Major initiatives in mental health education, scope of practice and specialty certification marked the 2004 Representative Assembly, as it attempted to lay the groundwork for stronger credibility in traditional and emerging OT markets.

The assembly stopped short of asking the Accreditation Council for Occupational Therapy Education (ACOTE) to consider requiring fieldwork in mental health, but it left the possibility wide open.

A 61-page report to the 2004 RA from AOTA's state affairs group, responding to a charge from last year's assembly, outlines in stark black and white the crisis in OT mental health practice. Charles Willmarth, head of the SAG, gave a summary of the report in the task force meeting that set out to examine the mental health motion for required fieldwork at this year's assembly, brought forth in Barbara Kornblau's presidential report to the assembly.

The state affairs group had looked into complaints from practitioners that in many states they were no longer considered "qualified mental health practitioners" (QMHPs).

"The educational level for those professions [recognized as QMHPs] was higher," Willmarth told the task group. "I think the current [OT] standards aren't specific enough to march into some statehouse and demand to be 'qualified.'"

Most professionals who hold that qualification come out of psychology and social work and are able to diagnose as well as treat specific mental illnesses.

The number of occupational therapists and OTAs practicing in mental health settings has fallen dramatically over the past two decades. Wendy Hildenbrand of Kansas, task group leader, is one of the dwindling number. "I can tell you that we're not even on the radar in my state," she said frankly.

Kornblau, who's been practicing for more than 20 years, told the group she'd brought the mental health issue forward because "it's a discussion the profession needs to have. To me, psych is the core of who I am as an OT; and if it's not the core, then I'm not sure who I am anymore. This isn't just 'where are we going to find fieldwork'; we need to broaden our perspective of what psych is."

Outgoing COE Chair Charlotte Royeen noted that upgrading psychology education could easily be incorporated into occupational therapy's strong grounding in neuroanatomy.

"We've got ICF behind us," she said. "We put it all together. Occupation is mental health."

Three years ago the World Health Organization (WHO) shifted its approach to measuring health and disability around the world to become proactive in terms of preserving quality of life. In 2001, 191 countries adopted the new International Classification of Functioning, Disability and Health (ICF) framework, which puts mental disability on a par with physical disability, and notes that depressive disorders are the number one cause of disability around the world.

ICF is now concerned most with "how people live with their health conditions and how these can be improved to achieve a productive, fulfilling life," according to a press release on its Web site.

Following discussion of the mental health issue the task group brought forth the original motion for required mental health fieldwork in two separate substitute motions, one designed to address the competencies necessary to practice in today's mental health market, and the other designed to look at what is necessary to train students in, and encourage them to use and document, their psychosocial skills with patients across all practice arenas.

The RA charged the commissions on practice and education to work with the mental health special interest section to explore exactly what is in each curriculum of its 298 OT and OTA programs across the nation that prepares them for mental health practice, and to set those competencies in a framework that will be understood by external audiences. A report is due back to the 2005 RA for review.

"We have packaged mental health coursework so well that we need to start examining programs to see how entry-level people are justified in practicing in mental health," Rep. Penelope Moyers told her colleagues. Moyers represents AOTA's Commission on Continuing Competence and Professional Development.

Meanwhile, in a separate motion, the assembly charged COE alone to look at the educational component of the profession to see what strategies might be used to "increase the capacity of graduates to apply the psychosocial core of occupational therapy across all settings." Some delegates felt that the situation in practice is so dire that such a report could not wait a full year.

Pennsylvania Rep. Ann Marie Potter urged her colleagues to require the report in time for the fall 2004 online RA meeting, usually held in October.

Iowa Rep. Jason Faris told the assembly, "I feel pretty passionate about this-otherwise I'd be at the APTA conference." His remarks drew applause from his colleagues. "This has been slipping badly, and we need to do something about it now!"

Delegates from Mississippi, New York and Maryland concurred.

Despite the sense of urgency, AOTA has no power to change educational program requirements, however, and ACOTE Chair Paula Kramer cautioned her colleagues both in task force and on the floor of the assembly that their collective input into ACOTE's current standards review process would not become a mandate.

"Comments from official bodies are given no special status," she said.

ACOTE is not an independent organization, but it operates under the AOTA Board of Directors, "at arm's length," a legal status that gives it independent power. As an accrediting body, it is recognized by the U.S.Department of Education and by the Council on Higher Education Accreditation (CHEA), an independent accrediting agency for accreditation bodies.

While OT and OTA programs are generally structured around the Standards, they also have to meet certain criteria of the schools and universities that sponsor them in order to stay in business. Mental health fieldwork sites are hard to find, and program closure is something Kramer doesn't want to see happen because ACOTE makes its requirements too stiff.

The upgrade in mental health is congruent with AOTA's all-around attempt to strengthen and secure the scope of OT practice. The assembly adopted a new scope-of-practice document that clearly delineates occupation as its core, and declares the profession's commitment to treating mind and body. The document puts teeth into the Practice Framework, passed last year, which outlines in detail the scope and methodology of OT practice. The scope-of-practice document will undergird AOTA's model practice act, for use by state regulatory bodies in upgrading licensure laws to reflect a more unified practice description.

To that end, the RA also passed a new definition of OT practice. Significantly, perhaps, the representatives amended the final vrsion to be more accommodating to wellness and prevention than it had been.

While the definition is meant to be a guideline, some delegates were concerned that its wording be perfect, because many states will use it as it is.

"Some states are using this as gospel," said Montana Rep. Lorie Heinrich. "We wanted to add something to it, and we weren't allowed to."

Others were equally concerned about that and complained that their comments about the new definition apparently hadn't been passed along to the task group discussing the motion. Sheryln Fenton, representing the Affiliated State Association Presidents (ASAP), reminded her colleagues that this was the 15th draft of the document.

The definition passed with an amendment adding health/wellness and prevention phrases.

The 2004 RA also established new board and specialty certifications under CCCPD which will begin construction of them this year, reporting their interim progress to the 2005 assembly in Long Beach, CA. These board credentials signify specialized knowledge in basic areas of practice and will replace and/or extend the board certifications AOTA offered previously in neurology, geriatrics and pediatrics. The new board certifications also will include gerontology and pediatrics, but will add mental health and physical rehabilitation.

Specialty certifications, which credential particular competencies rather than generalized knowledge, will include driver rehab and community mobility, cognition, environmental modification, feeding and swallowing, and low vision.

A highly divided debate arose over the prospect of reorganizing the Standards and Ethics Commission (SEC) into a quasi-independent body. Outgoing chair Shirley Wells told the assembly that the SEC was becoming overburdened with the number and complexity of individual complaints and organizational issues. The body has greatly extended its judicial role and experienced a number of conflicts of interest.

Board member Penny Kyler spoke out against the measure because of its liability ramifications.

"Doing this is an inherent conflict of interest," she said. "You're moving it toward legal status."

Treasurer Melanie Ellexson was concerned that creating such a body was out of AOTA's jurisdiction. "Why are we talking about forming a stand-alone committee when we are not the body that regulates practice?" she asked. "Is it fiscally sound to spend $12,000 to create a larger body that can do no more than take away membership?"

But other representatives felt the move was justified. All 129 members who had voted on the motion in a mailed ballot had voted in favor of it.

The motion failed on a count-off vote when five members abstained from voting. Though it had "passed" 29-25, parliamentarian Esther Bell ruled that by Roberts Rules, the abstentions counted as negative votes and had to be subtracted from the total.

After a lunch recess, the assembly allowed the motion to be brought back to the floor, however. It passed when the language was changed to imply a more comprehensive look at the issue. New RA Speaker Wendy Hildenbrand and AOTA President Carolyn Baum will appoint an ad hoc committee to explore alternative structures for the SEC, with an interim report due back to the 2005 RA, and final recommendations in 2006.

The RA also restored to voting status eight of its bodies and commissions that had lost that status during the reorganization of the assembly in the past several years. Now able to vote as RA members once more will be those who represent the Assembly of Student Delegates (ASD), ASAP, OTAs and consumers, and the chairs of the commissions on practice, standards and ethics, continuing competence and professional development, and special interest sections.

E.J. Brown is editor of ADVANCE. She can be reached at ebrown@merion.com.