In January of 2021, I resigned my position as a staff occupational therapist, after 35 years in the field. It has been, to say the least, an incredibly rich, as well as challenging, journey. Although I looked forward to retirement, it has been hard to 'hang up my goniometer.' If truth be known, I'm still working as much on-call as when I was full time. To the best of my knowledge, I had never retired before, so retirement provided an opportunity for reflection, along with questions related to "What the heck do I do now?" I’m going to leave the future in the future for the moment.
What I would like to do here is to give the reader a chance to laugh at some of my experiences, contemplate others and, hopefully, acquire a few more tools for life as an occupational therapist.
The stories that follow are roughly in chronological order, from fieldwork to present.
1) Over Before it Even Started (almost!)
My first patient while I was a student was a 30-something gentleman, who had crashed his ATV (all terrain vehicle) while out on a ride in the woods. Although he was in a coma there were almost no marks on his body, except for a pencil lead-sized wound just over one of his eyes. He had been tossed into a bush and a small branch had entered his brain just over that eye. I was asked to perform passive range of motion twice-daily until he 'woke up'. Sadly he never did; after his passing, a family member asked me if my therapy could have caused his death. I knew it had not, but the question was devastating. I seriously considered ending my occupational therapy career at that point. His attendant pulled me aside and said, "I know what you are thinking - and stop! You absolutely know that nothing you did caused this." Deep down I knew that, but I needed to hear it from another professional to regain my composure. Losing a patient can and will be devastating for your mental health. It will happen, but take comfort in the realization that you treat your clients with love and respect.
2) Learning from practice (Level 5 therapist?)
My second Fieldwork took place at a psychiatric institution in the state of Rhode Island. One of the funnier memories from that experience was working with a young man who wanted to make something nice for his girlfriend. This site, at that time, operated under the Allen Cognitive Model. In the 80s, the model had essentially six levels; the sub levels that now exist were added at a later time. My patient scored at Level 5 in terms of his abilities. People operating at Level 5 had minimal cognitive impairments, but often did not consider the consequence of their actions. My patient decided he wanted to make a ceramic vase and I went over the instructions with him. The final instruction was that, when the timer rang, he was to pour the slip (mud) out of the mould. This was actually a Level 6 activity, but I was convinced that the evaluation was in error as he was verbally operating at such a high level. He assured me that he understood the directions and I moved on to work with a second patient. I kept him in eyesight, so I could monitor his behavior and noted that, when the timer rang, he dutifully poured the mud out… onto the floor. He had done exactly what I asked him to do, as I did not tell him to pour it back into the container.
Prior to becoming an occupational therapist, I had earned a Master's degree in counseling. One of the courses we took required us to demonstrate competency in administering a number of cognitive evaluations. When I first encountered the Allen Cognitive Test I was extremely skeptical of its ability to diagnose cognitive function.
From this incident, I developed a deeper respect for some of the assessment tools found in occupational therapy.
The patient had significant skills in communication. What I neglected to consider was that verbal skills did not necessarily correlate with the ability to recognize potential errors in behavior. The entire experience was a lesson in humility... Perchance it was I who was operating at Level 5 that day?
My first physical disabilities position was at a medium sized hospital in Maine. Most days I found myself on the eleven bed rehabilitation unit. The nurses there were absolutely great and two memories about the compassion they displayed stand out. One day they brought in a survivor of a terrible automobile accident, an eleven year old boy. The family had been towing a new boat back to Maine when a strong crosswind caused the father to lose control. This child was the only survivor; he had lost his entire family in the crash. Certainly he had terrible physical injuries, but his emotional trauma was even greater. The nurses could have simply placed him in a wheelchair to move him down to the shower room each day. Instead, I think they sensed that what he needed most was emotional support, as each morning I would see one of them gather him in her arms and carry him to the showers.
Another patient was a terminally ill woman with a large astrocytoma. Since the day she arrived on the unit she was deeply confused, which led to a tremendous amount of agitation. She had spat on, sworn at, scratched and just generally made her nurses lives difficult for weeks. Yet, on the day she was to be moved to the hospice, every one of the nurses she had abused stopped at her gurney to hug her, kiss her forehead and wish her well. Their compassion greatly calmed her.
They also had a great sense of humor. On my last day at this unit I was talking with the charge nurse, when we heard a crash and call for help from the shower room. As she sped off she touched me on the shoulder and said, "We probably need help, come with me." We entered the shower room to see a transport chair on its side in one of the stalls. The next thing I heard was the door being slammed shut, as the curtains in each stall slid back to reveal more nurses armed with hand-held shower heads. They proceeded to use them on me, while my 'friend' the charge nurse made sure I couldn’t escape. Everybody got soaked but it was one of the funnier times I ever experienced as an occupational therapist. It was a hilarious way for them to send me off after two years on their unit.
In the years that I taught, I would always tell my students that I never wanted to hear any of them complain about those who chose nursing as a profession.
[Nurses] are truly the 'grunts in the trenches of a medical battlefield'. They deserve all the respect and assistance that we can possibly give them.
4) The Unholy Alliance: Physical and Occupational Therapy
Patient: I've finally figured out the difference between Physical [Physiotherapy] and Occupational therapy!
Us: Oh, what?
Patient: Well, PT stands for physical torture and OT means occasional torture.
During my college years and early on in my occupational therapy journey, physical and occupational therapy battled constantly over 'turf'. Thankfully, I believe that those battles are pretty much a thing of history. An OT and PT team is a powerful entity. In evaluations, much of what we collect is identical; joint evaluations allow the patient to provide demographic information only once. Joint treatments can be just as effective when conducted by a team. In this situation, two sets of eyes really are preferable to one. Unfortunately, in the US, Medicare disallows payment for joint PT/OT interventions. Yet if you can work together, your patient will benefit greatly.
5) 'Common Threads'
All too often we see our patients as 'the grouch in room 9', or one of a myriad of evaluations and treatments we need to do to get through the day. All this before we can even begin our documentation. I love working in hospitals, but some days we are overwhelmed by high caseloads and increasing demands.
A 'common thread' is something that a therapist and patient share. It could be an experience, hobby or interest; virtually anything that allows a patient and therapist to connect 'outside' the medical setting. This point of mutuality allows both parties to begin to develop a relationship based on trust and respect; I might argue that it is the origin of the therapeutic relationship. As a veteran, very often the common thread has its origin in the shared military experience.
When you first enter a patient's room, it is wise to remember that two evaluations are occurring simultaneously. Just as the therapist is evaluating the patient's cognitive and physical abilities, so the patient is evaluating the therapist.
The patient is assessing whether the therapist appears competent and whether we have something to offer, in terms of their recovery. In addition, the patient is evaluating the therapist's demeanour, deciding whether they even want to work with us.
Prior to starting a new evaluation on a 70+ male years ago, one of his caregivers told me, "Oh, he is the laziest man you’ll ever meet, he does nothing for himself." I introduced myself to the patient and explained what my role was in his recovery. When I asked him what he might like to do, he replied that he needed to use the bathroom. Afterward he gruffly told me he couldn’t perform his own hygiene (all of this was stated in rather more blunt terminology!) Needless to say, my initial impression of this man was not great. In the days to come he would always be too tired, uninterested or just irritable. I began to put him late on my daily schedule, knowing that he would refuse therapy. One day I entered his room to find him asleep (as usual) with a newspaper across his chest. It was opened to an article about a controversy, centered around the possible reclamation of two aircraft that had collided and crashed into a large lake in Maine, during WWII. The aircraft had been flown by Canadian student pilots and their remains were still in the wrecks. The Canadian government viewed the aircraft as gravesites and was against them being disturbed. As I looked at the article, my patient awakened and I asked him for his view of the debate. He replied, "I flew one of those during the war." My immediate thought was that he couldn’t fly his butt to the bathroom and back, so how could he have flown one of those. I said to him, "You flew an F4U?" I really didn’t believe him and thought I could test him, by referring to the official designation of this plane. His eyes widened and he replied, "You know about the Corsair?"
In the days that followed, I would always begin by asking him about his experiences in that plane. After a short history lesson he would look at me and say, "What do you want me to do today Bill?" His entire demeanour and willingness to work with his therapists changed. In the end I came to know that this was a man who did fly in WWII and who turned down an offer from his commander to attend law school free of charge, at war’s end. He did attend college, earning degrees in dentistry and theology. His post-war years were spent flying bush planes into remote parts of South America, bringing dentistry and religion to those he met. A mutual love/interest in aviation was our common thread. But the experience also taught me a valuable lesson: don’t write people off just because they are difficult. I used to tell this story to my students, along with the point that this patient had called me a 'gentleman' on our last day. I tried to make it clear to my students that, if I had not kept searching for some common ground, I would never have learned his story - and he would have gone to a nursing facility, instead of his assisted living residence.
6) Ahh I’m sorry, but can you repeat your question?
Standing in front of a class of students, who have chosen to major in occupational therapy, is simultaneously thrilling, terrifying, rewarding and frustrating.
If you ever have a chance, even as a guest lecturer, please take advantage of it. Students are hungry for clinical anecdotes, both as a way to understand the why of what they are required to learn, as well as how the learning will be used in treatment. The fact that many instructors have left the clinic to teach is one of my pet peeves. We need to be teaching content that is relative to what the student will encounter in her/his own professional life. I frequently compare students to chrome mannequins. If there is no framework to attach new learning to, it simply slides off. As a professor, my job was not only to be professionally competent in my skills, but to have developed a method to assist my students incorporate new learning into the frameworks they already have. It is challenging, at times frustrating, but so incredibly rewarding, when you see the light of understanding in their eyes.
Oh the title for this section? After years in the military, riding motorcycles and heavy use of power tools, my hearing gradually began to fail. It got to the point where any question posed by a student had to be repeated at least three times. If you approached me during a test, asking for a clarification of a question, whispering… there was NO chance I would understand. When I finally got my hearing aids, I turned to my class one morning and said, "If you talk behind my back now, I WILL hear you." We all got a big laugh out of that.
7) The Missing Switch
He had survived something like six strokes. Although physically able to ambulate, dress, bathe etc., he could not. I would ask him if he wanted to get dressed, to which he would reply "Yes", but then he would sit there. The patient could even describe in detail what we were asking him to do. At one point we began to think he was just flat obstinate. One day, a nurse walked by and asked him if he was cold without his shirt. He replied yes, at which point she held one out for him. He immediately took it and put it on. We began to realize that he could perform tasks spontaneously but not to command. He just couldn’t find that 'switch'. Sadly, he was never able to go home, as the family could not understand our explanation of his behavior. I went to treat him in his nursing home one day; walking down the hall I could hear someone saying "Help me, somebody help me" in a muffled voice. I walked into his room to find him in his bathroom. He was standing at the toilet, pulling toilet paper off the roll, but couldn’t figure out how to stop. The toilet bowl had the prettiest stack of white tissue in it, resembling a giant ice cream cone. When I handed him his toothpaste, he grabbed it and exclaimed, “Oh thank you." Essentially, our strategy was to stay one step ahead of what we wanted him to do.
Initially, the physical therapist involved in this case and I spent a considerable amount of time trying to understand why our patient could not follow requests. The patient was, at all times, friendly and eager to work with us, so assuming he was being obstinate did not seem likely. His behavior did not suggest either ideational or ideomotor apraxia. He understood the 'idea' of objects and tasks. He could perform 'motor' behavior spontaneously but often, as in the anecdote above, could not start or cease a behavior once initiated. These issues were not solely related to ADLs. As he and I walked to the bathroom one day, he spied the open doors of the wardrobe in his room. What do you do with an open door? Walk through it! Very shortly he had 'folded' his tall frame into the wardrobe. I got in with him and he laughed and said, "Bill we have to get out of here." I replied, "Yup, I'm working on it." My best guess was that the transient ischaemic attacks (TIAs) had damaged a portion of the brain responsible for initiating or stopping behavior.
8) “Well son, I’m 93 and no man has ever seen me naked”
Another rehabilitation hospital, this one in Portland, Maine. My patient was a 93 year-old woman, never married, who had just come through bilateral hip replacements (WHY would you do them both at once!) I went to meet her the day before and explained what we would be doing the next morning. I told her that I understood that she might be uncomfortable working with a man and asked her to think it over. I would try to find one of the women therapists to work with her, but that we were short handed. The next morning I entered her room and re-introduced myself. "Have you had a chance to think about bathing and dressing?" "Yes" she replied. “I’m 93 and no man has ever seen me without my clothes. Then I got to thinking; I’m 93, what the heck do I care?" she said, with a smile and a laugh. She did have to give up wearing her traditional garters, but she did go home!
9) North Carolina days
Bilateral shoulder pain in a 92 year-old female...
Me: "Ma’am, is there anything you do during the day that seems to aggravate your shoulders?”
She: "Well, when I’m out there chopping wood it bothers them."
Me: "You still chop wood?"
She: "Well, somebody's got to do it. My daughter works and the kids are all in school."
Me: "Ma’am, how much wood do you chop?"
She: (Looking at me incredulously) "I chops till it’s done."
Me: (To daughter out in waiting room) "Does your mom still chop wood?"
Daughter: "Oh yeah, we can’t keep her out of the woodpile!"
The patient and I agreed that she would count the number of pieces she split each day for a week. We averaged the number and I asked her if she might just chop half that number each day. She agreed and consequently the pain went away. Discharge ensues.
A Lifetime Together
She had fallen and incurred a fracture to the distal radius of her left forearm. The fracture heals well and motion begins to return. But she is absolutely one of the saddest people I’ve ever met. She related that her husband had recently died; that she had spent every evening in the hospital with her husband of 50 plus years. One morning, she awoke to find he had passed away during the night. He was on his side with his face pressed against the rails of his hospital bed. She could not shake the guilt that she had slept through his final minutes and he had died in such an uncomfortable position.
In her grief and guilt this lady had completely withdrawn from any contact with friends - and life in general.
In the weeks that had passed since her occupational therapy treatments had started, she had spoken often on how they had met, grown up together and eventually married. They had literally spent a lifetime in each other’s company.
The treatment prior to her final one I asked her to consider another possibility. Perhaps he had known that he would die that night and wanted his last memory to be that of the fifteen year old girl he had married decades ago. So he rolled onto his side, getting as close to her as was possible and gazed at her in those final minutes. She didn’t say anything, just donned her coat and left. A week later she entered the clinic one last time. "Bill, I don’t know that what you described is what happened. But I’ve decided that it might be and that I need to go on living my life. I’m going out with my girlfriends tonight and for the first time in months, I’m looking forward to it."
10) …and in the end
When I arrived at this final chapter I found myself completely stumped. No anecdotes to relay to you, nothing stood out from these last seven years. I finally began to realize that maybe I’ve come to a point where I can appreciate all my patients, not just the special cases. Every patient has a story, if you will just listen.
Therapy is a 'dance' between two people. Just as in a dance, sometimes you lead; but, to be effective, you need to be willing and able to step back and let your patient 'lead.'
The patients, who I have been honored to work with over these decades, have enriched my life as much as I may have helped them understand how to heal their bodies and minds.
In closing, I would like to leave you with the words of Michael Weisskopf, a Time Magazine Senior Editor, who was severely wounded while on assignment in Iraq. Weisskopf saw an object fly into the back of a truck in which he was riding. The object was a hand grenade and as he attempted to throw it out it exploded, taking off part of his right arm.
"For me, occupational therapy was a land of potential, a place to stop grieving and learn how to compensate for my injury, with technology and ingenuity. It was my bridge to a normal life."
Weisskopf, M. (2006) Blood Brothers: Among the Soldiers of Ward. 57.