- Re-post: The Passion from a kid's perspective
- The meaning of a word cloud
- The danger of assuming universal and singular narrative explanations of disability
- The Barton Project: AOTA 2017 Conference Handouts
- Governor Cuomo and the Early Intervention State Fiscal Agent boondoggle
- Reasons to yawn: Wrap up analysis of two recent SCOTUS cases involving IDEA
- You can't keep a good event down...
- A request for honesty about modern day practice in long term care facilities
- The Lenten message of Emmanuel practitioners that influenced the occupational therapy profession
- An unusual connection between American opera and George Edward Barton
- Occupational therapy history: A lopsided tale told by the 'designated survivors'
- The use of online journaling as a qualitative methods datasource
- Why occupational therapists need to stop romanticizing about Hull House
- The problem with a Mad Libs approach to advocacy
- Deconstructing the myth of clothing sensitivity as a 'sensory processing disorder'
- Isabel Gladwin Barton: Wife, Helpmeet, and Collaborator
- Guest entry: Taking a stand for patient safety with the Hospital Readmissions Reduction Program
- Guest entry: Advocating for FERPA rights
- Guest entry: Advocating for a loan repayment bill that could impact occupational therapy
- Guest entry: Advocating for canine training programs that benefit veterans
- Guest entry: Advocating for co-payment reform in New York State
- Guest entry: Advocating for people who have traumatic brain injuries
- Guest entry: Advocating for occupational therapy wellness programs
- Guest entry: Advocating for a workload approach in school systems
- Support for ESSA - not as simple as you think
This image caught my attention when I attended the Presidential Address at the AOTA national conference in Philadelphia last week, and it has been tweeted around in occupational therapy circles since that time. here and here and here and here, to link a few. What exactly is the meaning of this word cloud? The initial intent of word clouds was to provide a base narrative analysis of content within written text. Even at their best they are crude, because the words are presented in a decontextualized format. In this example the word cloud is a manipulative message driving tool that is mis-used to promote certain ideas over other ideas. In this particular representation we are led to thinking that Population Health" is an important concept and related critically to other concepts including "Care Coordination" and "Triple Aim" and "Outcomes" and "Patient Centered." The words are neatly arranged in appealing colors and in various sizes so that certain messages will catch our attention. But what is the source of the data that is used to populate the word cloud? Are we supposed to believe that these words represent occupational therapy practice? Or occupational therapy values? Or something that some academic dreamed up after nodding off during a Donald Berwick lecture? We are never given that information. We are simply presented with words, and led to believe that they are important. We are led into a state of obsequity, and it is assumed that we should just trust the messenger.I encourage population health or public health or occupational justice or social justice proponents to stop feeding the profession these word clouds (whether presented at a conference or in an academic journal) and instead try linking these ideas to real practice where they can be tested against reality of specific care contexts. The proponents of these ideas should also specifically address the many questions that have already been raised. Practitioners in the US see that social justice was taken out as an enforceable principle in the Code of Ethics. They have seen a statement on sustainability go up in flames in the RA. But they still see leaders promoting these same ideas in context of poorly defined population health models. Proponents of these ideas need to explain the justification for continued adherence to poorly defined ideas that have been the source of significant professional disagreement. Reference: Hammell, K.R. (2017). Critical reflections on occupational justice: Towards a rights-based approach to occupational opportunities. Canadian Journal of Occupational Therapy, 84(1), 47-57. doi: 10.1177/0008417416654501
In a presentation at the 2015 OT24VX online conference I stated that some occupational therapists are promoting a Fourth Paradigm concept focusing on population health and its relation to the "rights" and "justice" framework. The occupational justice paradigm, represented in a General Systems Theory framework, looks quite different from the contemporary paradigm that focuses on occupation. Instead of intervening at the level of the individual the new model suggests intervention at higher levels of social and cultural complexity. These new models all emerged out of the mid-1990s, a time where we have to consider the impact of the Internet and subsequent globalization of the profession. Through the proliferation of journals and the increased international communication, occupational science became a world-wide academic discipline. Suddenly we were contending with concepts of occupational justice, sustainability, climate change, and broad public health - ideas that were very new to an occupational therapy context and that dont always have social and political fit across international contexts. Many people question whether these ideas even fit into occupational therapy practice at all.
There is still little agreement among proponents of these models what all of the ideas actually mean or how they are translated into practice to help people and reimbursed by third parties. In fact the academics are still writing word cloud articles and admitting that their concepts have no logical coherence or systematization for practice (Hammell, 2017).
That does not seem to dissuade the motivated messengers. _edit: (added) Social media chatter apparently precedes action. I just learned that a group has created a new forum on OT Connections where they can congregate and discuss their ideas. The group, predictably, is comprised of almost all academicians and will be functionally sequestered and insulated from feedback from the profession at large via the protective membership paywall of AOTA. During the business meeting at conference we learned that half of all AOTA members are students who are frequently mandated to join by their academic programs, and a sizable but undisclosed number of other members are their professors. This creates a questionable context to hold a conversation about practice. Would the group be willing to move their conversation to a place where more practitioners would be more able to participate?_
In a recent article appearing on the CNN website, author Wayne Drash reviews the concept of wrongful birth in context of Lesli, a person who has developmental disabilities. Drashs profile states that he "specializes in stories off the radar" and that "his passion is to tell narratives about life and the unfolding drama of the world we live in." It would be more accurate to state that Drash cherry picked one persons perspective and advanced a fiction that serves one ideological perspective. His initial description of Lesli in his opening sentence tells us everything he believes about her person-hood. He immediately goes to the fetal position trope that promotes his message of Leslis helplessness and haplessness. For just a moment the reader is led to believe that there may be another side of the story to be told as he describes Leslis joy at having her mother hold her hand - but the author quickly reverts to reporting the pain that Leslis mother experiences, how she has cried more than anyone how she could barely sleep given the severity of her daughters condition. Then we are provided the quote that the mother does not know if her daughter even knows who she is. The story of Lesli and her mother is framed in context of proposed legislation in Texas that would reverse the decision that allows wrongful birth lawsuits. Apparently, Leslis mother won such a suit many years ago based on an argument that the doctor failed to tell her that she had rubella. The mother states that she would have chosen an abortion rather than "watch her daughter suffer pain." The testimony in this particular case is that the doctor states he did not think that the mother ever had rubella. So, there was no choice to offer her. She won a lawsuit against that doctor for his missed diagnosis. The money remains in a trust fund for the care of Lesli. The mother advocated strongly for Lesli over the years, pursuing education related to rubella and its impact on pregnancy, and working to improve the special education curriculum in Dallas and Wichita Falls. That might have been the narrative for the mother to hold - but her narrative instead is that she wishes that she was never born so that her child would have never been born. That particular narrative is unquestionably hers to have, but Drashs error is in elevating that narrative without telling any other side of the story. There is little doubt that this is a story where the mother experiences pain and there is little doubt that she has come to the narrative conclusions that she has come to. They are as real as the situation that she experiences. However, that narrative conclusion is not the same narrative conclusion reached by all people. That is a primary error in this story. That is also a reflection of the immoral choice by Drash that cherry picks a single narrative. What is the alternative narrative? Leslis mother might have defined her experiences in terms of selfless love given to a child. Or of how a single person can take on an entire system and improve education for thousands of other children. Or of the quality of life that Lesli experiences, exemplified by the simple act of human connection - of holding hands. We are not given any of that possible narrative because even though these things happened it is not the expressed narrative of Leslis mother. Does that mean that the narrative does not exist for others? All that we are given by the author is that when there is a meaningful interaction with Lesli, she _moans_. [_emphasis mine._] "Mom and daughter now hold hands. Lesli _moans_." "Lesli _moans _through much of the session..." Leslis mother has a right to form whatever narrative she chooses. But there are others. Not everyone defines their lives in the same way. Not everyone looks at their child who has a disability and would have chosen elective abortion to pre-empt their perspective on suffering and pain. If we accept the narrative of Leslis mother, where are we left? Would we abort all children who might experience suffering and pain? Would we eliminate that same pain from our lives? When we advance a single narrative to the exclusion of others we risk misrepresenting the story. It is not true, as Leslis mother states, that people dont care about her daughter. The article itself reports that Medicare and Medicaid will pay about $200,000.00 for the cost of Leslis care for the next year. That policy is an expression of a social value. That social value is rather clear that many people are caring. I dont doubt the pain that Leslis mother perceives, and I am not judging her perspective. I am just pointing out that it just happens to be a single narrative. And there are others. Some parents experience the same pain that Leslis mother experiences but they do not frame their perspectives in the same way. In fact, some parents frame their experiences in the exact opposite way and the idea of aborting their child, even though their is suffering and pain, is unthinkable. The alternate narrative, one that I have had a lot of experience with, reads differently. The alternate narrative focuses on the love expressed by holding hands. The alternate narrative focuses on the quality that the child can experience, or the meaning that the parent created out of what seemed like a senseless event. The alternate narrative sometimes turns the concept of disability on its head and forces everyone else to examine their values! The alternate narrative does not involve descriptions of fetal positions and moaning. It is best expressed in the words one parent told me that I will never forget: _So though there were tears, there was laughter more. _ _And though there was pain, there was joy more._ _And when things seemed bleakest, go... feed the birds._ _And the world will right itself._ That is another narrative that exists in the world. There are undoubtedly even more. It is good for us to be reminded of this fact when we are reporting on "narratives about life and the unfolding drama of the world we live in."
Hi and thank you for stopping here to look at the poster handouts that are being distributed at the 2017 AOTA conference! If you were unable to get a copy of the handout of the poster presentation, the files below are hi-res JPG scans that you can download and view in a larger format. This version of the timeline is one small step of a multi-year project attempting to document George Bartons life. I was always struck by the fact that his life story was documented in such a limited way as compared to other occupational therapy founders. The lack of previously published information on Barton motivated my effort. Having personal geographic proximity to Clifton Springs made the project interesting from that perspective as well. This effort started by happenstance and with a meeting my wife Caroline had with George Barton Jr.s wife Barbara. She was kind enough to supply materials to us that started this inquiry. A visit to Consolation House also yielded results with the owners (at that time) looking to have the occupational therapy community have possession of some additional ephemera. We accepted these materials with the promise to use them for study and for advancing the biography of George Barton which has previously not been fully highlighted. Over the last several years I have combined those materials with other biographical research and began constructing blog posts that are now catalogued under the www.OTHistory.com site. Over the last year it has been my pleasure to find new friends in Clifton Springs who were planning a 100th anniversary celebration of the occupational therapy founding that occurred in their community. I am especially indebted to the kind folk associated with the Clifton Springs Chamber of Commerce, the Clifton Springs Historical Society, various community members who are participating on their planning committee, and also some local educators who represent regional occupational therapy programs. Some of the information obtained through this ongoing project will also be presented on June 3rd, 2017 during the Sulphur Springs Festival that will feature an occupational therapy centennial celebration. I hope occupational therapists enjoy looking at these pictures and also enjoy looking through the blog and learning more about the history of their profession. Use the www.OTHistory.com address to navigate to the site, and use the Barton and History links on the blog to find more information. Many more detailed references can be found at the end of each blog post.
Another update in the ongoing saga of the failing New York State Early Intervention program: The Governors 2018 budget proposal adds new requirements on insurance companies and providers. Under other circumstances, a provider or fiscal intermediary would simply operate within the available rules that exist in the private marketplace, but since the State has designated a fiscal agent that is unable to compete in the free market, the Governor is forced to rewrite insurance laws in order to facilitate payment. In FY 2016, nearly 85% of claims submitted by the Early Intervention State Fiscal Agent to private insurers were denied. The idea of cost sharing with private insurance has been a failure because the State botched the implementation and has contracted with an incompetent fiscal agent. The breakdown of payment of Early Intervention costs has been as follows: Private insurance: 2% Medicaid: 41% NY State: 27% Counties: 30% This is AFTER the State invested millions of dollars into a private contract for a State Fiscal Agent. Providers went out of business in this transition and services to families have been compromised because of the ineptitude of the process - and now new laws are being proposed in order to address the obvious failure. The following new proposals are included in the Governors budget: 1. Placing new requirements on service coordinators and providers to obtain insurance information and signed IFSPs from referring doctors (attesting to medical necessity). 2. Requiring providers to exhaust appeals before unpaid balances hit County books. 3. New mandates for payment on insurance companies. Having a requirement for a doctor to certify that an IFSP is medically necessary is unrealistic. Additionally, not all early intervention services will fall within the strict guidelines of medical necessity because the program is not only a medical program. This issue hits at the heart of what happens when States get into the habit of using Medicaid funds for non-Medicaid activities. These kinds of reforms also become unwieldy and complicated simply because of the existence of the failed State Fiscal Agent. So as an example, a provider must now exhaust appeals which seems reasonable - but if an insurer is denying payment because the fiscal agent has improper coding procedures or if they are billing under a non-participating provider - it only serves to slow payments to providers even more. As I have advocated from the beginning of all this, releasing providers to compete directly in the private market and having them bill insurance companies directly would immediately solve all problems with participating provider denials and it would solve issues of odd local coding anachronisms. The State could be free to negotiate whatever cost-sharing agreement with the insurers, probably through the creation of regional service level caps, at which point the balances would be billed or waterfalled to a centralized New York State reserve fund. That would remove the Counties and the designated fiscal agent from the equation altogether, saving millions of dollars in program costs and in shifted Medicaid responsibility. As it now stands, the NYS Senate rejects the Governors proposals, the Assembly partially accepts them, and the Counties support the proposals but want even more protections in place so that these costs never hit their balance sheets. What does that mean? The proposal will be worked out in backroom deals in Albany, and the provider community and families will not have much voice in the process. The system will continue to fail. As I have indicated in the past, savvy providers will learn to participate in insurance networks privately (including Medicaid) and will learn to bypass this failed system by seeing families on a private basis. Read more at these links - and contact your representatives if you want, but the real solution of eliminating the failed State Fiscal Agent and adopting a modified model of privatization as outlined above is not even on the table. Read the FY 2018 Article VII Bill Health and Mental Hygiene (HMH): https://www.budget.ny.gov/pubs/executive/eBudget1718/fy18_budgetLegislation.html Read the FY 2018 Memoranda in Support, Health and Mental Hygiene (HMH) Memo: https://www.budget.ny.gov/pubs/executive/eBudget1718/fy18_budgetLegislation.html Read the NYSAC Budget Comparison Fact Sheet on Early Intervention: http://www.nysac.org/nysbudget
On 11/8/16 I wrote
_In both of these cases it is important to carefully analyze the details of what is actually being litigated. So often the truth of what is being discussed gets lost in poor reporting about the topics. For example, many news outlets focus on the evil school district vs. the child in the wheelchair with Wonder the GoldenDoodle meme instead of focusing on the decidedly less appealing what is the importance of due process angle._ _As OTs become more savvy with policy analysis they will avoid the bias-trap of media reporting and try to approach a more rational comprehensive method of considering the actual facts. They will also become more savvy by dropping the naive notion that just because an issue might have the superficial appearance of something that should be supported, it is important to dive deeply into the actual policy to make sure we are promoting what is best for the people who seek our services._Turns out that this analysis was essentially correct regarding the separate cases of Endrew and Fry. In the Fry case the issue at hand turned out to hinge on the concept of administrative exhaustion or whether or not a family had to satisfy IDEA due process rules before bringing an ADA lawsuit. According to the decision, if the issue is not related to IDEA, there is no such requirement. In this case the Fry family was not arguing about educational rights - they were arguing about wanting a monetary award for emotional distress. Since the gravamen of the concern was not IDEA the Court ruled that there was no need to exhaust IDEA due process. This will have little to no impact on service delivery in school systems. Over time we may see more lawsuits filed against schools earlier in the process, with savvy lawyers parsing out IDEA concerns and other non-IDEA concerns like emotional distress. Schools will have to respond differently to the possibility of dual-process complaints. Bottom line: this was not an IDEA case. It was a case that outlined rules for lawsuits under the ADA, wrapped in poor reporting and media obsession with the click-bait of little disabled children and their cute dogs. The media got their clicks, the family got to sue under the ADA, lawyers have new strategies for making money, and the rest of us can go about our work. ++ The Endrew case was specifically related to IDEA as it wrestled with the central question of FAPE and what was considered appropriate. There have been a number of interpretations about FAPE criteria - most of the criteria discussed openly in courts but not openly in IEP meetings. At issue was whether or not a de minimus standard could be considered appropriate and the Court ruled that it was not. That wont do many families much good because I dont believe that most IEP teams sit around the table and design plans aimed at that low bar - and even if that is the end result of their efforts you would be hard pressed to ever find that recorded. Schools will always believe that they are reaching for the stars. An analysis of the mission statement of any school district shows the public proclamation that the goal is to create exemplary world citizens _blah blah blah_. So even if the issue of FAPE came up in meetings before it was generally answered with We dont have to provide the _BEST _program; we have to provide a program they can _BENEFIT _from. In simple terms that is known as the Rowley standard, related to a previous SCOTUS decision. Again, most school districts do not openly publicize that their definition of benefit is a de minimus standard. The Endrew case is interesting in that it shuffles the words on FAPE, now indicating that a school has to provide an individualized education program that is reasonably calculated to enable a child to make progress appropriate in light of the childs circumstances. That is a rejection of the de minimus standard - something that a word-parsing lawyer might argue in court but that I have never heard as a guiding policy around an IEP table. Unfortunately, from the perspective of real world guidance, now you will hear schools say that their IEPs are designed in light of the childs circumstances and that they are reasonable. The Court affirmed the role of schools acting in a good faith effort based upon local professional judgement - and specifically stated that they have no interest in developing a "bright-line" standard for schools to follow. Deference is based on the expertise and judgement of the schools. Plain and simple. If you want to understand what the SCOTUS did with this case, look at this video, and imagine the bullets as the definition of FAPE As such, this decision also will not amount to much. The definition of FAPE is no more clear today than it was under Rowley. Perhaps the only thing that changed is that some lawyers will no longer make the de minimus argument. ++ Neither of these cases will have much lasting impact on everyday work in school systems. They only clarify strategies to be used and avoided by lawyers when the rare case actually gets into a court.
_...but you might delay things just a little while because of winter weather!_ Today a gathering was scheduled in Clifton Springs for a celebration of the occupational therapy founding. The mayor was also scheduled to issue a proclamation but the celebration had to be postponed due to inclement weather. THE EVENT WILL BE RESCHEDULED. _+++_ The March 8. 1917 Clifton Springs Press had an announcement about the upcoming First Consolation House Conference, but it also had an interesting article about George Barton. The subheadlines and text of the article are notable because they provide direct evidence of exactly how the Clifton Springs community felt about his efforts and also how influential he was.
We all look forward to the rescheduled celebration of George Barton and his efforts in Clifton Springs that founded the occupational therapy profession. "YOU CANT KEEP A GOOD EVENT DOWN!"
Follow-up to Ethical occupational therapy practice in nursing home care Studying historical phenomenon is helpful for framing modern problems - and so I would like to draw attention to an article that appeared in Modern Hospital in September 1922. The author of the article, Christine Newman, was Head Aide of the Howell State Sanatorium for Tuberculosis in Howell, Michigan. The facility is described as "a self-sufficient entity that aimed to meet the patients and employees every need with a working farm, apple orchard, convenience store, post office, water and heating plants and kitchen staff." This model of self sufficiency was common among asylums and sanitariums in the 19th century. I would like to recommend Dr. Katherine Ziffs book Asylum on the Hill as well as her blog; these resources are invaluable to understanding a model of asylums during this time period and offer a counterpoint for understand modern institutions. Ms. Newmans article, entitled "Defending my commercialism in occupational therapy," reminded me of the self-sufficiency model described in Ziffs book. Ms. Newmans article describes the way that she views the occupational therapy service in 1922 and provides a justification for her perspectives and methods. To start, she overtly states that the purpose of her occupational therapy work has both a "money and therapy aim." She is decidedly pragmatic in her approach, believing that occupational therapy can serve both a therapeutic and financial benefit. That is an unusual approach and occupational therapists today are not commonly heard discussing financial revenues so openly. She outlines an interesting sequence of thinking to support her interest in both aspects. Her core hypothesis can be represented in this sequence:
_An occupational therapy aide particularly needs clever things [merchandise] because she is too poor to put her valuable labor on things that will not sell. I know this sounds very commercial, but I still maintain there is just as much therapy in a number of salable things as in the same number of unsalable things, and I can do far more for my patients if my department is on a paying basis._In ten months of work she incurred $1197.30 in expenses which included her salary and cash received by sale of goods produced was $818.35, leaving $378.95 that the sanitarium had to pay in order to maintain the OT department for the full year. She was very hopeful that in the second year the OT department could pay for itself. I was impressed with her argument and presentation, even if the underlying economic focus was troubling, because she at least had some core philosophy (see sequence above) that was based on why she was doing certain activities. That got me thinking about modern day occupational therapy in many long term care facilities, where the therapy is often reductionistic, biomechanically oriented, and not attendant to the patients occupational needs. There does not seem to be much of a theoretical focus on why a therapist chooses an upper extremity ergometer over repeated exercises with a cane or dowel with weights attached. I also dont see anyone defending these methods. Occupational therapists just do them. And a lot of revenue is generated. What is even more interesting is that there does not seem to be too much open conversation about the gross profiteering that goes on in those departments. I am left wondering: what is the financial surplus of occupational therapy efforts in those facilities? Are the departments self-sustaining? Instead there are some general conversations about how therapists are supposed to be concerned about ethics in these environments and how different professional organizations get together and have concerns (AOTA/APTA/ASHA, n.d.). The purpose of this collaborative statement is to "emphasize clinicians responsibility to understand payers policies and regulations, as well as their obligation to act ethically and to report inappropriate practices." (Brown & Hemm, 2015). It is all very vague - and no one seems to be hitting the issue directly. We all know that a lot of money is being generated by modern day occupational therapy, and that money is going somewhere. So where is the modern day article from the clinicians in the field that is entitled "Defending my commercialism in occupational therapy?" As I am interested in seeing such an article in the modern period, I implore one of my colleagues to write it. Please incorporate a theoretical justification for the work being done in long term care facilities, even if the economic aspect will remain a primary focus. I wonder if I will ever see such an article. Perhaps people were just willing to be more honest about things in 1922? References: embedded links, and... AOTA/APTA/ASHA (n.d.) Consensus statement on clinical judgment in health care settings: AOTA, APTA, ASHA. Downloaded 3/2/2017 from http://www.asha.org/uploadedFiles/AOTA-APTA-ASHA-Consensus-Statement.pdf Brown, J. & Hemm, M. (2015, May). ASHA, NASL address concerns in skilled nursing facilities. _The ASHA Leader, 20(5)_, 8. doi 10.1044/leader.NIB1.20052015.8 Newman, C. (1922). Defending my commercialism in occupational therapy. _The Modern Hospital, 19(3)_, 250-252. Ziff, K. (2012). Asylum on the Hill. Athens, OH: Ohio University Press.
impact on George Barton in particular. I have also documented some lingering impact of concerns with spirituality and how the topic has been reflected in some occupational therapy documents over time. As we are on the eve of the Lenten season, and as we are properly situated in history to reflect on the crucible of values that contributed to the founding of the occupational therapy profession, this little sideways journey seems timely and appropriate. Many occupational therapists enjoy using the term holistic to describe their orientation and interest but few are adroitly capable of putting such diversity that includes spirituality into actual practice. This has always been the case - even when turn of the 20th century providers made the attempt. Emmanuel methods centered around a merger between medicine and spirituality: a medical clinic with free weekly examinations, a weekly health class with multidisciplinary lectures on medical, psychological and spiritual health, and private psychotherapy/counseling sessions. Reverend Elwood Worcester, founder of this movement, specifically recruited well known Boston physicians (Putnam, Cabot, Pratt, and Coriat) to lend medical credibility to his ministerial efforts (Caplan, 1998). From the start, Elwood Worcester had difficulty distancing his methods from the controversial Christian Science movement and the work of Mary Baker Eddy. The methods were not at all similar; in fact Eddy spoke out against what some termed the mind cure movement and specifically stated her opposition to people like Worcester. These differences were outlined extensively in Willa Cathers series that appeared in McClure magazine from January 1907-June 1908 (nom de plume Georgine Milmine). Clarence Farrar was a prominent psychiatrist who leveled blistering attacks on the Emmanuelists (1909), stating that their "faddist faith cure movement" arose from Boston, "the land of witchcraft and transcendentalism." This kind of criticism from prominent medical leaders led to the waning of support from the Boston doctors that Worcester recruited. As explained by Caplan (1998), these criticisms may have been primarily motivated by a desire for control over the growing psychological movement. Worcester and his colleague Samuel McComb attempted to respond (1909) but at that point the opinions of most medical practitioners were settled: psychotherapeutics was to be the domain of doctors and not of the clergy. The criticism was so powerful and effective that concerns were echoed many years later by occupational therapy leaders. In the Fifth Annual Meeting of the American Occupational Therapy Association there was discussion about the need to develop a research base to help doctors understand the role of the new profession. Herbert Hall (1922) stated, "We must be careful not to go about making claims for occupational therapy as the Christian Scientists do for their methods." The Emmanuel practitioners were never able to fully shake the incorrect association of their approach with the Eddyists, and it is clear that physicians like Hall were sensitive to the negative association. One of the final formal defenses of the Emmanuel method was published as an article in Good Housekeeping entitled _Lent: A friend to the nervous_ (McComb, 1910). Given the current season I choose to highlight this article in particular. The article is interesting not only for its chronology in the medicine vs. religion debate, but also for its clarity in describing the universality of a Lenten experience. McComb wrote
Now I would like to contradict this idea [Lent as an ecclesiastical custom] and to assert very emphatically that while Lent may and ought to be used for ends that are strictly religious, it is pre-eminently a _human _institution, with a vital bearing on our earthly life and happiness. We all need, at times, a complete break with our accustomed habits, with our ordinary ways of thinking, with our usual food and drink and recreations; and we all need this because we are all accustomed to get into ruts and grooves, until we become, as it were, mental and physical automatons instead of living, progressing, moral beings.McComb further argued that Wordsworth (notably, a Transcendentalist) was sadly correct:
The world is too much with us; late and soon, Getting and spending, we lay waste our powers;- Little we see in Nature that is oursMcComb believed that the Lenten season, applied across religious or non-religious convictions, could serve as a model for taking a pause in the busy-ness of life that was so culturally and socially unsettled at the time. This is the precise message that was given to George Barton by Worcester - a directive to let go of his own suffering and to make sacrifices for the other fellow. The Lenten season, from religious definition, is all about hope and an Easter beginning. The Lenten experience, from a secular perspective, is an application of spiritual hope on a backdrop of confused and complicated modern living. As a Christian man, Barton interpreted the Emmanuel Church message in directly Biblical terms, specifically related to Isaiah 61:3 when he used the term Beauty for Ashes on his Consolation House logo (see picture above). However, the Emmanuel Movements message was more broad than simple and direct religious application, as summarized by McComb:
Lent is a reminder that two worlds are ours: the lower, with its miseries, its cares, its distractions, its worries; and the higher world within to which we can make our escape, with its faith and hope and love and peace. As we lay hold of this higher, the lower world loses its grip upon us, ceases to paralyze us; and while we may not claim any mere stagnation or brute freedom from toil and care and responsibility, we may, nevertheless, have a secret that makes music in the heart and nerves us to rise triumphant over the strains and stresses of experience.That was McCombs Lenten message, and it was the basis for an occupational therapy message that Barton put into action at his Consolation House project. References embedded links, and... Archives of Occupational Therapy (1922). The Fifth Annual Meeting of the American Occupational Therapy Association, Meeting of the Board and Members of the House of Delegates. Caplan, Eric (1998). Mind Games: American Culture and the Birth of Psychotherapy. Berkeley, Calif: University of California Press. Chapter 6: Embracing psychotherapy: The Emmanuel Movement and the American Medical Profession. Available online at http://publishing.cdlib.org/ucpressebooks/view?docId=ft7g5007w4&chunk.id=d0e3438&toc.depth=1&toc.id=d0e3438&brand=ucpress Farrar, C.B. (1909). Psychotherapy and the Church, _Journal of Nervous and Mental Diseases_, 36, 11-24 McComb, S. (1910). Lent: A friend to the nervous. Good Housekeeping, 50(3), 327-329. Worcester, E. & McComb, S. (1909). Christian Religion as a Healing Power. New York: Moffat, Yard.
_THERE IS A GOD WHOSE LAWS UNCHANGING_ _NO ONE MAY HOPE TO DISOBEY._ _MANS OWN DESIRES FORCED UPON THE ORDAINED WAY. _ _HE FOR A MOMENT TRIUMPHS,_ _HE HAS HIS WILL,_ _HE PAYS THE PENALTY._ _ (BARTON, 1905)_ The Pipe of Desire is a one act play published in 1905 by George Edward Barton, and set to operatic score by Frederick Converse. It might be just a curious fact that architect George Barton attempted the role of librettist except for the historic implications of this effort. We know that as a young man Barton was raised in a family "steeped in the arts and letters" (de Lancey, 1958). From the same source we also know that he had a bicycle encounter in the English countryside with King Edward VII where they were both "whistling operatic arias." So although Barton may have had early exposure to and enjoyed the operatic form there is not much known about the specifics of how the historic collaboration with Converse actually came about. Coburn (1909) wrote, "Yet refreshing and spontaneous qualities of romanticism are distinguishing marks of Converses output. A brief analysis of the subject matter of "The Pipe of Desire" the words of which were written by Converses personal friend, George Edward Barton, a Boston architect, will perhaps reveal the kind of work in which this composer delights." Their collaboration may have been a simple function of an apparent friendship between Converse and Barton. This was a daring collaboration because of longstanding controversy regarding the appropriateness of opera sung in English. Coburn continues, "Popularization of American operatic music, such as Mr. Converses, is peculiarly notable. Serious opera has rarely emanated from an Anglo-Saxon source. It is, indeed, something of a shock to listen to an opera that is not phrased in Italian, German, or French." The world premier of The Pipe of Desire was on January 31, 1906 at Jordan Hall in Boston, and some reviews were unkind. Hale (1906) wrote,
"Mr. Barton, an architect in Boston, is a man of wide and curious reading. Where did he find this legend?... Even if the symbolism were suggested consistently throughout the libretto, the book would not be well suited to operatic purposes, for it lacks both action and human interest." Regarding Converse: "He has given dramatic interest to a libretto that is undramatic... All in all this opera music must be reckoned among the very first and few compositions of true importance that have as yet been produced in this country; it is music that would excite respect and admiration in any land."Again, the theme of skepticism of American opera is notable, although the critic is more kind to Converse than Barton. The Pipe of Desire was nonetheless accepted for performance at the Metropolitan Opera House on September 10, 1908 as reported in the Boston Evening Transcript despite the ongoing debates about validity of singing opera in English (Garofalo, 1994, p.37). After substantial preparation the work was finally presented on March 18, 1910, making the effort the first opera composed by an American and the first opera performed in English by the Metropolitan Opera. A reviewer from The Sun (Henderson, 1910) wrote,
"Of course the symbolism is easy enough to read. But as a stage subject the story is not at all potent. The book certainly furnishes opportunity for picturesque groupings of nymphs and gnomes, for beautiful effects of light and shadow, for an exquisite woodland scene, admirably provided at the Metropolitan, and for moods not unsuited to the language of music. But there is nothing in the employment of details to clamor for musical utterance. In fact the text is seldom poetic in thought or melodious in technic. Many of the lines are hostile to lyric song and many are awkward in themselves even when considered merely as pieces of English... Mr. Converse was not inspired by it or, if he was, the gods did not make him operatic. His music is of a kind which suggests the respectable atmosphere of the oratorio concert. It lacks throughout the distinctness of theatrical utterance. The declamation in the recitatives is angular and void of spontaneity. The arioso passages are labored, and their attempts at expression are but moderately successful."Perhaps, more simply, in the words of Isabel Barton, "The opera flopped." (de Lancey, 1958). As she did not know George Barton at the time, the only basis of her report would have likely been what he shared with her. And so it remains an unusual historic footnote that the first opera to be performed at the Met with score and libretto written by Americans and performed in English was a product of architect and occupational therapy founder George Edward Barton and his friend, Frederick Converse.
Some overtly prejudicial information has been published about George Barton. In an officially sanctioned history of the occupational therapy profession, Quiroga (1995) wrote that "Barton was undoubtedly an unusual if not eccentric character, who had difficulty knowing his own identity." She also stated that "some of Bartons writings may have created more foes than allies to the cause" and that "George Edward Barton was an occupational therapy zealot" with a "near-crusade mentality" who "was undoubtedly a difficult person with whom to work in the organizational phase of the national association" who "did not possess the interpersonal skills that he needed" and "simply did not fit the profile of what his contemporaries considered to be a professional leader." There is very little evidence to support this level of prejudice. Quiroga misinterprets Bartons claim to being a sociologist - forgetting to consider his training under William Morris. She fails to understand and correctly interpret Bartons metaphorical style in his paper, "Inoculation of the bacillus of work." There is no evidence at all that suggests Barton alienated the broad medical profession. In fact, his minimal involvement in NSPOT following his resignation makes it nearly impossible to have had some negative impact on the developing profession. As I have been documenting for the last several years, it is probably very fair to state that Barton was eccentric - but the extreme negativity is unwarranted. Based on a study of correspondence between the Founders it is more accurate to state that the negative feelings towards Barton resulted from his withdrawal of his participation as an officer, the reluctance of and social mores preventing others to assume leadership roles at the time, and slow revisionism and selective remembering. Within 15 years of the founding meeting in Clifton Springs, five extremely influential individuals passed away: Barton, Herbert Hall, Susan Tracy, Susan Cox Johnson, and Thomas Kidner. The truth is that Barton was not even alive long after the founding and could not have had much if any negative impact. This series of deaths essentially left Slagle and Dunton to tell the occupational therapy story, and even though an attempt was made in 1967-8 at the 50th anniversary to obtain a more accurate picture of what happened around the founding, the effort clearly fell short. Negative attributions of Barton were reinforced over time. In her farewell address to the profession, Slagle simultaneously respected and jabbed at George Bartons legacy:
"In the words of the first President of this Association, Mr. George Barton, who retained the office six months and resigned because we were in debt $150 (lawyers fee for legal services and organization papers) and because we saw no immediate way of raising the salary of a Secretary. "I relinquish the honour of being your officer, proud to have been of any assistance to a cause so noble, and I lay down the office content in the knowledge that it can be more ably filled."In fact, Barton did not relinquish his office because of the debt itself, but only because as President and Secretary he and Isabel could not take on the burden of fronting these fees by themselves. Barton resigned his office in a letter to Dunton dated July 23, 1917 where he wrote
After very careful consideration, I have decided not to accept the possible renomination as President of the Society, but to withdraw in your favor. This seems to me to be the eminently proper thing to do, and it will probably redound to the benefit of the Society. I am not, of course, withdrawing my interest, and hope to be allowed still some word in its councils.In response on July 27, 1917 Dunton wrote to Barton, stating
I am extremely sorry that you should have reached the conclusion that you have, but I hope that you will reconsider it. I am also sorry that you will not be presenting at the New York meeting. I hope that you can make arrangements to be present as it seems to me that it would create a bad impression if you are not. However, you are the best judge of your own conduct as I am not familiar with these circumstances which have brought about your decision. I naturally feel like calling you and Miss Newton slackers, quitters, etc, but my natural politeness restrains me."On the same day (July 27, 1917) Dunton also wrote to Slagle stating
I presume you have received Mr. Bartons notice. I do not know what is the trouble, but am inclined to think that he has grown somewhat piqued. I had written to him on Wednesday asking him to reconsider his decision of which he had written me, but evidently he had already made up his mind and my letter reached him too late to influence him. He suggested that I be made President. I do not want the job but at the same time I think it is very essential that our society be continued.Barton responded to Dunton on August 8, 1917
I am sorry for the tone of your letter of August 6, and feel that your attitude is most unjust. Also it seems a little strange to me that you are unable to understand that it is impossible for me to pay the salary of the Secretary of the Society. When I undertook at your request to get things started and get together, I neither undertook to give up all my life to the Society nor to pay its expenses.There is no record of the "August 6" letter in the AOTF archives that I could locate. It may be a date error or there may have been an additional letter from Dunton that is not available. Either way, Barton was quite clear on why he had to relinquish his office. It is also quite clear that Dunton was irritated by the action and did not understand Bartons concern. Slagle and Dunton carried their negative perceptions of Barton forward. Bartons role in the founding was minimized and sometimes even left out of the history altogether. Dr. Sidney Licht, a student of Dunton, wrote the following in 1948 even though he had no direct knowledge of Barton at all
This brief history comes to an end with the coining of the phrase Occupational Therapy. Many non-medical persons have made considerable contributions to the field of medicine and it was left to a layman to coin this term. George E. Barton, an architect by training, was greatly impressed by the type of work accomplished by Grohman and Hall and helped to organize at Clifton Springs, New York, an institution where by means of occupation, people could be retrained or readjusted to gainful living... Mr. Barton was an extremist and although he contributed much in the way of enthusiasm, he retarded the acceptance of occupational therapy by physicians as a result of his unbounded claims concerning the therapeutic value of work... It would be well to forget all but two of George Bartons words - _occupational therapy_.Dr. Lichts comments are all the more curious in consideration of his admitted lack of information on Barton and the founding of NSPOT/AOTA. George Barton published more early literature on occupational therapy than any of the other founders and was instrumental in coordinating and organizing the Consolation House meeting. He understood the problem of disability from multiple perspectives, had knowledge of how to start and organize groups, and was motivated by his own spiritual and physical reformation. Perhaps he was zealous and he was probably eccentric, but neither of those characteristics warrant the negative perceptions that have been published. The evidence is clear and indicates that he is guilty of a simple thing: he could not afford to front the money by himself to support a fledgling Society. I understand that some narrative approaches include a degree of sanitizing facts related to personal interactions of historical figures. However, since so much prejudicial information has already been published about Barton it seems reasonable to delve into source documents and letters between the founders to correct the historical record. The centennial anniversary of the occupational therapy profession offers a good opportunity to reappropriate Bartons contributions and cast them with a more even-handed perspective. Since there is ample access to source historical documents, it is not correct to have the narrative dictated by the prejudices of the designated survivors. References: Correspondence retrieved from Wilma West library, AOTA Archives, and... Barton, G.E. (1917). Inoculation of the bacillus of work. The Modern Hospital, 8(6), 399-403. Licht, S. (1948). Occupational therapy source book. Williams & Wilkins: Baltimore. Slagle, E.C. (1937). Editorial: From the heart. Occupational Therapy and Rehabilitation, 16, 343-345.
Ongoing ideas re: this topic. Previously posted (in part) - now with edits and with references updated.
During the Modern period most people achieved a basic level of education, opening up modes of writing including contexts of first person perspectives and autobiographies. Weintraub (1995) states “the autobiographic genre took on its full dimension and richness when Western Man acquired a thoroughly historical understanding of his existence.” Once this level of understanding was achieved it was possible for humans to consider their existence within individual contexts.
Breines (1989) identifies that “human action can be understood only in terms of the relationships that it generates with the world.” From a pragmatic perspective, Breines states that a person’s ability to ‘connect’ with the world is dependent upon active and meaningful engagement with the environment. Not only is this a functional outcome for the individual, but it is also a functional outcome for all of society. Writing provides a means toward both of these ends as it provides a medium for interactivity between the inner world of ideas and the outer world of reality. Sartre (1949) stated that all good writing is social writing and is illuminated and constructed through the writer-reader ‘relationship.’ By this definition, I can’t write as a lone individual – there must be some ‘Other’ that answers or responds to my assertions. In this sense, writing becomes an act of witness, and a medium for self-affirmation. Modern theorists refer to this as a dialogic learning process (Nour, 2014).
Even the seemingly disconnected medium of diary writing is a connected social discourse. This is particularly evident in the opening salutation that is so common in journal writing: ‘Dear Diary…’ Anne Frank addressed her diary as “Kitty” which was a personalization of her discourse where she stated:
It’s an odd idea for someone like me to keep a diary; not only because I have never done so before, but because it seems to me that neither I—nor for that matter anyone else—will be interested in the unbosomings of a thirteen-year-old schoolgirl. Still, what does that matter? I want to write, but more than that, I want to bring out all kinds of things that lie buried deep in my heart” (Frank, 1952)_._
Although Ann did not believe that anyone would be interested in her story, her diary has been translated into nearly every modern language.
An appropriate following question would be ‘Why _would_ people be interested in the private writings of another person?’ Bunkers and Huff (1996) explain that "diaries are not so much inclusive because they contain everything from a given day, as they are inclusive in the sense that they do not privilege amazing over ordinary events." This celebration of the ‘ordinary’ is a longstanding theme in understanding meaningful occupation. Diary writing and diary reading provides a vehicle of social connectedness through the ordinary. This is a human need and is the basis of interactivity between the writer and the reader.
The use of the diary as an interactive tool provides an example of what Rowles (1991) describes as a ‘surveillance zone,’ or an extension of personal space that has multiple uses. These zones surround individuals and act as an area of potential socialization and contact with others. Through the use of a diary, a surveillance zone may serve as an extension of a person’s self-definition and identity. Reflective journaling has been used by educators as a learning tool. Thomas (2015) used journals to collect qualitative data on the experiences of nursing students. The widely cited Kolb Model (1974) has reflexivity embedded in the learning cycle; journaling in all of its forms meets the criteria for reflective methodology. As an additional example, Garrouste-Orgeas, et al (2014) demonstrated the power of journaling in an ICU context and how a collective diary helped to facilitate communication and develop an ongoing narrative about experiences shared between families and staff.
Online diaries provide a postmodern methodology for studying social spaces and interactions. The term ‘postmodern’ is appropriate in this instance because it describes a virtual context where local environments and local relationships are no longer the basis of interactivity. Rather, people congregate online at virtual places (websites) where information is shared and where writing occurs. The nature of online interactivity includes, or even forces, dependence on the written form for communication. Some researchers are beginning to explore virtual methods as a good source for narrative data for research studies. Henker, Whalen, & Jamner (2002) identified anxiety patterns in a population of teenage girls through analysis of online journals and later adapted this virtual technique to monitor the caregiving stress of parents who have children diagnosed with ADHD (Whalen, Odgers, Reed, & Henker (2011).
The proliferation of online writing anecdotally attests to the enjoyment of interactive journaling in a virtual context. In addition to online diaries there are other ways that writing can act as an extension of Rowles’ ‘surveillance zones.’ For example, Stern (2002, 2004) discussed the opportunity of the Internet home pages as a forum for young women to create a narrative of their experiences. This narrative becomes a performance of their lived culture and provides a means of self-expression. Chandler (1998) applies the Levi-Strauss concepts of bricolage in describing the process that people use in construction of their online identities through authorship of their web pages. The new virtual context, essentially described by its reliance on the interactivity of writing on the Internet, is a powerful and important forum for individual self-expression. Dillon (2010) expanded on this method by using online journaling in place of interviews for understanding the self-identity construct in adolescents. It is interesting to note that online journaling was initially studied in context of teenage girls and college student learning; researchers are still developing best methods for advantaging these large datasets for other populations.
The Internet will continue to have a significant impact on the occupation of writing in the future. Hypertext allows people to write in a non-sequential post-structuralist format, such as was advocated for by Derrida; hypertext also meets the demands of multivocality, intertextuality and de-centeredness (Landow, 1992). Individual self-determinism in narrative construction is important to consider in context of the ethical reading and interacting of such online datasets (Buitelaar, 2014).
The occupation of writing has been critical in social and individual development of human beings. Writing offers a rich source of narrative information for understanding our historicity and for conducting inquiries into other occupations. The accessible format of online journaling and the associated proliferation of journaling websites are both instant sources of data for qualitative studies.
Breines, E.B. (1989). Making a difference: A premise of occupation and health, _American Journal of Occupational Therapy, 43_, 51-52.
Buitelaar, J. C. (2014). Privacy and Narrativity in the Internet Era. _Information Society_, _30_(4), 266-281.
Bunkers, S.L. & Huff, C.A., (Eds.). (1996). _Inscribing the Daily: Critical Essays on Women’s Diaries_. Amherst: University of Massachusetts Press.
Chandler, Daniel (1998). _Personal Home Pages and the Construction of Identities on the Web_. Retrieved on 1/17/17 from http://visual-memory.co.uk/daniel/Documents/short/webident.html
Dillon, L. (2010). Listening for Voices of Self. _Qualitative Research Journal_, _10_(1), 13-27.
Frank, Anne (1952). _The diary of a young girl_. New York: Bantam Books.
Garrouste-Orgeas, M., Périer, A., Mouricou, P., Grégoire, C., Bruel, C., Brochon, S., & ... Misset, B. (2014). Writing in and reading ICU diaries: qualitative study of families experience in the ICU. _Plos One_, _9_(10), e110146. doi:10.1371/journal.pone.0110146
Henker, B., Whalen, C.K., & Jamner, L.D. (2002). Anxiety, Affect, and Activity in Teenagers: Monitoring Daily Life With Electronic Diaries. _Journal of the American Academy of Child and Adolescent Psychiatry, 41,_ 660-670.
Kolb, D. A., & Fry, R. E. (1974). _Toward an applied theory of experiential learning_. MIT Alfred P. Sloan School of Management.
Landow, G.P. (1992). _Hypertext-The converence of contemporary critical theory and technology_. Maryland: John Hopkins University Press.
Nouri, A. (2014). Dialogic learning: A social cognitive neuroscience view. International Journal of Cognitive Research in Science, Engineering, and Education, 2(2), 87-92. Retrieved 1/17/17 at http://ijcrsee.com/index.php/ijcrsee/article/view/119/276
Rowles, G.D. (1991). Beyond performance: Being in place as a component of occupational therapy, _American Journal of Occupational Therapy, 45_, 265-271.
Sartre, J. P. (1949). _Literature and existentialism_. New York: The Citadel Press.
Stern, S.R. (2002). Virtually speaking: Girls self-disclosure on the WWW. _Womens Studies in Communication, 25_, 223-253.
Stern, S. R. (2004). Expressions of Identity Online: Prominent Features and Gender Differences in Adolescents World Wide Web Home Pages. _Journal Of Broadcasting & Electronic Media_, _48_(2), 218-243.
Thomas, J. A. (2015). Using unstructured diaries for primary data collection. _Nurse Researcher_, _22_(5), 25-29. doi:10.7748/nr.22.5.25.e1322
Weintraub, K. (1995). Autobiography and historical consciousness. In R. Smith (Ed.). _Derrida and autobiography. Literature, culture, theory #16_. Cambridge: Cambridge University Press.
Whalen, C. K., Odgers, C. L., Reed, P. L., & Henker, B. (2011). Dissecting daily distress in mothers of children with ADHD: an electronic diary study. _Journal Of Family Psychology: JFP: Journal Of The Division Of Family Psychology Of The American Psychological Association (Division 43)_, _25_(3), 402-411. doi:10.1037/a0023473
The settlement house movement originated in England in the late 1800s and was a mechanism for supporting poor people through social and cultural integration. The model was translated to the United States by the efforts of social reformers like Jane Addams who founded Hull House in Chicago (later supported by the efforts of future occupational therapist Eleanor Clarke Slagle) and Robert Woods who pioneered the South End House Movement in Boston (supported by the design efforts of future occupational therapist George Barton). These efforts were notable for their philanthropic origins; that is, they were primarily funded by the private and charitable efforts of socially-minded people who genuinely wanted to improve the living conditions and outcomes for poor people. As turn of the century immigration grew the ability of private philanthropists to address urgent needs was strained. Hull House is a good example of an institution that started off being funded through charity and then later became a focal point for advocacy to the government and eventually a recipient of money spent by the government on social welfare efforts. Unfortunately, Hull House also became a model for the problems associated with replacing private charity with unreliable and strained government funding. Hull House ran out of other peoples money in 2012. Occupational therapists have been proud of their historical association with Hull House in particular (and perhaps unaware of even earlier association with the settlement movement in Boston). On the recent Rose Bowl parade float that was largely sponsored by occupational therapists, Hull House was featured prominently on the design of the float. Romanticizing refers to a mindset of describing something in an unrealistically inflated manner. The efforts of the settlement house movement are something to be celebrated, but more importantly they are something to be critically appraised because in some ways our society in the United States again has issues to contend with regarding poverty, immigration, and assimilation - all of which were issues that the settlement house movement were designed to alleviate. There is a hue and cry from many modern day people who share the spirit of Jane Addams - people are currently concerned about the official stance of the United States related to immigration policy. However, outside of political theater related to safety and security, there is also the reality of funding - who will pay if the United States continues a trend toward open immigration? People like Jane Addams and Louise deKoven Bowen poured their family fortunes into their philanthropic efforts - before they turned toward lobbying the government (and other people). This is a significant disconnect in the argument of current open-immigration supporters. It feels good to support the ideas of open immigration but there is not a lot of evidence of personal investment other than social media rantings - now popularly referred to as hashtag advocacy or elitist slacktivism. The issues are very real in some communities - Buffalos Lafayette High School has been turned into a modern day settlement house community - except that there is a disconnect on philosophy and funding to sustain the effort. A balanced perspective will identify the good intentions and solid efforts of local folk who are trying to make things work, but critical analysis also indicates the severe strain that is created by elites who would locate these new settlement houses in places where they are not living themselves - burdening the already strained communities that can ill afford the attempt. What happens to the existing population that was strained at the start of the new settlement house movement? Occupational therapists should care deeply about this problem. As an example, children who were already socioeconomically disadvantaged were living in those areas, with corresponding higher rates of learning difficulties and need for educational supports. Getting services for that population was already difficult - and is now exponentially complicated by introducing a population of distressed refugees. This is a recipe for social disaster. Here is a street level perspective of the problem: in a 30 mile radius of my private practice I have wealthy families in suburban districts who seek out occupational therapy services for children who have (relatively) minor incoordination or attention problems - and they are accustomed to their school districts being responsive to their (relatively) minor concerns. Also in this 30 mile radius are schools that cant cope with the problems associated with immigration efforts. There is very little hope that anyone can receive help in these schools. There is nothing romantic about a historical connection to a settlement house movement particularly when the modern day incarnation of these efforts is the source of so much human suffering and societal strain. It is easy to make a float and it is easy for suburban districts that are 90%+ white and middle to upper class say We support ALL people. OUR schools are welcoming to EVERYONE. That is the definition of hashtag advocacy and elitist slacktivism. If the occupational therapy profession wants to celebrate settlement houses and if they want to support open immigration policies then its members should come to Buffalo NY or work in similarly distressed communities. What is the current reality? Non profit human service agencies struggle to find people who are even willing to enter these neighborhoods. That is not a demonstration of values consistent with Hull House. References: Please read embedded links - all containing very important context.
Please note first that there is no formally recognized clinical designation of sensory processing disorder. It is a term constructed by occupational therapists that has not been formally recognized by the larger medical community. In our clinic we receive many referrals from local pediatricians when parents have concerns about children being overly sensitive to their clothing. Most often the children referred are from four to seven years old and the families are severely disrupted by the childrens behaviors and responses to clothing issues. Commonly, children will have severely constricted tolerance for certain outfits, want to wear the same clothes repeatedly, complain that clothing is itchy/scratch/bumpy/wiggly/ouchie, and this all leads to disruption of daily dressing routines. There is no doubt that the behavioral concerns are very real. The pediatricians tend to be appropriately conservative and provide families with good behavioral management suggestions before making a referral. Families are very challenged with managing the problem and often resort to online assistance before being referred to us. Most parents have already completed sensory questionnaires online, tried seamless socks, and read books on sensory sensitivity in children long before they ever come in for an occupational therapy evaluation. The pre-conditioning that parents receive online is unfortunate because one of our first objectives in assessment is to inform the parent that it is important that we dont want to fall into the trap of trying to identify the nature of the problem before we even complete any testing. For this reason we do not have the parent complete any sensory-based questionnaire in our office as we find that these assessments serve as a point of confirmation bias as soon as parents begin to answer the questions. Instead, we complete these assessments last - after all other observations are completed and after we have already discussed results of other tests with the families. We also have the parents complete these assessments remotely via computer administration to encourage as much neutrality into that line of questioning as possible. Even when we get the results, we tend to give them very little weight given their tendency for confirmation bias. It is critical to inform parents that most children who have sensitivity to clothing do not have any neurological-based sensory processing disorder. We carefully educate parents and help them to understand that the presence of a neurological condition would be supported if the child has accompanying deficits in motor skill, motor planning, attending, socialization, and learning. So, for all children who are referred because of clothing sensitivity we complete a thorough developmental assessment including motor, language, cognitive, social, and adaptive domains. We are also very careful to educate parents that there are no unique sensory receptors that respond only to clothing, or that only respond to certain kinds of clothing, or that only respond to certain kinds of clothing in the morning when a child is getting ready to avoid missing the bus. It is also important for occupational therapists to reflect on their training in anatomy and neuroanatomy so that they remember tactile processing pathways, affective limbic connections, and neural regulatory mechanisms. It is difficult for a therapist to justify calling a clothing sensitivity a neurological tactile defensiveness if they spend any amount of time reflecting on evidence associated with neuroanatomy and behavioral correlates. There are thankfully only a very few children who, when tested, exhibit concerning delays in these other areas. Such children sometimes go on to have diagnoses of autism or dyspraxia or attention deficit disorder. In our experience these constitute an extreme minority of the total population of children who have clothing sensitivity. The vast majority of children do not have any corresponding developmental delays. They are sometimes slow to warm up, have some mild socio-emotional delays (people often use the word immature but I am not always happy with the negative connotations of that term), or have some mild degree of anxiety or obsessive tendencies. Sometimes they have experienced varying degrees of normal developmental trauma that is not handled well - death of family member, divorce, birth of new siblings, family stressors, etc. Often it is a combination of many different factors. The fact that most of these children do not have serious developmental conditions is actually a good thing - and that is something that we reinforce to parents. At the same time, we are always careful to remind parents that the absence of a serious developmental condition does not minimize the functional behavioral problem that they are experiencing at home. The vast majority of these situations are easily managed with some parental coaching, some developmental support, and some cognitive-behavioral language re-framing for the children - e.g. "These socks are itching me a little, but thats ok!" Sometimes for older children behavioral contracts and confidence building positive behavioral support models can be very effective. Most often we need to de-condition the parents from reinforcing the childrens behavioral responses. All of this can be generally accomplished in a few sessions, at most. The worst thing that occupational therapy professionals can do to families is to reinforce a mythology that the child has some sensory processing disorder. This is dangerous because it pathologizes a very common early childhood behavioral response pattern to stress. It also externalizes the nature of the problem in such a way that the family becomes dependent on the occupational therapy expert who alone understands and can solve the problem. This commonly leads to over-utilization of therapy which is critical to avoid. I would like to encourage my occupational therapy colleagues to reconsider the way that they talk to families about these matters. There are pages and pages of Google search results that point parents to a mythological sensory diagnosis - and this far outstrips the actual incidence of significant developmental problems that may have sensory modulation difficulties as a feature (e.g. autism). Again, most children who have these atypical behavioral responses do not have significant developmental delays. The pages and pages of Google search results should reflect positive behavioral supports and cognitive-behavioral reframing and parent training. Google search results should accurately reflect the actual nature of the problem - which is exaggerated behavioral response to contextual developmental stress. This post is my effort to change the online narrative that unnecessarily pathologizes this issue as a sensory processing disorder. This too often unnecessarily sends families down the rabbit hole of a diagnosis that is not accepted by other medical professionals. Proper framing of the problem leads to appropriate conservative treatment approaches. This should be the goal for all occupational therapists.
To go back to the calling of the conference at Consolation House prior to the formation of the National Society, Mr. Barton had contacted four leaders in their various fields, and so it was that these five zealous workers in the subject, with a very young, most inexperienced though intensely interested sixth, the young secretary, came together at Consolation House in March 1917.She served aptly as the first secretary of the National Society of the Promotion of Occupational Therapy. Review of the correspondence between Barton and Dunton at the time indicates that Isabel Newton was able to effectively coordinate the development of mailing and membership lists, dues collection, and many other tasks that were critical for the new profession. In fact, following her resignation, it is clear that the record keeping associated with the group was a significant challenge for her successors. Isabel Newton married George Barton on May 6, 1918. She continued serving as secretary to George Barton and Consolation House. In Bartons book, Teaching the Sick: A Manual of Occupational Therapy and Re-Education, he dedicates the book to Isabel and writes:
_To Isabel Gladwin Barton_
_My Wife, Helpmeet, and Collaborator_All of this evidence indicates that Isabel Gladwin Barton, although young and inexperienced and certainly not a luminary in any field such as nursing or medicine or social work or teaching or architecture, was still a critical point of support for George Barton. George had ongoing challenges with disability and there is no doubt that his wife Isabel helped him to achieve the goals that he set out for himself. The November 2013 AOTF Research Resources has a column entitled Occupational Therapy: History in Focus. That article includes an inaccurate description of Isabel Barton. The article states
Every dutiful occupational therapy student is led through the professions "catechism" of history; typically memorizing the names of the OT founders pictured in the famous photo shown here. Of course, serious students know that some of the key players responsible for occupational therapys emergence are not even pictured; and one who was pictured (Isabel Newton, secretary and paramour to Mr. Barton) was largely incidental.I believe that use of the term paramour trivializes the important work that Isabel did for the National Society for the Promotion of Occupational Therapy in general and for George Barton in particular. Following her husbands death she withdrew from active participation in occupational therapy, focusing on raising their young child. She regularly followed the developments in the occupational therapy field and as noted above was called upon to present the history of the occupational therapy founding at several important events (30th anniversary, 50th anniversary). Isabel was not just a secretary, as her husband George noted in his book dedication. She was a dedicated parent, an accomplished seamstress, a faithful correspondent, and she loved her parents and other family members. She was also fiercely independent and took care of Consolation House on her own for many years. At the end of a long day after her son was asleep she would read books deep into the night and she would also indulge in going to the movies, which she loved. She also remained deeply in love with George, and celebrated their wedding anniversaries long after his death. These details were all made available to me as I have had the privilege of reading five years of her personal diaries. Isabel Gladwin Barton was recently named to the AOTA Influential Persons List. Her support for George Barton and the skill that she brought to her role as Secretary of NSPOT was certainly not incidental. Her appearance on this list is an honor that is deserved. References: American Occupational Therapy Foundation (2013, November). OT: History in Focus. Downloaded from http://www.aotf.org/Portals/0/documents/News/Research-Resources/November%202013%20Research%20Resources.pdf Barton, G.E. (1919). Teaching the sick: A manual of occupational therapy and re-education. Philadelphia: WB Saunders, Co. Barton, I.G. (1968). Consolation House, Fifty Years Ago. American Journal of Occupational Therapy, 22(4), 340-345. Newton, I. (1917). Consolation House. The Trained Nurse and Hospital Review, 59, 321-326.
_A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share. The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics. _ _This information in the form of a narrative blog post is provided courtesy of a graduate student who is interested in promoting increased awareness of impacts of the Hospital Readmissions Reduction Program. Because the author only has fieldwork experience and the facility or patient could be possibly identified, with the students permission I have conducted my standard ABC Therapeutics mash-up of details and narrative so that the intent of the experience could be expressed while maintaining confidentiality. _ In school occupational therapists learn all about diagnostic conditions. They also learn about ways that people might have difficulties with their occupations. Occupational therapists also learn how to assess and treat those people so that their conditions will not limit them in the future. Occupational therapists also learn that some conditions are acute, that some are chronic, and that some are progressive. None of that really matters though because the best thing about occupational therapy is that knowledge about disability can be matched to the patient’s need, no matter where they are in this process. That is how it is supposed to work. These skills that I learned in occupational therapy school did not prepare me well to respond to the needs of one of my patients on my Level II fieldwork. I completed my fieldwork at a large hospital and I saw people with common diagnoses including heart and lung diseases, joint replacements, and similar acute conditions. Unfortunately, I learned that a persons care is not always determined by what I think is most appropriate as a professional. The pace of work at the hospital was fast and the evaluations were simple, but functional. One aspect of my experience that I did not expect was my work in the hospital’s emergency department. When a patient entered the ED, the doctor would write an order for an occupational therapy evaluation. The occupational therapist would ask the patient about their home setup and prior level of function as well as have the patient complete simple ADL tasks and transfers. Throughout the evaluation, the occupational therapist would assess the patient’s cognition and safety awareness as well. Was the patient able to safely complete essential ADL tasks? If not, the occupational therapist is responsible to document that the patient is functionally unable or unsafe to return home and must document appropriate discharge recommendations. I learned that in October 2012, Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act, which established the Hospital Readmissions Reduction Program. This program was established with the purpose to reduce hospital readmissions – which is defined as an admission to the same or another subsection hospital within thirty days of an initial hospitalization. The purpose of the program is to improve quality of care and to reduce Medicare spending. Under this program, Medicare payments to many hospitals across the United States are deducted three percent to hospitals with ‘excess’ readmissions. The program specifically looks at the kinds of diagnostic categories that I saw on my Level II Fieldwork, namely heart failure, myocardial infarction, pneumonia, COPD, THA/TKA, and CABG. During my Level II Fieldwork, I evaluated many people; however, there is one person who literally and figuratively stands out. Mary came to the emergency department with complaints of severe pain in her hip after a recent hospitalization for a total hip arthroplasty. Mary is an active and healthy 66-year-old woman who had a big personality and even bigger life responsibilities. She is a caregiver for her disabled spouse, watches her grandchildren during the week, volunteers at the local library, and enjoys socializing with her friends. She had a small physique, but her personality was oversized! She was very friendly! "I have to be independent," Mary told me during the evaluation. "My husband had a stroke and he needs me - and what would my babies do if I didnt watch them?" I loved how she called them her babies, even though she was the grandmother! During the evaluation, she had difficulty with simple dressing tasks using adaptive equipment. She was also unable to transfer to or from the toilet. In fact, when asked to demonstrate, she unsteadily stood facing the toilet with her hands on the wall as if she was getting arrested and her legs apart straddling the toilet as if she was aiming at a target. My immediate thought was, "How is this safe? And if she is this unsteady, how is she able to do all of these other tasks safely?" In fact it was not safe. I became very anxious thinking of all the things that could go wrong in this situation. Does the walker fit over her toilet at home? If not, does she rely on the wall for support? Where is the toilet paper located? How does she reach the toilet paper if it’s behind her? How does she keep her pants from falling to her ankles? If her pants fall, how does she reach them without breaking her hip precautions or losing her balance? How is she caring for her husband or her grandchildren when she could not even safely care for herself? Because of this, I recommended that she receive skilled services at the hospital and then transfer to another facility (SNF) for additional skilled services to maximize functional return and safety. I based my recommendation on other patients that I saw who were in in the rehab program. I thought that perhaps Mary just wasnt ready to be home, especially if she was supposed to be the primary caregiver for other people. However, the hospital disapproved of my recommendation and this caused a lot of tension between the rehabilitation director and my supervisor. That is not generally a situation that you feel comfortable creating when you are a Level II student! The rehabilitation director, my supervisor, and myself all met to discuss the issue. It was apparent that the rehabilitation director was using this meeting as a ‘teaching opportunity’ since I was a student, as she stated, “this is the part of healthcare you don’t learn in college.” This made me feel discouraged and defeated. Despite my attempts to defend my recommendations, the hospital discharged Mary with a script for more pain medications and outpatient therapy services. I believe that the hospitals decision to avoid readmission was influenced by the threat of reduced Medicare payments. During the meeting with the rehabilitation director regarding this issue, I was told, “it is cheaper for the patient to receive outpatient services.” I left the conversation feeling frustrated. Whose needs were met in this situation - the patient or the hospital? Instead of focusing on the patient and her needs, which we are taught to do in school, the hospital is focused on financial incentives or penalties. This not only affects the patient as it puts her at a higher risk for falls at home or other serious injuries, but this also affects the occupational therapist who is held accountable for discharge recommendations. Overall, I understand the importance of reducing excessive and preventable healthcare spending, which is the primary goal of the Hospital Readmissions Reduction Program. However, I believe that hospitals should not solely focus on the financial penalties imposed by the Centers for Medicare and Medicaid Services (CMS) nor that occupational therapists decisions should be influenced by this policy. Instead, both hospitals and occupational therapists should focus on providing appropriate, quality care to patients in need of skilled services. Patients like Mary rely on our ability to make decisions and recommendations that are in their best interest, and not that are influenced by the bottom line of some hospitals balance sheet.
_A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share. The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics. _ _This information is provided courtesy of Sarah Watson, a graduate student who is interested in promoting increased awareness of privacy concerns and FERPA in context of computerized record keeping and documentation._ _Extra note: I was really happy to see one of my students tackle this topic - I have seen many privacy breaches because of improper permission settings in common software used by many school districts, most notably the IEP Direct product. School support personnel need to be regularly inserviced on how to use permission settings so that providers do not have blanket access to a districts entire special education database. This is a common problem._ _Additionally, procedures need to be tightened so that notices about IEP meeting schedules that have protected information are not sent out in global emails to multiple agencies who are all providing services to school districts. _ "I am an occupational therapy graduate student at Keuka college. I have created an infographic for my Global Advocacy class on Family Educational Rights and Privacy Act (FERPA). The infographic has been a result of a semester long project on the policy process. I encourage everyone to read it and watch the video. I am very passionate on the topic of FERPA and the educational community that it impacts as a future occupational therapist. Protecting student privacy is so important and can happen only when the right steps are taken. Please SHARE and feel free to comment and ask questions. This assignment is for my final project and my goal is to have several people look it over! Thank you!" Click here to open up the chart in your browser!
_A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share. The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics. _ _This information is provided courtesy of Nagella AL-Balushi, a graduate student who is interested in promoting a bill that improves health professional workforce distribution via a loan repayment program when practitioners work in underserved areas._ "Greetings fellow OT students and future colleagues, I am a graduate OT student seeking opinions, feedback and thoughts about a legislative bill that would potentially have a great impact on the field of OT if passed! This act would have three main professional consequences including establishing a new federal loan repayment system, increasing the overall distribution of our health care services, and ultimately making the role of OT more commonly understood across the nation. The Access to Frontline Health Care Act is designed to provide a federal loan repayment system for health care professionals (including Occupational Therapy) in exchange for two years of service at a federally regulated agency, such as hospitals, clinics, nursing homes, and schools located in underserved areas. The Access to Frontline Health Care Act was drafted in 2015 by Congressman David Loebsack of Iowa and thanks to his time and effort in creating this Act, the Access to Frontline Health Care Act would be able to save various working professionals in healthcare from the despair of endless student loan payments. The reasoning behind establishing the loan repayment system is to incentivize recent grads to work in remote areas to create a more balanced distribution of health care workers across the country. Not only will you, the professional, receive aid in paying back your student loans, but more importantly you will have the ability to help those who truly need it and dont have regular access to your services! On the biggest scale, by providing services in areas where OT or other health professions are not commonly found, we are diversifying our profession and spreading awareness of what Occupational Therapy is to people who would not normally have reliable access to our services. The infographic attached is provided to give you a visual explanation of the Access to Frontline Health Care Act, and the overall impact it would have the U.S. health care system. As mentioned before, I would love to hear your opinions about the Act and its potential effect on the OT profession. Regardless if it is positive or negative, all feedback is beneficial!! Thank you for your time and good luck in your future endeavors! Nagella" CLICK HERE to see the infographic in your browser. Link to Bill: https://www.congress.gov
_A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share. The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics. _ _This information is provided courtesy of Nina Fusco, a graduate student who is interested in increasing awareness to HR 3016, particularly those sections that support canine training programs that would benefit veterans who have PTSD and other conditions._
"The Veterans Employment, Education, and Healthcare Improvement Act is a federal bill currently in committee in the Senate. Upon meeting with a legislative aid from Senator Gillibrands office, it was recommended to me that attaining statewide and nationwide support would be the best course of action. Support from both New York and the nation will help push to amend and reintroduce Veterans Employment, Education, and Healthcare Improvement Act.
I have provided a link to a presentation I created on this bill, that I have posted on YouTube.
I hope you will consider taking a few minutes out of your day to watch and listen, and getting back to me with some feedback. Thank you."
_A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share. The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics. _ _This information is provided courtesy of Tori Persons, a graduate student who is interested in legislation that would help alleviate the burden of out of pocket costs for people receiving occupational therapy services. _ "Existing laws in New York have stated that health plans must cover occupational therapy services. However, the insurance companies have found loopholes and bypassed these laws. They did this by shifting the majority of the costs for OT services onto the patients by increasing the cost of copayments.
This increase in copayment cost has caused financial burdens on patients, changed access to occupational therapy services, and overall has defeated the purpose of insurance coverage for occupational therapy.
There is currently a bill in New York Assembly to expand health insurance coverage for occupational therapy services. The bill is in the very early stages and has not been put to a vote in either the state Assembly and Senate.
Occupational therapy practitioners across New York State have the opportunity to advocate for our patients by encouraging legislators to vote for the passage of Bill A9384.
_A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share. The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics. _ _This information is provided courtesy of Ashlee Lytle, a graduate student who is interested in advocating for people who have traumatic brain injuries. Under a current plan, transitioning this population to a managed care system will impact the quality of their care._
"As I am soon entering the profession of occupational therapy this May, I have become increasingly interested in the individuals that I will soon be providing services for.
After researching information regarding traumatic brain injury, which is my area of interest, I came across the transition plan proposed by the Medicaid Redesign Team to remove the Traumatic Brain Injury (TBI) & Nursing Home Transition and Diversion (NHTD) waivers that currently exist and transition these services into Medicaid Managed Care.
Placing individuals who have experienced a traumatic brain injury into the managed care system will jeopardize their frequency as well as quality of services available to them in the community.
There is currently a bill in the Assembly awaiting approval to prevent this transition known as Bill A09397.
I strongly encourage those who are interested in advocating for these individuals to take a look at the info-graphic, located below, that was created to give you knowledge and resources to refer to in order to educate yourselves and understand the importance surrounding this issue.
Thank you for taking the time to read this.
Just try and remember that you can only make a difference if you try.
To see the info-graphic in your browser in a larger format, click on this link!"
_A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share. The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics. _ _This information is provided courtesy of Emily Scholl, a graduate student who is interested in promoting occupational therapys involvement in wellness programs. She found an interesting bill that promotes wellness in NY State and is advocating for occupational therapy to be added to the existing bill._ "Occupational Therapy should be added to the list of qualified wellness programs in NYS Assembly bill A4238.
The 2015-16, in-process, NYS Assembly bill A4238 authorizes NYS health insurers & HMOs to provide policyholders with reductions in healthcare premiums and potentially waiving related costs or co-payments, in exchange for active, voluntary participation in approved wellness programs.
This policy would operate on a non-health contingency basis, which means that obtaining these financial rewards would NOT be based upon personal health details. Participation would be enough.
People want to live healthy, successful, meaningful lives. OT should be added to the list of wellness programs in this bill.
Why? Lifestyle education and enacting personal change is hard. It requires moral support, goal-setting, guidance, enjoyable activities, collaboration, and a greater degree of involvement than just knowing what one “should” be doing. The features of wellness programs that are outlined in this bill would be greatly supported by the occupational therapy professional skillset.
If we can get car insurance discounts for participating in related programs, why not get health insurance discounts for participating in occupational therapy wellness programs? This would allow the citizens of NY to save on rising healthcare costs AND improve health!
Check out the poster attached below or click on this link for a larger version in your browser. Thank you!"
_A number of my students at Keuka College have been working on policy and advocacy projects that I wanted to share. The students researched a topic of their interest, met with their legislators, and developed a broad action plan to increase awareness of their topics. _ _This information is provided courtesy of Jenna Soldaczewski, a graduate student who is interested in promoting a workload approach in school systems. She found out how a parallel profession in NY (speech therapy) promoted change by advocating for alterations to the Part 200 NYS regulations that govern special education:_ Many occupational therapists in school settings have caseloads so large that it negatively impacts the way that they can help children. Some therapists have proposed using a workload approach for better managing productivity in the school systems. After studying the caseload versus workload approach debate I created a quick presentation to encourage and inform OTs about what they can do to advocate for a workload approach. This presentation provides facts and information on the topic and also encourages OTs to speak with policy makers. This information is specific to New York State but could be generally applied in other locations. Please feel free to share the presentation with other professionals or on social media sites to spread the word regarding this topic. My goal is to encourage as many people as possible to use this information to engage with policy makers. Click here to see the presentation via your browser, or scroll below. Thank you!
This week has been identified as the #OTWeekOfAction by the American Occupational Therapy Association. They are encouraging member actions on a number of policy initiatives; however, as noted in the previous blog post, it is important for occupational therapists to independently assess the nature of these proposals before blindly writing letters of support to Congress. Individuals may learn that they agree with the positions of the professional association or they may learn that they disagree. Todays topic is the Every Student Succeeds Act (ESSA) which is an important law for pediatric practitioners to be aware of. The act was signed into law in December 2015 and its purpose is to replace the No Child Left Behind Act. ESSA has new requirements for accountability and transparency in school operations and includes mandates for low performing schools. It continues the NCLB testing regime and mandates 95% participation in testing for grades 3-8. However, only 1% of all students can be given alternative tests (around 10% of all special ed students). Large new block grants are proposed for a range of new policy initiatives and mandates. The problem is that much of this is unfunded by the federal government and represents new mandates for local school districts that are already burdened under local property tax caps. Additionally, there is no portability in funding that would allow the money to follow students into charter or private schools if the parents wish to move their children out of low performing dysfunctional educational programs. This lack of funding portability is significant because it limits parental choice of methodologies to help their children in low performing districts. Ironically, this is the precise aim of ESSA - to help those same students. ESSA introduces us all to a new term: specialized instructional support personnel. This terms replaces the previous term pupil services personnel. The purpose of this renaming is to ensure that relevant stakeholders are included in school-wide decision making. I become concerned whenever a new law comes ready-made with an entire organization of organizations to prop it up. On a practical level, the professional associations are hoping that this will allow their respective interest groups to infiltrate new areas of intervention, such as expanded roles for speech language therapy professionals in literacy initiatives, or expanded roles for occupational therapists in bullying prevention programs. The intention behind these objectives is probably good, but the reality is that there is little evidence to support the effectiveness of all these new initiatives and given the limitations in funding it is unlikely that states can afford the proposals. The testing mandates are an important issue for many people interested in federal education law. The new ESSA eliminates Adequate Yearly Progress (AYP) mandates but keeps the testing regime intact. States are more free to establish their own metrics for progress, but the fact that excessive testing is still required will remain burdensome for many schools. Professional associations, like AOTA, ask members to support these kinds of initiatives but responsible civic participation means that we cant just support programs that serve as special interest slush funds. If there was evidence that all of these new programs were effective then it would be easier to support. If there was portability of funding so parents could place their children in charter or private schools it would be easier to support. If our economy was different and if there was more discretionary funding it would be easier to support. The end result is that good intentions of new federal mandates end up being unfunded and partially funded. This has a negative impact on practice. I understand that the intention is to have more money flow into schools so that there are new programs and expanded opportunities for students. Few people disagree with these noble goals. However, what happens instead is that the mandates are handed down from the federal government and there is NOT ENOUGH MONEY allocated to fund the programs. That leaves the states responsible for funding, and they are already cash-strapped. Cash-strapped states then wander through a dizzying array of federal mandates - some legal, some in regulation, and some only in guidance - and have to decide what precious and sparse funds will be allocated in what directions. Decisions are made - and in the world of unfunded IDEA mandates the districts have great latitude in how they interpret qualification for service. So what starts off as a noble idea ends up as an unfunded mandate that siphons money away from existing IDEA programs. School administrators start to fiddle with their numbers of special education students and implement local policy around eligibility determination to meet budgets. Even worse, special education students are trimmed from their designations to meet testing targets, or to satisfy RTI percentages. Perhaps it is not correct form to state openly that these are the end results of new unfunded mandates but it is my lived experience. Professional associations, including AOTA, would provide a better service to their members if they stopped encouraging people to write Congress for full funding on something that will never happen and instead focus on providing education on unfunded mandates and how they actually impact local schools. They should also focus on providing members with skills to advocate for students who get removed from special education rolls and how to establish defensible and reasonable eligibility requirements for services that will protect children and families. Finally, they should educate members on methods to counsel families on home activity programs, options for private therapy, and how to meet needs outside of the educational system given the constricted funding. So dont be a policy lemming. Dont advocate for something that wont happen, cant happen, or if it does happen will not be helpful for the people you are intending to help. Background resources: Fact Sheet: Congress acts to fix No Child Left Behind National Alliance of Specialized Instructional Support Personnel The Every Student Succeeds Act: An ESSA Overview The Every Student Succeeds Act: More programs and federal intervention in pre-K and K-12 education New Details on ESSA Funding for Healthy, Safe, Well-Rounded Students US Department of Education Every Student Succeeds Act