Avoiding Therapy Dependency

By Jane Sorensen, PhD, OTR, ND

Posted on: September 2, 2008

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Q: I agree very much with your thought on focusing on the children who may indeed enter into society as a priority (July 21). How have you been able to convince/persuade/educate physicians, other therapists (disciplines) and parents regarding this?

A: My first OT job was in Manhattan State Hospital in New York City in the mid 1960s. I was responsible for all the patients on two wards, female admissions and female intensive treatment. There were 100 patients, all with OT "prescriptions." I had my own clinic on a different floor. It held 20 patients.

I learned the difference between treating directly and indirectly very fast. Patients who were most likely to respond to individual treatment in a group came down to the clinic for daily therapy. The 10 most alert, communicative women on admissions were seen daily on their wards. For the 70 or so patients I did not select for direct treatment, I gave regular consultative advice to staff so they could manage these patients more therapeutically.

I had to learn to evaluate and predict functional outcomes. I had to learn to explain to relatives, staff and psychiatrists why I selected one patient over another. Just as important, I had to learn when to discharge. Discharge was seen as positive by and for the patients. It was an achievement.

Then I worked in a large general hospital, treating babies and children. I also saw children in my private practice.

In both hospitals I had great OT supervision. And in my private practice, I retained private supervision with a pediatric psychologist. She taught that professionals should treat kids short-term and teach the parents how to work with their children. This strengthened the family unit.

A number of years later, I was asked to treat seven children in a special ed high school. There were 50 children in the school, 43 with no access to OT! They were all higher-functioning MR/DD but not candidates for regular employment. They all would be aging out of school. Some would go to group homes, some would stay at home and do supervised employment.

The seven designated for OT had no apparent issues that were different than the others'. So I proposed to the principal that I work indirectly with all the students. He loved the idea.

I gave a workshop to the teachers on what OT could and couldn't do. I posted my schedule, and teachers would list whom they would like me to see and where. So, I might pop into kitchen class to figure a better way for a student to hold a utensil or bowl, or go to gym to see if we could keep Charlie from falling so much.

At the end of the year, all of them were performing at maximum potential.

The agency I was with didn't know how to discharge kids from OT! The high school found out how to do it, and I called each set of parents to tell them that their child "graduated" from OT, and answered their questions. I explained, as I do with all parents whose permanently disabled child is performing at his maximum potential within the reality of the disability, that more treatment won't mean more function right now. The system the child is in is therapeutic and will encourage him to do his best and use what he learned in OT.

I was shocked the agency didn't know how to discharge. Then I realized each child was bringing in at least $5,000 over the school year, and discharging reduces cash flow.

Are many OTs who work for agencies encouraged to keep children in treatment? I believe it is our responsibility to the children to discharge them from direct service when they have reached realistic goals within the reality of their diagnoses. Being in therapy forever causes dependency, not independence.

I thought it was a shame that we didn't offer consultative services to all children in special ed and EI, instead of following a few directly year in and year out.

How many children might benefit from a few sessions but not a whole year? How many teachers and other professionals might learn from us?

How many parents might have a question answered and learn a technique to aid their kids?

The 2004 reauthorization of IDEA has now made it possible for OTs to get referrals from classroom teachers to intervene with children outside special ed who are having problems, before they actually fail. School systems should encourage this approach.

I've always had parents understand about discharging their child. I did get into an argument with a physician once. I would not put a child on treatment for a second time. I explained that she was absent from school more than half the time. There was no follow-through by her parents on anything. She was MR/DD and needed repetition at home to learn. I did not believe she was a candidate for OT. She hadn't and wouldn't respond, and couldn't use such a high level of care.

He listened carefully, then said, "You are the first realistic person I've met in the school system."

Jane Sorensen, PhD, OTR, ND, practiced in all traditional OT areas over 32 years and wellness for 25 years in private practice. She currently has a supervisory and consulting practice. She has written A Therapist's Tales (www.lulu.com/drjane) and was ADVANCE editor E.J. Brown's co-author for An Overview of Early Intervention (http://www.proedinc.com/). You can reach her at 212-744-5836 or drjane@hvc.rr.com. <% footer %>

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I agree with the statement that telling a parent that no more OT in indicated "right now". I always explain that the parent can seek a new evaluation if new difficulties arise, the child gets to a new motor or cognitive developmental level, they start a new grade or a new school, etc. I would like to hear from others if they have experienced wanting to D/C a child but no other professional agrees with this clinical reasoning/philosophy that the child and family should not become dependent on therapy (such as the PT working with the child) and a conflict arises when the parent does not want to discharge. My question then becomes- can I help the family to the point of seeing this as a positive? Or, do I continue therapy and try to 'wean' them to become less dependent? Or, is it not my place to change their point of view? In the past I have discharged them (with the support of the PCP) and they have left unhappy, and sought out therapy elsewhere, as others have mentioned in their responses.

Julie	September 17, 2008

In my experience, the most important aspect in discharging children is the parents.

They MUST understand why their child is being discharged and they must agree with you.

It is important you help them understand, in detail, the effect of their child's diagnosis/disability on his occuational performance. I have always found parents want to know as much as they can about diagnoses and the limitations/challenges presented to their children. When they understand their child has done the best he can within the reality of his disability/diagnosis, and has achieved goals, they agree with discharge.

In EI I reveiw all the activities/excercies I've taught to the parents and make sure they understand that continuing them is important.

In school age, I have the parents come in for a session, demonstrate by the child's doing that IEP goals are met and give them a few activites to follow thru with at home.

Again, the parents' understanding and empowerment is the key to accepting discharge. As it should be, in my opinion.

Jane Sorensen, Dr.	September 05, 2008

another long one - if too long please read in entirety at http://abctherapeutics.blogspot.com/2008/09/power-of-words.html

I read the this magazine article today and still felt uncomfortable as I kept stumbling over what Dr. Jane Sorenson wrote:

“At the end of the year, all of them were performing at maximum potential… I explained, as I do with all parents whose permanently disabled child is performing at his maximum potential within the reality of the disability, that more treatment won't mean more function right now… I believe it is our responsibility to the children to discharge them from direct service when they have reached realistic goals within the reality of their diagnoses.”

I wanted to do some self-checking to be sure that I wasn’t applying any bias to reading her based on my disappointment over her previous comments. After a lot of consideration, I think I understand the nature of my concern and discomfort.

It is the words.

As an amateur anthropologist I have some passing understanding of the Sapir–Whorf hypothesis. This hypothesis states that there is a power to words and that words frame our perspectives and understandings. This is not a discussion about political correctness which has pejorative connotations because of the way that the concept has been co-opted in American political discourse. This is about the power of words and the language we use.

Language is a medium for expression of a culture – and a culture is a shared set of beliefs and practices. In the simplest form, language transmits the beliefs and practices of people. I would be remiss if I did not also reference Jerome Bruner, who described the construction of reality through narrative. In short, words are powerful. Words reflect our beliefs that frame our narratives and support our culture.

Occupational therapists have a culture. There are variations in the culture but there are some basic beliefs that most occupational therapists hold. Perhaps the most important of those beliefs has to do with human potential.

I am not talking about human potential from some wishy-washy 1960s mind-expansion perspective. I am talking about the basics of humanistic psychology, and people’s needs, and how they experience their lives and how their needs are met. Occupational therapists, perhaps more than any other professionals, understand this dynamic nature of human need, and how needs ‘imperatively demand satisfaction’ – which I believe is an Eric Fromm quote that was recycled by Mary Reilly in her Slagle lecture. People have needs and meeting those needs is often derailed and impeded by life experiences or disability.

So what are we saying when we state that someone is performing at their maximum potential? What exactly does that mean? What is potential and how does one know when it has been maximized? Is there anyone that reads this who has ever believed that their own potential has been maximized?

For your potential to be maximized your needs must be met. To state that someone has maximized their potential is to state that they Need no more.

If you Need no more, you can not have growth. And perhaps you have no meaning. If I say that you Need no more than I have placed you in a box, de-humanized you in every way possible, and stated that your human potential is complete. To take away your Need is to take away your human-ness. You are a defined object and not a self-actualizing subject.

The words are horrifying – I can only imagine the punched-in-the-stomach feeling that a parent would feel to have someone tell them that their child has no Needs and that they are at their maximum potential within the reality of the disability.

Whose reality? The reality of the all-knowing professional who after having completed some assessments in a limited contextual understanding of that child completely and abjectly disregards the parent’s larger hopes and aspirations? Is that reality?

I can’t imagine harsher words. That is where I am getting stuck.

There is no doubt that there are times to discharge a child. There are times to change from direct to indirect interventions. There are times to make all kinds of changes in the recommended intervention program of a child. These are not real issues – everyone knows these things.

But it should never be time to use words that limit the human potential of anyone.

Here is an easy fix – how about saying that “the child has derived the maximal benefit from participating in occupational therapy at this time.” I can accept that.

I can’t accept the statement that they have achieved their maximal potential given the reality of their disability. It is just too cruel and this is not the culture of occupational therapy.

There is a difference of articulation here: is the child done and do the parents need to accept some reality? Or is the therapy done for that particular time and context?

I know they are just words – but let’s hear your opinion – isn’t there a difference?

Christopher Alterio, Owner, ABC Therapeutics	September 04, 2008
East Amherst, NY

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