How many of us OTs have proposed arts and crafts activities to people who are resistant to the idea because they believe they'll really stink at it? Or how often have our clients done really well with the component skills of a creative project, only to produce something they don't like the looks of?

Well, as Apple, Inc. says, "there's an app. for that": The Ugly Necklace Contest. This is an annual event, sponsored by a jewelry-making supplies store called "Land of Odds." The entries (not to mention the finalists) range from disturbing to hilarious; merely ugly to truly hideous. The contest is more challenging than you'd think, however. First of all, just because you think it's ugly doesn't mean it is. Ugly is also in the eye of the beholder: one contestant sold her "monstrosity" to an appreciative customer before she had a chance to enter it. (Of course, that customer didn't necessarily have good taste, but given the "rules of ugly" the site lists, the necklace probably didn't really qualify). I could relate to that: several of my creations that I've been bitterly disappointed in have gotten lots of praise from my fellow artists, and they've usually sold before my own favorites have.

An interesting "twist" to the contest is the requirement for entries to include a poem about the necklace. Now, the only thing I know about poetry is that I don't enjoy it as reading material, and certainly have no idea how to write any except so-called 'free form" (which to me means ordinary prose with sentence breaks in odd places). Reading the ones at the Ugly Necklace Contests is re-assuring: it doesn't have to rhyme, or even have a discernible rhythm. It just has to say something about the necklace. The contest rules also require at least 3 different photos of the necklace: one showing it worn by someone; one a closeup of either the entire necklace or a representative section of the necklace that is particularly ugly; and one a closeup of the clasp assembly.

What an opportunity for an OT plan, especially for people with mental illness, cognitive and/or visual deficits! Creating an Ugly Necklace requires at least sequencing, fine motor, eye-hand coordination, visual processing and some problem-solving skills. Planning, organization and color perception are somewhat optional, since deficits in those areas contribute to the "winning" designs. Writing about the necklace can be an excellent outlet for emotions associated with the disabilities being addressed in OT. Using a digital camera, and setting up the required shots, provides more skills challenges and opportunities for the client.

Materials choices fueled by mental illness could, in the context of the Ugly Necklace Contest, be downright inspired! You think I'm kidding? The 2008 winner's materials list stated "The...Wire Caged Beads are recycled hay, grain and water, uniquely formed by our horses' colons, no two are exactly alike. In other words, their turds!"

Clearly, the sponsors of and participants in the Ugly Necklace Contest aren't constrained by any particular concept of "normal"! So it can be a welcoming place for people trying to come to terms with "limitations".

Whether or not the client is interested in competing in the Ugly Necklace Contest, just knowing there is such a thing could take the sting out of "unappealing" results of their OT crafts efforts. I suppose you'd have to be careful about using this project idea with someone who has depression: losing an "ugly" contest could be even more devastating than losing a "regular" one.

The Ugly Necklace Contest is entertaining, so even if you have no "use" for it at work, I recommend you visit it (and vote for your "favorite" during the open voting period each year. This year's ends 7/15/09).

There’s more to this story than just the break in our bookclub routine. At the WFOT conference in Montreal in 2002, I attended a presentation by Australian OT Linsey Howie on her research about the occupations embedded in bookclubs. One of the bookclubs in her study had been meeting for 40 years! Mine (of which I’m an original member) has been in existence only since ’95; we’re babes in the woods by comparison! But a development in my bookclub shortly after WFOT 2002 makes me think regularly now of Howie’s project :

Carol decided to start bringing food that had some relevance to the book we were reading to each meeting. Since some books mention food only generically; and some not at all, Carol often faces challenges beyond the mechanics of the food preparation. One meeting, Carol had us scratching our heads over the platter of bologna sandwiches she brought, until she explained that the prairie setting of the book (I think it was Willa Cather’s My Antonia) reminded her of the food of her childhood in South Dakota. Many of the club members try to guess what food mentioned in each book Carol will create for us, and they trade speculations before the meetings start; but she often surprises us. Even if her choice is the "obvious" one, Carol usually has an entertaining story about what she went through to produce that evening’s treat.

The weird thing is, although I now tend to notice food references more often in my own book choices, I usually finish a bookclub read with no memory of anything food-related. I don’t understand my "selective blindness". Maybe it’s somehow related to the fact that I never try to guess the endings of mysteries, or to read the final page of any book before I get to it naturally: Carol’s offerings are part of the book, and therefore, part of "how things end" and not to found out prematurely.

On the rare occasions Carol can’t make it to bookclub (which normally meets at our local public library) and there is no food for us, the whole group vibe is different. Carol herself has often talked about how much she enjoys the challenge of creating the things she makes for us. She started this ritual for our bookclub, and we’re all hooked on it.

Howie found "that ritualising, a component of book group activities, facilitates specific customs and experiences of social order and community that are relevant to heightened self-concept[, and] that further research is needed into the practices of occupation-based community groups and the role of rituals in facilitating the development of occupational identities." ¹

Carol’s husband is disabled, their children have long flown the nest, and she’s been struggling with unemployment for more than a year now. Whatever other meanings "Chez Bookclub" has had for her, she’s made it clear that feeding us once a month is now more important to her than ever. However, she’s such a delightful hostess, even at the regular meetings at the library, you’d never know how much pathos there is in her joyful ritual.

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¹ Howie, L, Ritualising in Book Clubs: Implications Evolving Occupational Identities. Journal of Occupational Science, 10 (3) 2003 130-139

In 2004, we visited Peru, and spent a week at a lodge in the Amazon jungle. The staff at this lodge ran an informal animal rehab. center. Whenever they would go to Iquitos for supplies for the lodge, they would visit the live-animal section of the outdoor market; buy animals that seemed ill or injured; bring them to the lodge and nurse them back to health; then release them. Many of the former "patients" returned to the lodge periodically for the snacks left out for them; and some of the visitors would interact with the guests, as well as the staff they were used to.

Right away, I was taken with three species of parrots that spent a lot of time at the lodge: a small blue-green one ("Margarita"); a medium-sized green one ("Pedro"); and a scarlet macaw aptly named "Chico Malo" (Bad Boy) because he liked to bite people for no apparent reason. Margarita lived full time at the lodge, because her wings had been clipped before the staff rescued her, so she couldn't fly. Pedro and Chico Malo came and went as they pleased; but Pedro usually showed up shortly after we got up in the mornings, and when we returned from excursions; and he and Margarita were always willing to hop up on my arm or shoulder to ride around for awhile. I enjoyed their attention and they apparently liked the way I stroked their feathers. 

But Chico Malo fascinated me the most, and whenever he was on the perch by the lodge "entrance" (boat landing), I would stand just out of beak reach, watch him intently, and talk to him.

By the second day, Chico Malo had taken an interest in me. If I was sitting in one of the open areas of the lodge, he'd fly in from the surrounding jungle, land next to my feet, and immediately try to bite my toes. I'd jerk my feet out of the way, and Chico Malo would walk or hop to the new "bite zone" and try again. He'd play this "keep away" game for as long as I stayed put. In return, I would live dangerously and try to touch his wings or back, ready to snatch my fingers out of reach of his powerful beak when he'd turn to bite me (as I knew he would).

On day 3, Chico Malo decided to let me touch him briefly before he'd try to bite me. He also seemed to be jealous, now, of my attention to Margarita and Pedro: if they were sitting either next to me or on me, Chico Malo would come swooping out of nowhere and the other birds would scatter as Chico Malo dived for a choice biting position; and our "keep-away" game would commence.

Day 4, Chico Malo let me stroke the top of his head. I must've found a "sweet spot", because he'd close his eyes and droop his head for a minute. Then, as if remembering himself, he'd suddenly jerk his head up and try to bite my hand. I never trusted him completely, so always managed to pull my hand away in time. Chico Malo could've easily followed through on his lunge and taken a serious chunk out of me; but apparently didn't want to. We played this higher-stakes keep-away throughout the day, and the staff and my traveling companions watched and laughed and made fun of me; but I didn't care.

Even Pedro, Margarita and the "returnee" monkeys started gathering around (at a safe distance) to watch Chico Malo and me do our routine.

The fifth day was our last. Chico Malo knew something was up and let me stroke his head longer than usual before snapping at my hand; but then he suddenly hopped to the ground and lunged for my ankle. As soon as he missed, he stalked off a few feet flying out into the jungle. I didn't see him again, even though we didn't leave the lodge until several hours later.

During the long trip home, I thought about the development of my interaction with Chico Malo, and started to wonder if he'd "seduced me" into a macaw mating ritual at which I failed miserably because I didn't know the signals and behavior patterns. His near-miss bites reminded me of how the boys in my elementary school classes would show their affection for their favorite female classmates by (relatively) gently hitting or shoving us. Maybe scratching Chico Malo's head was too intimate a gesture from me when I wasn't going to "go any further". I don't know anything about birds - and certainly not about the very intelligent parrots. I just figured most living creatures like to be touched in ways that feel good; and parrot feathers felt good to me.

What does my "affair" with Chico Malo have to do with OT practice? Well, that experience made me pay closer attention to my interactions with clients from cultures overtly different from my own. Whatever I might think is "basic human-ness" might not really be as common a ground as I assumed from which to build rapport, understanding and trust. Chico Malo taught me that I should not only ask questions I hadn't thought of before, but ask familiar ones differently.

Unlike my previous blog titled "The "F-word: Function(al)", I'm easing in to telling you what my "R-word" is. That's because some people consider this word a profanity. It isn't on the list of the "usual suspects" in the English language; but plenty of Americans consider it obscene, especially in the context of health and human services. Some articles, advertisements and talk show hosts taking a stand against various ideas for U.S. health care reform count on the R-word's "shock value" to convince the audience of the danger of the reform plan(s) being discussed. Nevertheless, we OTs should consider how avoiding the R-word seriously undermines our efforts to do our very holistic best for our clients.

OK, here goes nothing: the R-word is "Rationing". As much as we Americans hate to admit it, the health and human services in our "free market" are parceled out according to various standards of need (usually a euphemism for "ability to pay"). Insurance is a rationing mechanism: policy language determines what the payment shares will be. Professional practice acts, licensures, and the various rules about referral mechanisms and professional hierarchies (e.g. which disciplines can "open" a case) affect who gets what when (or if). The various codes that determine reimbursement (e.g. DRGs, RUGs, CPT, etc.), and other categorizing mechanisms, are attempts to create objective and "fair" responses to the fact that resources aren't infinite, so we need to use the resources as wisely as possible. The increasing emphasis on Evidence-Based Practice (EBP) is another tool for minimizing the effects of human emotions on difficult resource-allocation decisions, while simultaneously optimizing the "person-resource match".

All this dancing around the R-word gets us nowhere, especially with the renewed attention to "health care reform" in the U.S. In 5 Misconceptions About Health Care, Shannon Brownlee and Ezekiel Emanuel stated,

"...[A]ccording to the Congressional Budget Office (CBO), there appears to be no connection between how much...payers spend on patients in different parts of the country and the quality of the care the patients receive."

Quality is directly related to optimizing the "person-resource match." Of course, one of the many variables affecting "best match" is timing. We aren't always involved with people when the best matches are possible. But cobbling together sub-optimal or poorly timed person-resource matches just to avoid facing the truth that we can't be all things to all people does everyone a dis-service. For an OT to say that s/he doesn't have anything to offer "at this time" is not admitting incompetence or even failure. For one thing, "at this time" leaves the door open for changes in circumstances in which the same OT could make an objective difference for the client. It could also mean that a different OT - or even a different discipline altogether - with his/her own set of experience, perspective and resources, would be a better match for the client.

When a client seems to have plateaued, and/or I'm out of ideas on how to stimulate progress, I haven't been shy about discussing options with the client, referral source and/or payer that amount to "firing" me. Believe me, that approach has paid dividends in terms of new referrals, as well as in getting "off the map" support for my ideas from people who have come to trust my judgment. I've had payers wave off my offer to provide details of my rationale for what seems to be a "wild hair" idea, and just OK it. One even said, "You've pulled rabbits out of hats before; I'll sell tickets to this one." I'm not the only "magician" OT; but I tend to have an easier time than most in getting support for working the magic of occupation on behalf of my clients, because I respect, rather than demonize or fear, the R-word, and approach the system accordingly.

Yet many OTs seem to pretend the R-word doesn't exist, rather than demonstrating how our understanding of occupation can make it work better. For example, the firestorm of responses to "Avoiding Therapy Dependency" highlighted this aversion to the R-word (though the author didn't use it). The respondents couldn't see how to use OTs' unique understanding of occupation to focus attention on what we can do to optimize the matches between our clients and resources. Cost-effective person-resource matching is what rationing is; and as such is not inherently bad. Why would we want anything but best-matches for our clients?

I urge all OT practitioners to think differently about the R-word and how their OT services can be seen as being among the wisest use of resources in any given situation.

I haven't lost my mind. It's backed up on disk somewhere. - bumper sticker

I'm sure I'm not the only one who suffered through classes that had no apparent relevance to real life. But I found out that my seemingly "useless" Physics classes in both high school and college turned out to be valuable after all.

In general terms, Physics has helped me understand the biomechanical aspects of occupation and work. But I didn't think I actually remembered any of the details. Then along came a big-rig/long haul truck driver with a back injury.

Mr. B. lived in a rural area that had only a small PT practice available for rehab. Although Mr. B. had made objective progress with his exercise program, he was approaching discharge without the PT (Mr. C.) being willing to give an opinion about whether Mr. B. could safely resume the DOI [date of injury] job task of (de)coupling the truck cab and trailer. This task required Mr. B. to turn a large crank that would raise the trailer (weighing as much as 35 tons loaded) above the swivel plate so that there would be enough clearance to lower (or stow) the parking supports, as well as to free the cab section for maneuvering. Mr. B. admitted he was afraid he would re-injury his back doing this task.

Without definitive information about the demands of the (de)coupling tasks, the treating doctor (Dr. S.) was reluctant to release Mr. B. to return to his DOI job. The DOI employer had stated there were no alternative job offers to make if Mr. B. couldn’t maneuver the trailer alone. Thus, we were facing job search in a limited labor market, and we were all (insurer, too) feeling various degrees of pessimism about the eventual outcome.

I met with Mr. B. and Mr. C. to review the situation and suddenly got an idea for using a leg exercising machine in a way that could provide a graded simulation of the cranking task. Both Mr. B. and Mr. C. looked at me like I was crazy when I proposed it, so I showed them what I meant. You could almost see light bulbs going on over their heads. Mr. B. tried it at the lowest weight setting, with Mr. C. and me coaching Mr. B. on the correct body mechanics to use. Mr. C. agreed the idea had merit; but how much should the goal weight be?

Here’s where the Physics "dust bunnies" stirred themselves. I remembered setting up formulas to calculate forces under various configurations; and although the formulas themselves weren’t going to re-appear in my head, I did remember what information needed to be "plugged in".

I engaged Mr. B. in the project of gathering the information by listing the measurements I needed. Mr. B. agreed to contact the manufacturers of his truck's equipment to get them. Mr. C. took the relevant measurements of his equipment, too. Once I had all these numbers, I phoned the Physics department at the U. and asked to speak to whomever was available to solve an equation for me. A friendly professor came on the line and 10 minutes later I had what I needed. I phoned Mr. C. to report that if Mr. B. could maintain good body mechanics while completing 25 repetitions with 70 pounds of weight on the modified exercise machine, there was a good chance Dr. S. would release him to return to his DOI job.

Well, it worked! Dr. S. first teased me about "playing Dr. Frankenstein with an innocent exercise machine", and then said he wanted to see the "contraption" for himself. We walked over to the clinic and Mr. B. demonstrated while also describing what he was "doing to the truck." When Dr. S. commented on Mr. B.'s consistent use of good body mechanics while cranking, Mr. B. said that doing the research on the crank specs. helped him understand the concepts behind the body mechanics, which made it easier for him to pay attention to how he did things. Dr. S. stated that Mr. B.’s confidence in his own ability to resume the DOI job demands reinforced the observable function. He signed the work release and Mr. B. returned to his DOI job without any problems.

Do you get any new ideas about OT practice from your recreational reading? Maybe doing this blog has made me more alert, but I've been seeing OT themes in many unexpected places. I say "themes" because not every idea I get is directly transferable to OT practice – that is, I'm not suggesting that OT practitioners can be all things to all people. But if anything I say helps you expand your thinking about how OT can help people identify and pursue occupations that wouldn't otherwise have occurred to them, then this blog has served its purpose.

I recently read an article¹ that compared and contrasted the author's (Max Alexander) experience with a funeral process that is considered "typical" in U.S. culture, and one called "home after-death care", which advocates suggest is more meaningful for the survivors, not to mention less costly. As you can imagine, calling something "meaningful" raises my OT antennae. So does information about saving money, especially when it comes to expenses arising from emotions that can be more focused on healthy grieving, rather than on how death expenses affect the families' budgets and economic futures. Alexander pointed out that most Americans spend "an average of $6,500 for a funeral, not including cemetery costs....That's 13 percent of the median American family's annual income."

Did you know that many states do not require bodies to be embalmed before burial, and many also allow do-it-yourself burials? This information is particularly relevant for the families of people who choose to die at home, with or without hospice services. Being able to forgo embalming affects the rituals – and their flow – the survivors will participate in. For example, the way Alexander described the body in the open (home-made) coffin resonated with me: "[he] looked unquestionably dead, but he looked beautiful." The first time I looked into an open coffin, I had the startling thought that there'd been some mistake: the person looked better than she had alive, and therefore, couldn't be dead. I was so repelled by the idea of makeup hiding the person's natural (dead) color, I've never been able to approach an open coffin since. I know my reaction was irrational - I had no difficulties facing the cadavers in Anatomy Lab - but I'm not going to risk a shock like that again. Even after that experience, I didn't recoil from my dad when mom and I visited him in the hospital morgue before his body was transported to the crematorium: because no one had tried to alter his appearance, I knew what to expect. If I ever attend a visitation where I know the body hasn't been altered to look "not dead", I will consider taking a final look.

Home after-death care opens up possibilities for additional activities to honor and memorialize the dead. Alexander describes building the coffin from scratch with his son; and then preparing his father-in-law's body for the visitation (before cremation). There are so many ways an OT practitioner can contribute to the family's consideration of and experience with such activities. Alexander also describes the bureaucratic hoops his family had to jump through to keep his father-in-law's body out of the typical funeral system. Many people, in their "anticipatory grief", could not deal with the institutional barriers to facing the "physical reality of death" without support. Think about how an OT practitioner could help relate the infuriating and exhausting "hoop-jumping" to meaningful occupations associated with preparing for and grieving someone's death.

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¹ Alexander, M. (2009) "Which Way Out?" Smithsonian Magazine, March, 2009, pp. 86-93

Thank you, Ed Kaine, for introducing me* to the organization ALOFT, and its trademarked titles "Registered Functional Therapist" (RFT) and "Registered Functional Therapy Associate" (RFTA). I'd like to start a discussion about this initiative. Please visit ALOFT, then use the comments section of this blog to express your opinions.

I admire the entrepreneurial spirit of the ALOFT team and the time and energy they're devoting to their beliefs. I also give them credit for using the word "associate" instead of "assistant" in the RFTA designation, thus addressing the long-standing controversy in the OTA community about the term "assistant".

Nevertheless, I don't think creating an "expert in function" title does Occupational Therapy any favors, and in fact, might undermine us in any number of ways. For example:

• A separate title specific to "function" implies that OT practitioners who don't have it lack the skills to address functional challenges. If you think the general public has difficulty understanding what we mean by "occupation", how much more confused do you think they'll be about OT practitioners who don't have a "function" title? "RFT/RFTA" is not equivalent to specialty certifications denoting advanced practices or additional academic degrees; but most of the general public interprets professional acronyms as such. To ALOFT's credit, the RFT or RFTA is not currently available to OT practitioners who aren't also registered with NBCOT. This requirement provides some mechanisms for consumer protection and speaks to the professionalism of ALOFT's founders. However, there are some OT practitioners who choose not to maintain the right to use NBCOT's trademarked "OTR" or "COTA", and rely instead solely on their states' licensing. Where does their "RFT(A)-ineligibilty" leave these OT practitioners in the struggle for recognition of Occupational Therapy?


• As I suggested in "The F-word: Function(al)", I believe OT practitioners waste time and energy trying to "own function." As much as I respect the allied professionals for their skills and knowledge, I don't care to be "lumped in" with them on the basis of "function". Not only that: I'd just as soon leave the "functional" groundwork to the other disciplines. That frees me up to focus on occupation without the distractions of "component remediation."


• ALOFT and its trademarks were created in response to OT practitioners' fatigue from endlessly trying to explain what OT is and isn't. There are actually groups on Facebook called "I'm tired of explaining what Occupational Therapy is!"and "Yes, I am a Occupational Therapist and no we don't wipe bums [backsides]!!" The "I'm tired..." group has more than 10,000 members! But I don't think creating a function-specific title will clarify anything. I can't say I'm any better at "summarizing" OT than anyone else, but I don't agree with Tim's 4/23/08 comment to the F-word post that "we are stuck with the fact that occupational means work to the public at large." We're "stuck" only if we give up.


• Ed has told me that he considers creating RFT/RFTA exclusively for OT practitioners as preventing other disciplines from defining OT. I see it as accomplishing just the opposite. I also consider the assumption that OT is only about work and jobs to be a conversation starter about what an AOTA motto calls the "job of living." Maybe having spent more than 20 years in the work. comp system makes it easier for me to see the conversational potential. But I've also chosen to look at the difficulty as a result of the broad application of our profession to the nearly endless variety in human life. I celebrate being in a profession that doesn't "fence me in" with easy definitions or descriptions the way the "component" disciplines do.


• Is there a danger of RFT/RFTA making it harder for OT practitioners to focus on occupation? That is, if a "function" title makes people stop asking us what we do, will it be harder to keep occupation at the forefront of our thinking and service delivery? You've already heard me complain about the "occupation-less" interventions I've seen from my so-called OT colleagues. If they can't find their way out of the "performance components" woods now, how will a title like RFT(A) help them avoid further erosion of their occupational focus?

Now it's your turn: please use the comments section below to voice your opinions. If you're worried about what people who know you might think of you, notice that you can choose to reveal only your first name to the public. So come out of "lurker" mode and speak up!

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*by way of his 4/30/09 comment on the blog entry "The F-word: Function(al)"

A reader, Linda, who commented on my 4/28/09 entry questions my characterization of case management as an advanced practice. She agrees with me that case management is an integral part of OT practice, and that OTs should "assert themselves as the excellent, well-rounded case manager that they already are." However, she also suggests that by referring to case management as an advanced practice, I will hold OTs back from "starting something". I'm not sure what that "something" refers to, but my live conversations with many OTs so far suggest that the lack of understanding about what case management is results in practitioners holding themselves back.

I don't exactly disagree with Linda's position that OTs can be case managers "right out of the box." The issue from my perspective is that until academic OT programs more uniformly include the specifics of case management in their curricula, OT practitioners are neither equipped for the complexities of case management, nor for keeping occupation at the forefront of case management interventions and plans for which they're responsible, until they've got some real-world experience. That doesn't mean new-grad OT practitioners shouldn't do case management, or shouldn't apply for jobs where case management is the primary responsibility or job title. I just think that OT practitioners need to recognize what they don't already know about case management as it is defined by non-OTs, especially as long as OT is under-represented among case managers, and under-utilized in health and human services. Also, having met several OTs practicing as case managers who think they've stopped practicing OT, I question the level of understanding of either OT or CM "alone", much less as an integrated service.

That said, there can very well be situations in which OTs are "intrinsically" qualified, given the diversity of case management practices and contexts. I was part of a group of OTs that successfully made that very point relative to Minnesota's workers' comp. system; and wrote about the issues and process by which we prevailed. So by all means, make your case. Here are just a couple of ways:

• Email the Commission for Certification of Case Managers (CCMC) if you're interested in participating in the Role and Function Study CCMC will be starting soon. You will receive notification of when the study begins (online).
• Do a research project on points you want to make about OT and CM. CCMC offers a $10,000 grant each year for research related to case management.

In the meantime, please add your voices to those who have commented on my blog so far.

A ship in harbour is safe - but that is not what ships are for - Unknown

My favorite moment at the AOTA Conference this past week was when a student told me that she and one of her classmates are so excited about what they'd learned in school about case management, they're going to make sure their OT jobs prepare them for that advanced practice specialty.

I wish every OT practitioner had such enthusiasm for case management, even if "only" as an integral part of his/her practice at any stage of his/her OT career. Many of the practitioners who spoke with me at the exhibit for the Commissioner for Certification of Case Managers (CCMC) indicated that they might consider case management when they get "too old" for the physical demands of their current OT practices. Although that's certainly a worthwhile consideration - sort of an "aging in OT place" strategy, I suppose - I felt kind of sad that case management would be considered a "last resort" full-time practice instead of something an OT would do while still in his/her professional prime.

Perhaps some of the differences in perspectives can be attributed to how one interprets the "doing" of case management, and therefore, who "does" what in any given multi-/inter-disciplinary intervention plan. An OT clinician might not "do" the same case management tasks as the "actual" case manager(s) involved in a case; but that doesn't mean the clinician isn't doing any case management. There can be multiple case managers involved in with an individual client; and each CM can have different roles and responsibilities. Hopefully they all talk to each other to determine who is in the best position to "do" whatever needs to be done within each one's particular CM context.

Even if there is only one CM involved, s/he can delegate many "doings" to other team members. Why can't some of the delegation be in the other direction: from an OT who has identified certain case management issues and works it out with other team members throughout the service continuum - on who is in the best position to follow through on addressing the issues? An OT's case management approach to issues can be particularly effective if no "official" case manager happens to be involved. But even when one or more CM is involved, an OT communicating with them in CM terms and contexts can often get more across about the significance of occupation than when staying within one's traditional activity patterns.

Gupta & Wallock (2006)¹ emphasized that OTs can [and should] deliver services that "...transcend...systemic barriers...." Incorporating the core components of case management into all practices increases the transcendent effectiveness of OT.

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¹ Gupta, J. & Walloch, C. (2006) Process of Infusing Social Justice Into the Practice Framework: A Case Study OT Practice, August 28: CE-1-CE-8.

This week, I will be attending AOTA's national Conference in Houston, TX. I will also have the pleasure of helping to staff the exhibit for the Commission for Certification of Case Managers (CCMC). If you will be at Conference, please stop by CCMC's booth (#838-near AOTA Member Resource Center) to find out more about the certification process. I will be there during all unopposed times - starting with the Grand Opening on Thursday evening - so if you have specific questions about Case Management as a specialty OT practice, and/or ways to increase your eligibility for the Certification exam, I would love to talk with you in person at CCMC's exhibit.

In order to qualify to take the Certification exam, applicants must demonstrate, via their application materials, that they have performed all of the essential activities of five of the six core components of Case Management¹. Most OTs are likely to have difficulty documenting experience with the components Healthcare Management & Delivery and Healthcare Reimbursement. Even within the components OTs do have experience with, their application materials need to highlight that they

...provide services across a continuum of care, beyond a single episode of care, that addresses the ongoing needs of the individual being served.

...[are] responsible for interacting with other relevant parties within the client's healthcare system.

...[are] primarily responsible for dealing with the client's broad spectrum of needs.²

OTs interested in obtaining CCM should carefully review the knowledge domains and sub-domains of Healthcare Management & Delivery and Healthcare Reimbursement³, in order to determine how they might need to change the way they practice OT so as to fill in the gaps.

And if you're in Houston this week, stop by CCMC's exhibit and brainstorm with me.

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¹ CCMC (2008) Guide to Certification , pg. 6

² CCMC (2008) Ibid.

³ CCMC (2008) Ibid., pg 9

"If the relationship functions, then there's nothing to talk about. If the relationship doesn't function, then there's nothing to talk about, either." - Gunborg Palme 'On The Psychologist's Couch'        

Do you make any distinctions between function and occupation? Do your service plans and documentation articulate the distinctions?

I believe that we OTs will continue to lack recognition for our unique skills until we are consistently careful to articulate the differences between "function" and "occupation". I believe that "function" used in the health and human services context implies a requirement for "health" and "absence of illness or disability", regardless of what people are actually able to do. Therefore, I consider "function" to be a subset of "occupation" and as such, of limited descriptive value.

I have many "functional" deficits, but I am occupationally intact. I have plenty of things "wrong" with me, but I've adjusted my occupational choices, and adapted many components of those occupations, as a result of changes in my functional abilities. Granted, for a variety of "functional" reasons, I prefer sedentary activities (an understatement: I could win a medal in a "couch potato" Olympics); but as my recent trek up Mount Kilimanjaro indicates, there are activities for which I'm willing to go beyond my "functional limits".

Rehab. and medical professionals use the terms "within normal limits" and "within functional limits" as questionable descriptions of recovery and abilities. But I've seen plenty of "WFLs" and "WNLs" that haven't automatically translated into meaningful occupations after discharge from rehab.

As a Case Manager who's always thinking in occupational terms, I can do a lot to bridge the gaps in understanding between "function" and "occupation" even while people are still in the treatment and rehab. phases of their recoveries. Keeping occupation in mind also serves the long-term, "post-clinical" phases of my clients' journeys. My efforts have often made the difference in the things Case Management is intended to maximize: the efficacy of diagnostic and treatment decisions; types and appropriateness of referrals; duration of services; reimbursement decisions; and most certainly outcomes.

By the same token, OTs can think in Case Management terms - and provide vital information for Case Managers - if we consistently focus on and emphasize the "occupational whole", instead of the "functional subsets".

I was going to have cosmetic surgery until I noticed that the doctor's office was full of portraits by Picasso.- Rita Rudner

How often have you engaged your clients in reviews of the occupational implications of treatments and services offered to them? Have your concerns about possible "non-compliance" been tempered by what you've learned about your clients' occupational priorities? I had a lot of time to reflect on those questions during my recent ascent of Mount Kilimanjaro in Tanzania, Africa.

During our group's orientation the night before we began our 7-day quest for the summit (19,340 feet/5894 meters above sea level), our trek guide, Ian, reviewed strategies for mitigating or avoiding altitude sickness. He is trained as a high-altitude first-responder, and specifically recommended against taking acetazolamide, a drug several of us were prescribed to mitigate altitude sickness. I asked him why we should ignore the recommendations of our licensed doctors and he replied "because they have no experience with high altitude and we do." It was neither the time nor place to start a debate about the accuracy of that claim (I know for a fact that one of my doctors has vacationed above 12,000 feet). I also couldn't think of a diplomatic way to ask about the qualifications of Ian's source(s) of information. But I wondered about the scientific evidence basis of our doctors' decision vs. the validity of practical experience.

Ian also told us that we should eat a lot, even if we had no appetite; plus drink at least 3 liters of water every day, more if we could manage it. I knew from hiking the Inca Trail in Peru several years ago that following these instructions would be tough: I didn't force either food or fluids on that trip, and I felt fine. I also used acetazolamide on that trip. But Kili's summit is 5000 feet above the highest point I reached on the Inca Trail, so I decided to try harder this time to eat and drink. I wasn't going to stop taking the acetazolamide, however.

30 hours into the trek, my body made it very clear that it wouldn't tolerate the amount of food and liquid I was forcing down my throat. I was so nauseated and dizzy, I could hardly walk. I also hadn't gotten any sleep the night before because I'd had to urinate every 20 minutes. So by lunchtime, I'd reverted to my Inca Trail ingestion patterns. By the time we got into camp that evening, I felt much better. I also decided not to drink anything after 7:00 each night. I felt fine - and slept well - from that evening on. My traveling companions ate and drank heroic quantities every day - and every one of them became far more familiar with the pit latrines and searching for privacy along the trail than I needed to. A couple of them spent the better part of at least one day vomiting (and they kept force-feeding and -drinking, so always had plenty to purge); and one woman vomited so frequently during the final ascent to the summit, two guides literally dragged her by her armpits to the top. Ian himself had several bouts with headaches during the 7 days we were with him. He treated them by drinking even more than the 5 liters he normally consumed. It made my stomach roil just thinking about it! But I didn't get any headaches, either.

As a case manager, I have opportunities to accompany my clients to their appointments with various service providers. Even my English-speaking clients have asked me for help in processing the deluge of information into actions that made some sense to them; and I long-ago found that providing an occupational context for their questions of me and the service providers had the most productive results. The results of a Yale study¹ "indicate that when given the probable outcomes of treatments, including possible impairment, a patient's acceptance of the treatment often changes".²

My Inca Trail and Kili decisions, though contrary to "expert advice", made it possible for me to engage in one of my favorite occupations. So far, I haven't developed any maladies as a result of temporary anorexia and mild dehydration. Many of my clients' "questionable" decisions have led to much better outcomes than I expected. Effective case management involves educating and coaching people as they try to navigate through life. Helping people identify the occupational contexts of the decision-making processes makes OTs particularly effective case managers.

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¹ Fried, TR, Bradley EH, Towle VR, Phil M, Allore H. (2002) Understanding treatment preferences of severely ill patients. NE Med J. 2002:346:1061-1066

² Groves, J & Hall, JM (2009) Hospice Care: Critical Concerns for Occupational Therapists Today in OT March 16, 2009: 23-27