The 2013 Slagle Lecture
On Friday, Glen Gillen, EdD, OTR, FAOTA, gave the Eleanor Clarke Slagle Lecture. His talk, titled "A Fork in the Road: An Occupational Hazard?" looked at contemporary OT practice through a historical lens. He couched his metaphors in terms of one of the basic plots of fiction, the Voyage and Return (think Gulliver's Travels or the Wizard of Oz). This basic plot follows a common storyline: starting with normalcy, there is a fall into another world; the protagonist becomes fascinated with new and unfamiliar things; frustration follows; and finally, an escape from the other world and a return to normalcy, accompanied by lessons learned and a fundamental change in the protagonist.
"There have been times," Gillen said, "we have lost confidence in our methods." He used the example of OT's role in motor rehabilitation. Gillen's literature review showed that, until the late 1950s/early 1960s, OT interventions in this area were active interventions that involved patients dynamically engaged in performing/practicing tasks and activities. After that time, however, the literature showed a shift toward methods that may have been viewed as more sophisticated - or "sexy," Gillen said - such as icing or inhibiting movement. These were interventions that OT adopted from other professions, and that today we would consider preparatory. This "fall into another world" also shifted the patient's role from active participant to more passive recipient of therapy services.
As time passed, OTs became frustrated because their traditional interventions began to be adopted by other professions. In the last decade, Gillen said, there has been an explosion of research that has justified traditional OT interventions for motor recovery. Evidence supports OT's return to normalcy (ie, traditional OT interventions). The problem, however, is that in many cases, these interventions are no longer being called OT.
Gillen also used the example of cognitive intervention. Historically, literature about OT cognitive approaches didn't surface until the 1960s, the same time period when OTs began moving away from traditional approaches in motor recovery. When OTs did begin practicing in cognition, they started by using assessment and intervention approaches that had been formulated by other professions (a fascination with unfamiliar things, in the context of the plot).
While OTs have developed a number of assessments that show how cognitive performance affects occupational performance, Gillen asked whether OTs are actually using these in practice. "In both research and my experience, the answer too often is no," Gillen said. Meanwhile, colleagues in other professions are starting to talk about ecological validity - the value of an assessment or treatment in the patient's natural contexts.
The frustration in this scenario is that OTs have already designed, developed and tested their own performance-based assessments; however, OTs aren't using them, while other professionals are. The return to normalcy: "We need to reclaim what we do and realize nobody does occupation better than we do," Gillen asserted.
Whether in motor recovery, cognition or any other practice area, the big question, Gillen said, is "how do we hasten our return to normalcy?" - i.e., how do we get back to occupation as quickly as possible? The profession is already moving in that direction, Gillen said, and in many ways OTs have already done much of the groundwork in developing and validating their own assessments. He also offered several suggestions for speeding up the process:
- Make an effort to reduce the amount of preparatory activities used in practice
- Use authentic occupations instead of "contrived, catalog-purchased activities"
- Move away from therapists doing to and back to clients doing
- Look like occupational therapists (ie, use OT-based treatments and evaluations and stop encroaching on colleagues' approaches)
- Embrace performance- and occupation-based assessments now ("We don't have time not to use them to maintain our professional identity," Gillen said.)
"We are at a critical point in our voyage and development," Gillen concluded. "Our normalcy is supported by evidence. We need to put the occupation back into occupational therapy!"