So…….what is OT?? It’s a question we’re used to getting from non-OTs, but I see an increasing number of OTs asking this as well. I’m going to give you my thoughts, and you can give me yours, and maybe just maybe we can definitively answer this question. I bet an answer immediately came to your mind, and maybe it was something along the lines of one of these:

• “Well, occupational therapy is where we help people be able to do anything that they need or want to be able to do, but can’t for some reason”

• “It’s engaging people in occupation for therapeutic purposes”

• “We problem solve why a person can’t participate in their daily occupations by looking at the whole person, and we remediate or compensate for those things”

What beautiful statements! Let’s jump over to a brief history of OT to see how we developed these ideas in the first place. I read chapter 2 of my good ol’ Willard and Spackman book that I still have for some reason, and gathered the following:

Until the late 1700s, mental and physical illness was viewed as the result of poor morals, and people with those illnesses were treated as such (not super well). Luckily, people began moving away from this idea and decided to treat those patients more humanely by giving them rest and care (“rest cure”).¹ 

But then we discovered the “work cure”, and how staying active (rather than just resting) is vital for improving mental and physical health. 

Hull House began in 1889 for those with mental health ailments; folks with specific skill sets (typically a craft), nurses, and lay volunteers taught patients various handicrafts (Hello “arts & crafts movement”!) and life skills.¹ The work cure idea began to spread, and by the end of 1910, most hospitals in the U.S. were using occupations as part of “treatment protocols”.¹ (Note that “treatment protocols” implies that already-established medical professions were carrying this out. OT was not yet officially established until just before WW1 when AOTA was formed). 

WW1 occurred, and we sent over “rehabilitation aides” (PTs and OTs) to tend to soldiers and veterans. Some provided rehabilitative massages and exercises. Others provided handicrafts and “support for shell shock”…can you guess which ones were or became “OTs”?¹ There was so much confusion after the war regarding OT’s role, and one doctor, Dr. Krusen, believed that OT and PT should merge, as it seemed that OT was a “special application” of PT; Canada’s rehab programs incorporated both.¹

In 1935, accreditation of U.S. OT programs was solidified. OTs were primarily working in rehab units and hospitals specific to tuberculosis and mental health patients. While engaging patients in handicrafts, we began to adopt (not invent) goniometry and treatment of strength, range of motion, and endurance to help the patients do their handicrafts more effectively.¹ 

Let’s jump to post-WW2. The handicraft movement evolved into a focus on rehab methods with more formal research to gain credibility and recognition as a medical profession. 

We began to address underlying causes of dysfunction and involved ourselves in things like prosthetic training, NDT, motor function, etc., with the outcome aim of reintegrating veterans into society.¹ 

This meant that for a while, we took a turn away from directly using occupation; however, in the 1960s, there was a push to be occupation-centered again, and many OTs dove into theory to try and establish us some more (ahh theory).

So now that we’ve covered a very brief history of our profession, can I ask an honest question? Do PTs and other medical professionals actually not have the goal of improving everyday occupational performance? Truly, I think that is the goal for everyone. 

“But we use occupation, rather than rote exercise, to do this”. 

Ok, but maybe that’s because right before WW1, we decided to claim this as our own and made a separate field called “occupational therapy”, rather than merging with PT? 

From what I’ve experienced so far in a couple of different pediatric settings, we often think we are using occupation (i.e. play), but in reality are not. Going along with this, I think we are guilty of dwelling on underlying deficits, despite appropriate occupational performance, just as much as PT can be (here’s a fun challenge: ask the parents of your kids who you’ve had on your caseload for years if they have any functional concerns at home. You might be surprised).  

Willard & Spackman spoke about our return to the use of occupation (“top-down approach”?). But what does this mean? Does it mean we can mimic PT in rote exercise, as long as we have the client’s desired occupations in mind? Does it mean that we use functional activities, rather than rote exercise, to work on underlying skills? To me, this is still a bottom-up approach, with a cute functional flare added. For example, lifting plates into a cabinet rather than lifting weights or using resistance bands. PT can easily do this and is starting to do this more.

Maybe it means going straight to the occupation of concern, rather than similar or other functional activities, and working directly on that occupation for the sake of being able to do that specific occupation (rather than doing other functional activities for the sake of improving specific underlying skills, for the ultimate sake of being able to do a desired occupation…Roger that?). 

Could it also mean running a program in which clients engage in an occupation for the sake of participating in something fun, and therefore promoting general physical & mental health? Sounds like two kinds of people: our handicraft ancestors, and non-OTs who are skilled in something, and then share that something with people who may or may not have a disability. 

For example, I read about a skilled surfer who started an organization in which he engages Autistic kids in the leisure occupation of surfing, which ends up having great therapeutic benefits. Is this not technically “OT” because it’s not conducted by someone who spent a lot of money on the letters “OTR/L”? Is that highly skilled surfer not also looking for ways to adapt and modify the task of surfing depending on the child he is working with? Wouldn’t that skilled surfer conduct a better “activity analysis” of the sport they have in-depth knowledge on, than say, a non-surfing OT working with a client who wants to surf? 

Is OT all of the above? If so, do we have clear guidelines on when we can take more “bottom-up” approaches rather than “top-down”? 

I want to revisit Dr. Krusen from our history of OT. He believed that OT and PT should merge, as it seemed that the boundaries of OT were becoming unclear, and most hospitals were incorporating this new paradigm of meaningful occupation by 1910 (aka, PTs and other already-formed health professions were using this new approach). 

I agree with Dr. Krusen, and I am curious why we felt such a strong need to become a separate field when we also believed that the use of meaningful occupation was so important…so why not help the medical fields continue to grow in the adoption of this, rather than separating it into a different category that has its own monetary expenses which may pose as barriers to people accessing it? 

I further find it interesting that once we made the move to make the use of occupation a separate field, we then had to branch away from the use of occupation to gain credibility and recognition as a stand-alone “medical” profession. 

So we started as people who figured out that doing meaningful activity is important for all-around health. We shared this great, simple idea. We implemented it in hospitals. Then we decided we should do it on our own. We weren’t seen as a formal medical profession, so we tried to gain legitimacy and recognition by attempting to analyze every possible thing that could be impacting everything a person needs/wants to do, and now we have absolutely zero boundaries or actual scope of practice. And I believe we have now over-complicated what started as a great, simple idea. 

We are a “jack-of-all-trades, master of nothing” type of people. Some people say it is better to be this way. We’re the “glue” that can see all aspects of something and bring every other profession together. 

Ok, so perhaps we should be administrators who organize our medical teams, rather than be a stand-alone “medical” profession? Perhaps we should be administrators who bring together doctors, PTs, SLPs, dieticians, psychologists, and other people with in-depth knowledge and expertise on specific areas that could be causing occupational dysfunction, and help them work together better, to promote a holistic approach in our entire medical system (not just in one profession). 

Because what in-depth knowledge are we adding to the table? OT: “Hey, don’t forget about these 10 person factors that could be impacting this client! Oh yeah, here’s __profession to give you actual expert information about those factors. Just wanted to make sure I mentioned them!” I think that’s what we are. 

We are too broad. We try to do too much. Have a problem? Call the OT! They know everything! They’ll fix it! Now it’s sounding like a fad…

I read through definitions of OT from Willard & Spackman, the OTPF, AOTA, WFOT, and Google Dictionary. Most of them emphasize the direct use of occupations that clients need and/or want to be able to do to promote participation and modify those occupations and/or environments as needed. This, to me, means going straight to those occupations of concern, practicing them, and making adaptations as needed. Yet how are we to address every possible occupation that a person could ever need and/or want to do, along with every possible factor that could be impacting their performance? Where’s our actual scope of practice and depth of knowledge? 

Another definition mentions using any everyday activity to “improve health & participation”. This sounds to me like the surfer example, which can be done by any non-OT (PT included). 

If we essentially claim to do everything, then we aren’t really a single something. 

So now that I’ve gone from a history report to an exposé of my unpopular opinion, what do you think? 

Please help me keep the conversation going by contacting me with your thoughts! Click the “Contact” tab to get started. 

Until next time,

The Inquisitive OT 😉 

P.S. Please note that I mean no disrespect to all the amazing OTs out there who I know are making big impacts on their clients’ lives. But I do think this needs to be a conversation. I believe OT is still going through a significant identity crisis. Other medical professionals aren’t confident about what we are, and I don’t think we are, either. 

¹ Willard, H., & Spackman, C. (2019). A contextual history of occupational therapy. In B.A. Boyt Schell & G. Gillen (Eds.), Occupational therapy 13th edition (pp. 11-37). Wolters Kluwer.