strategies because I had been told or shown them, and not necessarily looked into the research (which was sometimes very weak or non existent) behind it.
Does this make me a terrible therapist? I don't think so. I think it makes me a therapist that might not be as good as I could be, but I don't think it makes me a "bad" one. I do set meaningful goals, I do look at the environment, I modify, grade and adapt tasks. I might slip into bottom up thinking from time to time, but I've also been told (on more than one occasion) that I always see the best in those I work with (and that maybe sometimes I should be a little more "realistic"... I refuse to accept that one!). I have to acknowledge that it is hard to be up to date on research for everything I do, and that I often need to use my clinical judgement and previous experiences to guide me. Research is limited, and a study may not have included the clientele I work with, or it may have been a small sample size. Sometimes I do have to focus on the individual, and work on their individual needs, but this should not be at the expense of meaningful and purposeful activities. An activity might be fun, but that doesn't necessarily make it meaningful.
I think it comes down to having pride in our profession, and refusing to be cheapened by pseudoscience or quackery. We must hold ourselves accountable, at every moment and during every decision. I don't want ever want to be asked "why did you do that?" And have my answer be "to fix blah blah blah". Instead, my answer should be “in order for this individual to engage in an occupation that is meaningful and purposeful to them”.
Last year, I had an OT colleague say to me "I think occupational therapy is just common sense". To me, this is as bad as occupational therapists spruiking advice that has no evidence behind it, or being deficient focused. We should not hold ourselves to such a low standard. If what you are doing is “just common sense”, then you're probably not doing it right. It's easy to look at a situation the same way as everyone else. As occupational therapists, we are trained to look at things differently. Sometimes simple is best, but if your answer is always "just common sense", then you aren't applying your skills effectively.
It's easy to fall into bad habits, to do what others do without thought. It’s easy to be sucked in by convincing people who sound like they know what they are talking about. What's not so easy is being consistently vigilant that what you are doing is true to your profession. That what you are doing is evidence based. I think there is a reason we don’t have mountains of research in occupational therapy; we’d generally prefer to work with someone than analyse statistics. But we must hold ourselves and each other accountable. We need to be critical of therapies that put our profession at risk of a poor reputation through encouraging poor or lazy practice. We need to be able to define what sets our profession apart from others.
I'm committed to making my practice better every single day. Who's with me?
Originally posted on Rocket OT, as 'Standing on My Soapbox: A Paediatric OT's Ramble.