I often get asked by colleagues and prospective applicants what students should major in if they want to become an occupational therapist. My standard response is that prospective applicants should select a major that interests them and to be sure to take the required prerequisite coursework. I think that people are really seeking to learn what makes a good occupational therapist. Is it a background in psychology, sociology, education, art, the basic sciences, or exercise and movement science? I’ve taught and worked with occupational therapists who have completed undergraduate degrees in each of these subjects, and many more. From my perspective, the best occupational therapy students and practitioners enjoy solving problems.
Occupational therapists, like other health care providers, make hundreds of clinical decisions each day. Such decisions include which client would benefit from services, which assessment tool to use, which intervention would be the most effective for this client or population, how to grade the intervention to meet a specific client’s needs, and when to discharge a client from services. The reasoning process by which occupational therapists make decisions has been described as both a science and an art. Rogers described the process of clinical reasoning in her 1983 Eleanor Clark Slagle Lecture:
The artistry of clinical reasoning is exhibited in the craftsmanship with which the therapist executes the series of steps that culminates in a clinical decision. It is expressed in the interpersonal skills through which the therapist invites involvement in decision making, builds trust, explains treatment alternatives, and offers encouragement. Artistry manifests itself in adeptness with which the therapist gathers cues by selecting questions, probing for information not volunteered, clarifying discrepancies, administering tests, and observing performance. The degree of perfection with which the data to be processed are obtained influences the reliability and validity of that data and hence puts limits on the quality of the final judgment…Artistic insight reaches its peak in combining evidence and opinion to support arguments convincingly, thus bringing closure to the decision-making process (p. 615).
The field of occupational therapy has a distinct focus on occupations, or the activities that people want and need to do in everyday life, and how the use of such occupations promote and restore physical and mental health. Because of this focus, occupational therapy practitioners engage in a unique clinical reasoning process that holds occupation in the foreground and blends both mechanistic and phenomenological perspectives.
The mechanistic perspective is shared by many other healthcare providers and is common in the field of medicine. This type of reasoning is based in biomedicine and focuses on diagnosis and understanding “what is wrong” through the identification of symptoms or cues that point to a particular type of dysfunction or impairment. The phenomenological perspective involves deliberating the best and most appropriate course of action to be taken in therapy based on the client’s lived-experience. The lived-experience of the client is framed as the “anthropological concern” (Mattingly & Fleming, 1994; p. 64) and related to what impairments or performance differences mean to a given individual, while managing specific roles, and in a particular context.
To blend these two perspectives, occupational therapists use theory to guide their clinical reasoning. At the most basic level, occupational therapists base their clinical decisions on how they understand the match or mismatch between three factors: the client, the task or occupation, and the environment (Cahill & Lopez-Reyna, 2013). In order to achieve this understanding, the Accreditation Council of Occupational Therapy Education (ACOTE) requires that occupational therapy students have foundational knowledge and understanding related to:
- The structure and function of the human body
- Human development throughout the lifespan
- Concepts related to human behavior and mental health
- The role of sociocultural, socioeconomic, and diversity factors and lifestyle choices in contemporary society
- The ethical and practical considerations that affect the health and wellness needs of those who are experiencing or are at risk for social injustice, occupational deprivation, and disparity in the receipt of services
- Global social issues and prevailing health and welfare needs of populations with or at risk for disabilities and chronic health conditions.
- The use of technology to support performance, participation, health and well-being (ACOTE, 2011; B.1.0-B.1.8; p. 18-19)
This foundational knowledge provides occupational therapy students with a basis by which to begin exploring the tenets of occupational therapy theory and intervention in order to work with clients to solve problems that impact their everyday performance and participation. Students that enter occupational therapy programs from backgrounds where rigid logic processes were extolled (i.e., if you observe A, then do B) often experience a period of disequilibrium as they leave the dichotomous world of “right” and “wrong” answers and enter a community of learners that are constantly striving to find “the better” answer for their specific individual client, group, or population.
There are many important aspects of health that require the application of biomedical knowledge and rigid logic processes. For example, if a person’s oxygen saturation levels fall below a certain point, provide oxygen via nasal cannula. If a person’s ability to walk is reduced by leg weakness, provide specific exercises to strengthen the legs. Occupational therapy education asks students to consider questions that reside in the space between what can be answered by applying biomedical knowledge and what the client knows through his or her own lived-experience. Occupational therapy education requires students to consider both the mechanistic and phenomenological aspects of the problem to answer questions related to occupational performance and participation. For example, in practice an occupational therapist may answer the following questions:
- How can a 55 year old business man travel alone for work 10 weeks after bilateral carpal tunnel repair?
- How can adult children caring for their 91 year old mother with Alzheimer’s disease include her in the family’s holiday traditions?
- How can a 12 year old with sensory processing differences and symptoms of anxiety attend and enjoy his first sleep over party?