Evolved Living Podcast

You asked a careful question about your scope and got an answer delivered with total certainty and no source. Maybe it came in a comment thread, maybe in a team meeting, and you felt yourself shrink a little inside a profession you spent years training for. If that has happened to you, this essay is for you, and so is the free journal club I’m hosting this Saturday.

Details are at the end, or you can join the Evolved Living Collaborative here now and meet us there Saturday.

I see some version of this exchange nearly every week, in practice groups, in team meetings and in hallways outside treatment rooms. I’ve de-identified it, since what matters is how it works and nobody in particular.

A practitioner asks whether OTs can perform digital stimulation as part of a bowel program for a client with a spinal cord injury. She has already checked her state practice act and the AOTA materials, found nothing explicit either way, and is asking before she proceeds. That’s exactly what a careful clinician should do.

Someone answers in two words.

Absolutely not.

They cite no statute, regulation or professional standard, and often give no sign that they hold the credential they’re ruling on.

That answer will land on somebody’s practice. Maybe not hers, since she was already reading the source documents. Somebody watching, though, will absorb “OTs can’t do that” and carry it into a team meeting six months from now, where a person who no longer remembers where they heard it will repeat it as fact.

A scope shrinks one confident, unsourced sentence at a time, repeated until it hardens into something that feels like law.

The missing-sentence fallacy

The reasoning under that two-word answer goes like this: I can’t find this intervention named in an OT document, so it must be prohibited.

Our own professional resources ask for a much fuller process. That process includes checking whether applicable documents actually contain language prohibiting the practice (American Occupational Therapy Association [AOTA], n.d.-c), and I’ll lay out the whole sequence below.

AOTA describes occupational therapy as a dynamic and evolving profession responsive to societal needs, system changes, emerging knowledge, research and technology. It also makes clear that professional documents do not supersede state laws and regulations governing practice (AOTA, 2021). Silence in a document tells you the document is finite, and by itself it proves nothing about prohibition.

Sometimes that silence tells us something more hopeful. A practice that has not been extensively codified may simply be an area where the profession has not yet developed the evidence, competency infrastructure, educational resources or policy language practitioners need. People may already be doing pieces of that work in clinical programs and communities, while much of their knowledge stays in clinical reasoning, local outcomes and conversations with one another.

That gap is an invitation to build, responsibly. When practitioners pool what they have learned, document outcomes, collaborate with researchers and communities, develop competencies, and bring that evidence into professional and regulatory conversations, today’s missing sentence can become tomorrow’s resource.

I’m doing exactly that right now, working on a paper with Dr. Tim Dionne and Dr. Susan Burwash, and I’ll come back to it at the end.

So when you can’t find a practice named anywhere, one question is absolutely whether you are permitted and competent to do this now. Another is who ought to be developing the evidence and infrastructure this area still needs, and sometimes the answer to that second question might include you.

Where our certainty actually comes from

I’ve been watching how scope gets argued online for a long time, and the pattern is remarkably consistent. People who answer scope questions with total conviction are often drawing on something far more local than they realize.

They’re drawing on when and where they went to school, and on what the curriculum emphasized in that particular decade. A clinician trained twenty years ago and one trained last spring can hold very different pictures of the same profession, and each may describe theirs as simply “what OT is.”

They’re also drawing on the traditions of the agencies they’ve worked in, meaning the way a department has always done things and the precedent nobody has questioned since the manager before last.

Very often they’re drawing on their own personal boundaries as well. “I would never do that” is a legitimate thing for a clinician to feel, and “I have not developed competence to do that safely” is an important professional judgment. Delivered as a statement about an entire licensed profession, however, that individual boundary can become personal preference dressed up as policy.

Six things we collapse into one

Most scope arguments in our profession are really six different conversations wearing one label. Untangling them is the skill:

* The profession-wide scope of occupational therapy

* State practice-act regulation

* Clinical guidelines and standards of care

* Areas of natural overlap with other professions

* Employer or facility policy

* An individual practitioner’s scope of competence

“I haven’t been trained in this and wouldn’t perform it” is a complete, honorable, professional sentence, and it belongs to the sixth category. Once it gets upgraded into “our profession isn’t allowed to do this,” it has quietly taken over the other five, usually without anyone in the room noticing.

AOTA’s own decision process gives us a better sequence. Is this consistent with occupational therapy’s professional domain? What does state law permit or restrict? Do applicable professional documents or clinical guidelines prohibit it? What education, training, supervised practice or credentials are required? Has the practitioner demonstrated competency? What does the evidence support? What do the payer and the organization require? And can the practitioner articulate why this service belongs within occupational therapy for this client? (AOTA, n.d.-c).

Answering those questions takes literacy. Answering in two words takes two seconds and can shape somebody’s access to comprehensive care.

What this looks like in real questions

Scope arguments sound abstract until you watch one land on an actual client. Here are four questions I see come up again and again, and each one sits on a different layer.

Can OT address bowel and bladder management after a spinal cord injury? This is the question from the opening. Our own practice framework names toileting and toilet hygiene among the activities of daily living (AOTA, 2020b). For someone living with SCI, a bowel and bladder routine can decide whether they can hold a job, travel, date or sleep through the night, which makes it about as occupational as a need gets. I’ve still watched practitioners hand it off entirely because somebody once called it “a nursing thing.” Nursing has a real role here, and so do physicians, and so do we. That’s category four, natural overlap, being mistaken for category one. Whether a specific technique like digital stimulation is permitted in your state is a separate and legitimate question, and it deserves a sourced answer. Part 2 walks through how to get one.

Can OT address addiction? Occupational therapists look at how substance use reshapes a person’s self-care, productivity and leisure, and help people rebuild daily routines that can hold (Ercan Doğu & Özkan, 2023). AOTA’s own practice publications describe OT’s role in return to work for people with substance use disorder (Wheeler et al., 2022). A national survey of practitioners found genuine interest in working with this population alongside real gaps in confidence and knowledge (Mattila et al., 2022). That’s a category-six gap in education and competence, and a profession can close that kind of gap.

Can OT work in pelvic health? I’ve heard “pelvic floor is a PT specialty” stated as settled fact more times than I can count. Pelvic health covers bowel and bladder health, vaginal and uterine health, and sexual health, including the muscles and structures involved (Akselrud & Vestal, 2021). Our practice framework names toileting and sexual activity among the activities of daily living (AOTA, 2020b), and AOTA’s own clinical guidance says OT practitioners can address underlying body structures and functions, such as pelvic floor strengthening to reduce bowel and bladder leakage, to improve everyday performance (AOTA, n.d.-e). OTs are already practicing and publishing in this area. Specific techniques, including internal assessment, still depend on your jurisdiction and your training, so that question gets answered by your state’s rules and your own competence. What doesn’t hold up is the claim that the whole area belongs to one profession. That’s category four, natural overlap, being mistaken for category one again.

Can OT perform dry needling? Here state law really is most of the conversation, and it shows how quickly that layer can move. At the professional level, AOTA’s policy on interventions to support occupations names dry needling among the techniques that may be used in preparation for, or alongside, occupation (AOTA, 2023). The states have gone very different ways. In 2023, Florida’s Board of Occupational Therapy declined to find dry needling within OT scope. The question then moved to the legislature, and since July 1, 2026, Florida law has authorized OTs to perform dry needling once they meet defined standards for experience, training and demonstrated competency (Florida House of Representatives, 2026; Laws of Florida, 2026). Alaska’s board concluded in 2023 that its OT statute didn’t support dry needling, then retracted that position after conflicting legal opinions and began work on clarifying language (Alaska Board of Physical Therapy and Occupational Therapy, 2023).

So sometimes the honest answer to a scope question really is no, at least for now. A careful no that comes with a citation protects clients and practitioners alike, and it can even become the starting point for change. The no that does damage is the one that arrives with no source at all.

For occupational therapy assistants, the layers multiply

Add an OTA to the picture and every one of those questions picks up another layer.

OTAs deliver a large share of occupational therapy services across settings, and their practice exists within the profession’s scope. Their actual responsibilities are also shaped by state supervision requirements, payer rules, facility requirements, the nature and complexity of the clients being served, their demonstrated service competency, and what the supervising OT appropriately delegates.

An OTA’s individual scope of competence is not necessarily frozen at graduation.

AOTA’s supervision guidance describes supervision as a collaborative process supporting safe and effective service delivery while fostering professional competence and development. It also describes OTAs as providing services under the supervision of and in partnership with occupational therapists, with delegation dependent in part on demonstrated service competency (AOTA, 2020a, 2025). AOTA’s scope decision guidance likewise identifies training and supervised practice as mechanisms through which practitioners can establish competence in an area of practice (AOTA, n.d.-c).

That means mentorship matters. When an OT has developed competence in an emerging or specialized area of practice, supervision can become one mechanism through which an OTA develops the knowledge, skills and demonstrated service competency necessary to participate appropriately in that work.

The supervising OT is not rewriting state law or personally expanding the OTA’s legal scope. Both practitioners remain accountable to state law, applicable regulations, payer requirements, professional standards and facility policies. What can expand is the OTA’s individual capacity within that legally permitted professional scope.

What OTAs are already doing

OTAs are already practicing more expansively than many people assume, and that includes some OTAs themselves. Here are four sentences I hear repeated as rules, and what the sources actually say.

“OTAs don’t do evaluations.” AOTA’s position is more nuanced. OTAs can contribute to the evaluative process, especially the occupational profile, and can administer standardized and nonstandardized assessments once they’ve established competency (AOTA, 2024). The OT still interprets the data and holds responsibility for the evaluation. California’s board goes further and allows OTAs to perform reassessments and discharge plans under OT supervision, as long as the OT reviews and interprets what the OTA gathers and both sign the plan of care (California Board of Occupational Therapy, n.d.).

"Maintenance therapy is therapist-only." Medicare's home health rules did reserve skilled maintenance therapy for therapists until 2020. CMS then changed its regulations so OTAs can furnish maintenance therapy under a program the OT establishes, within their state's scope of practice (Centers for Medicare & Medicaid Services [CMS], 2019a). The OT still handles the initial assessment, the plan of care, program development and reassessment every 30 days, and supervises the OTA. CMS noted that the change brought home health in line with SNFs and said it would let assistants practice at the top of their state licensure (CMS, 2019b). If your agency still tells OTAs that maintenance visits are off-limits, it's worth asking what source that rule rests on.

“OTAs can’t use modalities.” AOTA’s position statement names OTAs alongside OTs as practitioners who may use physical agent, mechanical and instrument-assisted modalities as part of occupation-based intervention (AOTA, 2024). Its ethics guidance adds that where state regulations permit, an OT may delegate modalities to an OTA who is trained and has demonstrated competency, and both keep records of that training (AOTA, n.d.-d). Many states add competence requirements of their own, and that’s the state layer doing its job.

“Advanced practice is for OTs.” California’s board answers this one directly. OTAs can provide advanced practice treatment in areas such as hand therapy, modalities and dysphagia when they’re supervised by an OT the board has approved in that area (California Board of Occupational Therapy, n.d.).

Each of these runs through supervision, demonstrated competence and state law. Taken together, they show how far that structure can stretch when an OT and an OTA treat it as a pathway for growth, and how much gets lost when it’s treated like a fence.

Delegation also remains contextual. Something appropriate to delegate for one client may require greater OT involvement for another because of complexity, instability, risk, the nature of the evaluation, or the clinical reasoning required.

AOTA describes OT-OTA practice as intraprofessional collaboration, a far richer thing than handing a fixed checklist of tasks from one practitioner to another (AOTA, n.d.-a). Delegation is itself an act of clinical reasoning. When it works well, the OT and OTA are partners in shared clinical thinking, each bringing professional knowledge and judgment to the care while remaining accountable to their respective roles.

Flatten that relationship into a universal list of approved tasks and we lose the possibility of mentorship, professional development, evolving competence and two trained minds working together in service of the client.

The risk of crowdsourcing policy

Every answer here depends on where you’re standing. State law varies, and so do regional practice patterns, payer requirements, agency policy and practice settings. The dry needling example makes that vivid: the same question gets a different legal answer in Florida than in Alaska, and a different answer in Florida this year than it got three years ago. A confident answer from someone in another state, setting or profession might be accurate for them and wrong for you, and a comment section gives you no way to tell which.

The open internet is a wonderful place to find colleagues and a risky place to source policy.

When someone meets a nuanced policy question with black-and-white conviction, it’s worth asking a few quiet questions of your own. What source are they relying on? Does that source actually govern this practitioner in this jurisdiction and setting? Does it prohibit the practice, establish conditions for it, or simply not mention it? Are they describing professional scope, legal scope, organizational policy, payer coverage, or their own scope of competence?

Each of those is a very different claim. In Part 2, I’ll walk through the sequence I recommend when you need a real answer.

When the interpretation belongs to whoever runs the building

The same pattern has a quieter version, and it happens inside our own workplaces.

In many settings, the working definition of policy and scope ends up becoming whatever a middle manager, regional lead, director or compliance consultant says it is. Their interpretation gets written into facility policy and repeated at onboarding until it becomes the only version anyone on staff has ever heard.

Facility policy matters, and so do compliance, payer requirements, credentialing, plans of care and organizational responsibilities. Facility policy still can’t stand in for the legal scope of a profession. Clinical determinations about an individual client’s needs require the professional reasoning of the practitioners responsible for evaluation and service delivery, operating within applicable law, payer requirements, organizational policy, evidence, ethics and demonstrated competence.

That distinction matters because policy frequently leaves room for individualized professional judgment. Two clients with the same diagnosis may need very different levels or types of skilled intervention, and the practitioner who evaluated them is the one positioned to say which. Medicare’s coverage of skilled maintenance therapy, which I’ll come back to below, is a striking example of how much room that judgment was always meant to have.

Facility policy is one of the layers above, and a legitimate one. It is also a layer practitioners can engage. Asking what statute, regulation, payer requirement or evidence an organizational rule is based on is a reasonable professional question, and so is bringing clinical reasoning and evidence to the people responsible for writing policy.

Sometimes the answer really is, “That’s how we’ve always done it.” Even then, the conversation can keep going.

Why I went back for the doctorate

That mechanism is the reason.

The number one barrier I hit in the field was a perceived policy wall that, every time I chased it back to its source, often turned out to be hearsay wearing a lab coat. It had been handed down from manager to manager and from fieldwork educator to student until it felt like federal law, and it quietly set the ceiling on what I was allowed to offer a human being whose life I had been invited into.

So I spent three years chasing those sentences back. What I found was a much more layered relationship among law, regulation, payer policy, professional guidance, evidence, organizational policy and clinical reasoning than the version I had inherited through rehabilitation culture.

What policy is actually for

Licensure exists to protect the public. Regulation establishes boundaries around who may practice, under what conditions and with what accountability, and those foundations matter enormously.

AOTA identifies state law as ultimately defining the legally authorized scope of occupational therapists and occupational therapy assistants, while advocating for practitioners to practice to the full extent of their licenses (AOTA, n.d.-b). Those two ideas sit together comfortably. A boundary can protect the public without requiring us to make the professional world inside that boundary as small as possible.

Competence, evidence, ethics, training, client safety and state law all matter, and none of them require us to pretend that the narrowest version of practice we personally inherited is the permanent definition of occupational therapy.

Top of scope, bottom of code

CPT coding and professional scope answer different questions. Billing terminology provides standardized language for reporting healthcare procedures and services, while legal professional scope is established through state law and regulation. A billing code should never stand in for the legal or conceptual definition of occupational therapy practice.

When the narrowest interpretation of a billing category becomes the definition of the work, the service can shrink to whatever is easiest to describe. Our clients rarely fit that neatly. People living with complex, fluctuating or rapidly progressing conditions require skilled judgment, interpretation and real-time adjustment.

Medicare’s history gives us a powerful example of what happens when shorthand gets mistaken for policy. For years, some providers and contractors operated as though Medicare therapy coverage required a beneficiary to demonstrate potential for improvement.

The 2013 Jimmo v. Sebelius settlement did not create a new improvement exception. CMS describes the settlement as clarifying Medicare’s longstanding policy: coverage of skilled nursing and therapy services under the SNF, home health and outpatient therapy benefits does not depend on whether a beneficiary is expected to improve. Skilled care may be covered when it is necessary to maintain function or prevent or slow deterioration, provided the other Medicare coverage criteria are met (CMS, n.d.). CMS further acknowledges that the settlement may have changed practice among providers, adjudicators and contractors who had erroneously believed that improvement was required (CMS, n.d.).

Think about what that means. A restrictive interpretation can become so normalized that an entire service culture starts behaving as though it is the rule, until someone goes back and rediscovers what the policy actually said.

What restriction costs

A restrictive reading usually feels like the safe choice, since nobody gets written up for saying no. The costs are real, and they fall on people who never had a say in the decision.

Clients pay first. When a service is withheld because someone assumed it was prohibited, the person who needed it goes without, or gets routed to a provider who may not see the occupational picture at all. Picture the man with a new spinal cord injury whose bowel routine never gets built around his return to work, because everyone assumed it belonged to someone else. Jimmo showed how long that kind of assumption can go on before anyone checks the source.

The profession pays next. Every area we talk ourselves out of gets filled by another discipline, or by nobody. Over time the public, referral sources and payers learn a smaller version of what occupational therapy is, and that smaller version becomes the one we teach students.

Our future sustainability pays too. Community practice, population health, behavioral health integration, prevention and the areas still emerging are where new service lines and reimbursement pathways get built. A profession that backs away from them before exploring them gives up income for its practitioners and viability for its programs long before any regulator has weighed in.

Our workplaces pay as well. When scope conversations run on fear, colleagues start policing one another, and a question can get treated like a confession. A practitioner who asks about an intervention, or who already uses it with appropriate training and competence, can find herself accused of practicing illegally by someone who has never read the relevant statute. OTAs often absorb the sharpest version of this. Accusations like that damage reputations and push careful clinicians into silence, and silence is where moral distress grows and good practitioners quietly leave.

Much of this comes from scarcity, the belief that scope is a small, fixed territory where any expansion by one practitioner or profession threatens everyone else. Our clients’ occupational needs far outstrip the workforce available to meet them, and there is more than enough work to go around.

Precision and curiosity serve us better than suspicion. If a colleague’s practice genuinely concerns you, the professional response is a direct conversation grounded in sources, and where clients are at real risk, formal channels exist for exactly that. An uncited accusation in a hallway or a comment thread carries none of that accountability.

A broad profession, and a focused practitioner

After all of this, you might wonder whether a broad scope means every OT and OTA is supposed to do everything. It doesn’t.

You’re allowed to specialize. You can love hand therapy and have no interest in dry needling, or spend your whole career in school-based practice and never build a bowel program. You’re allowed to say “that’s outside my competence” or “that isn’t work I want to do,” and both are legitimate professional boundaries. Earlier I called “I haven’t been trained in this and wouldn’t perform it” a complete, honorable sentence, and I meant it.

A personal boundary stays healthy when it stays personal. Mine can shape my caseload and my continuing education. It doesn’t get to set the ceiling for the colleague down the hall, or for the practitioner in another state building an emerging area I’ve never studied.

The profession stays broad so each of us can go deep somewhere. When I respect your zone of excellence and you respect mine, we end up with a field full of practitioners who refer to one another with confidence and who together reach far more of our clients’ occupational lives than any one of us could alone. Some of those zones will be well established, and some will be emerging practice that someone is patiently building right now.

Nobody has to hold all of it. We only have to stop shrinking the parts other people are holding.

Which brings me to Saturday, and to Elizabeth Yerxa

None of this is available to a profession that isn’t fluent in its own science. You can’t argue thoughtfully for an evolving scope from a foundation you can’t put into words, and confidence without grounding is just volume.

Twenty-six years ago, Elizabeth Yerxa described occupational science as part of a “renaissance of service to humankind” through the development of knowledge grounded in occupation (Yerxa, 2000). Reading her now feels like receiving a letter from someone who loved this profession enough to ask what kind of knowledge we would need to become what we claimed we could be.

We can close the distance between that scholarship and everyday practice through translation, carrying occupational science from the academy into the field and into an ordinary Tuesday afternoon.

That’s part of the purpose of the Evolved Living Collaborative: an accessible home for occupational science literacy for OTs, OTAs, students and colleagues interested in understanding what an occupational perspective can contribute.

Another piece of that work is emerging. There remain significant gaps in how practice-based knowledge from emerging and developing areas becomes visible, studied, refined and eventually translated into accessible professional resources. Dr. Dionne, Dr. Burwash and I are exploring an evidence-based pipeline for emerging and developing practice settings, so knowledge being created in real-world practice can become increasingly practical, usable, researchable and anchored in occupational therapy’s distinct identity and science base.

Perhaps the missing sentence from the beginning of this essay is something we need to learn how to write, together.

Come read with us

Journal Club: Elizabeth Yerxa, Occupational science: A renaissance of service to humankind through knowledge (2000) Saturday, September 26, 1pm Pacific Free, inside the Evolved Living Collaborative

OTs, OTAs, students and curious colleagues from other disciplines are all welcome. Come whether you’ve read the article closely, skimmed it on your lunch break, or plan to arrive with nothing but curiosity and a coffee. The classroom has a summary, reflective prompts and an audio walkthrough if you want a running start.

The session will be recorded and reposted in the group, since knowledge translation is the entire point and I want people who can’t make 1pm on a Saturday to have access. If you’d prefer your contributions edited out, you’ll have that option, no explanation required.

Join the Evolved Living Collaborative here: https://www.skool.com/evolved-living-collaborative-6395/about

See you Saturday.

Coming in Part 2 on Monday: what to do instead. I’ll cover where to start when you need a real answer about legal and ethical scope, and how a “not yet” from a regulator can become a map, which is exactly what happened with dry needling in Florida. I’ll also unpack what this month’s Justice Manual update actually means for practitioners, and open three beta spots to work on this with me one to one.

Subscribe so Part 2 lands in your inbox Monday.

References

Akselrud, R., & Vestal, L. (2021). The role of occupational therapists in pelvic health: An interview with Lindsey Vestal. SIS Quarterly Practice Connections, 6(3), 12-14. https://www.aota.org/publications/sis-quarterly/home-community-health-sis/hchsis-8-21

Alaska Board of Physical Therapy and Occupational Therapy. (2023). Frequently asked questions: Dry needling [Position statement update, November 17, 2023]. https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/PhysicalTherapyOccupationalTherapy/FrequentlyAskedQuestions.aspx

American Occupational Therapy Association. (n.d.-a). OT and OTA intraprofessional collaboration. https://www.aota.org/practice/practice-essentials/ot-and-ota-intraprofessional-collaboration

American Occupational Therapy Association. (n.d.-b). Occupational therapy scope of practice. https://www.aota.org/practice/practice-essentials/scope-of-practice

American Occupational Therapy Association. (n.d.-c). Scope of practice questions and answers. https://www.aota.org/practice/practice-essentials/scope-of-practice/scope-of-practice-questions-answers

American Occupational Therapy Association. (n.d.-d). FAQs about ethics. https://www.aota.org/practice/practice-essentials/ethics/faqs-about-ethics

American Occupational Therapy Association. (n.d.-e). Women’s health. https://www.aota.org/practice/clinical-topics/womens-health

American Occupational Therapy Association. (2020a). Guidelines for supervision, roles, and responsibilities during the delivery of occupational therapy services. American Journal of Occupational Therapy, 74(Supplement 3), 7413410020. https://doi.org/10.5014/ajot.2020.74S3004

American Occupational Therapy Association. (2020b). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Supplement 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

American Occupational Therapy Association. (2021). Occupational therapy scope of practice. American Journal of Occupational Therapy, 75(Supplement 3), 7513410020. https://doi.org/10.5014/ajot.2021.75S3005

American Occupational Therapy Association. (2023). Policy E.18: Interventions to support occupations.

American Occupational Therapy Association. (2024). Physical agent, mechanical, and instrument-assisted modalities in occupational therapy practice, 2024. American Journal of Occupational Therapy, 78. https://doi.org/10.5014/ajot.2024.78S103

American Occupational Therapy Association. (2025). Supervision 101: Important considerations for supervisors and supervisees. OT Practice, 30(12). https://www.aota.org/publications/ot-practice/ot-practice-issues/2025/supervision-101-important-considerations-for-supervisors-and-supervisees

California Board of Occupational Therapy. (n.d.). Supervision: Frequently asked questions. https://www.bot.ca.gov/forms_pubs/supervision_faqs.shtml

Centers for Medicare & Medicaid Services. (n.d.). Jimmo settlement. https://www.cms.gov/medicare/settlements/jimmo

Centers for Medicare & Medicaid Services. (2019). Medicare and Medicaid programs; CY 2020 home health prospective payment system rate update; home health value-based purchasing model; home health quality reporting requirements; and home infusion therapy requirements [Final rule with comment period]. Federal Register, 84(217), 60478. https://www.federalregister.gov/documents/2019/11/08/2019-24026/medicare-and-medicaid-programs-cy-2020-home-health-prospective-payment-system-rate-update-home

Centers for Medicare & Medicaid Services. (2019b, October 31). CMS finalizes calendar year 2020 payment and policy changes for home health agencies and calendar year 2021 home infusion therapy benefit [Fact sheet]. https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-calendar-year-2020-payment-policy-changes-home-health-agencies-calendar-year-2021-home

Ercan Doğu, S., & Özkan, E. (2023). The role of occupational therapy in substance use. Nordic Studies on Alcohol and Drugs. https://doi.org/10.1177/14550725221149472

Florida House of Representatives. (2026). CS/HB 867 bill analysis: Dry needling by occupational therapists. https://www.flsenate.gov/Session/Bill/2026/867/Analyses/h0867c.HCB.PDF

Laws of Florida. (2026). Chapter 2026-110, Committee Substitute for House Bill No. 867. http://laws.flrules.org/2026/110

Mattila, A., Santacecilia, G., & Lacroix, R. (2022). Perceptions and knowledge of substance use disorders and the role of OT: A national survey. American Journal of Occupational Therapy, 76(Supplement 1), 7610510156p1. https://doi.org/10.5014/ajot.2022.76S1-PO156

Wheeler, S., Davis, D., & Acord-Vira, A. (2022). Occupational therapy’s role in return to work and substance use disorder in a general practice setting. SIS Quarterly Practice Connections, 7(1), 30-33.

Yerxa, E. J. (2000). Occupational science: A renaissance of service to humankind through knowledge. Occupational Therapy International, 7(2), 87-98. https://doi.org/10.1002/oti.109

The thinking and writing are mine. I use AI as an editing tool to organize complex ideas, untangle long sentences, and translate dense scholarship into accessible language often after speaking my thoughts into a recorder. I review and take responsibility for everything I publish.

It’s Tuesday afternoon…

You’re sitting in a care conference, IEP meeting, team meeting, or nursing station listening to someone explain why your client doesn’t need OT.

You know what you have observed.

You know what the client has told you.

You know there is more happening here than what fits neatly into the criteria being used to make the decision.

Maybe a discharge plan is being made and you weren’t included.

Maybe someone in the district is telling you why a student no longer requires your involvement.

Maybe someone in the nursing facility has already decided what happens next.

Maybe the person making the decision simply has more organizational authority than you do.

Your client wants something different.

You see something that isn’t being discussed.

And you can already feel the cost of being the person who says so.

So you sit there doing the calculation.

Do I say something?

How hard do I push?

Am I overstepping?

Is this actually policy, or just how this organization does things?

Will I be labeled difficult?

Will speaking up change anything?

What will it cost me if I do?

What will it cost my client if I don’t?

You want to be respected.

You want to be collaborative.

You also want to practice with integrity.

And increasingly, those things can feel like they are pulling you in opposite directions.

So you walk on eggshells.

You notice how the system is affecting the client.

You notice how it is affecting your colleagues.

You notice how it is affecting you.

But there is enormous pressure not to talk about any of it.

Eventually, that constant calculation becomes exhausting.

I think a lot of what we call burnout contains something more specific:

Moral fatigue from seeing what is happening while feeling increasingly powerless to change it.

I know that feeling.

And I have been following the questions underneath it for a very long time.

I didn’t find policy through occupational therapy

Occupational therapy gave me language for questions I had been carrying much longer.

I grew up in rural America with a mixed-race cousin who had a severe chromosomal disorder.

I watched someone I loved encounter structural barriers to receiving care that recognized the fullness of her humanity.

And somewhere inside that experience, I began imagining something different.

I dreamed of a world where she and I could grow older together.

Where disability did not automatically mean separation.

Where the services someone needed could come to them.

Where community, relationship, dignity, care, and belonging could be organized around a person’s life rather than requiring a person’s life to be organized around the limitations of a system.

I didn’t have language like aging in place, community-based care, occupational justice, implementation science, or structural determinants yet.

I just knew I wanted a world where we could age in place together.

There was another story in my family, too.

Before I was born, an uncle who was suspected of being autistic was institutionalized.

He later died in circumstances my family understood in relation to neglect and the deterioration of social supports surrounding people like him.

I inherited that story before I ever entered a policy classroom.

Before I knew what an occupational therapist was.

Before I knew how reimbursement worked.

Before I understood that decisions made in legislatures, agencies, institutions, school districts, hospitals, insurance systems, and organizations could eventually determine extraordinarily intimate things:

Where someone gets to live.

Who gets to remain with their family.

Who receives care.

Whose needs are considered too complicated.

Whose knowledge is believed.

Who gets included in decisions.

What support is considered worth paying for.

And what kinds of lives our systems are willing to make possible.

That is probably where my interest in policy actually began.

Not in Washington, D.C.

Not in a professional association.

Not with CMS.

At home.

Eventually, I learned that these intimate experiences had structural dimensions

As an undergraduate, I found student advocacy and lobbying alongside campaign and labor organizing work and study.

Later came occupational therapy.

School-based practice.

Outpatient pediatrics.

Acute care.

Home health.

Post-acute care.

Mobile outpatient services.

State and federal advocacy and policy work, including work related to shaping applied behavior analysis policy in Washington State, partnership with AOTA, AOTPAC-related involvement, and leadership development.

Then occupational science, education, scholarship, and my growing inquiry into agency-centered, critical, and co-constructive implementation science.

The settings changed.

The scale changed.

My language became more sophisticated.

But I am not sure the underlying question ever changed:

Who gets to participate in authoring what becomes possible for a human life?

My clinical work kept giving me different views of that question.

School-based practice showed me how policy, eligibility, institutional interpretation, educational priorities, and family realities shape participation.

Outpatient pediatrics showed me children and families trying to integrate recommendations into lives much bigger than the clinic.

Acute care showed me how quickly decisions about function, safety, discharge, and someone’s next stage of life are made inside complex institutional systems.

Home health showed me what happens when those decisions arrive at someone’s front door.

Post-acute practice made staffing, transitions, reimbursement, productivity, and interdisciplinary coordination impossible to separate from care.

Mobile outpatient practice showed me what becomes visible when care moves closer to where occupation actually happens.

Different settings.

Different populations.

Different payment structures.

Same human lives.

Same question:

What becomes possible under these conditions?

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Then I started asking what those conditions were doing to us

Last year, I wrote Therapy Isn’t Just Biomechanical: Reclaiming the Psychosocial Heart of OT.

It came out of a conversation about why occupational therapy practitioners can sometimes feel almost “naughty” for bringing psychosocial reasoning into supposedly traditional OT settings.

That word stayed with me.

Why would an occupational therapist feel as though practicing expansively requires permission?

What happens when an organization’s operational version of OT becomes smaller than the occupational lens we were educated to use?

And what happens when we adapt to that version for so long that we stop recognizing the adaptation?

Later, writing about school-based practice pushed me further into the relationship between occupation and policy.

I started putting language around something I had witnessed across settings:

Policy mediates occupation.

And then another realization followed.

Practitioners are occupational beings, too.

We spend our careers examining how environments shape someone else’s participation.

But we have environments.

Policy is part of our environment.

Reimbursement is part of it.

Productivity is part of it.

Documentation systems are part of it.

Staffing is part of it.

Hierarchy is part of it.

Organizational culture is part of it.

Professional identity is part of it.

The stories we’ve inherited about what “counts” as OT are part of it.

This matters because I don’t want to individualize structural problems.

You cannot mindset your way out of inadequate staffing.

You cannot personally fix reimbursement.

You cannot positive-think your way around an inaccessible service model.

But I don’t think the only alternative is powerlessness.

There is a territory between:

“This is all my responsibility.”

and

“There is nothing I can do.”

That territory has become increasingly important to me.

This month, I wrote back

On September 14, I submitted an 11-page public comment in response to the CY 2027 Medicare Physician Fee Schedule Proposed Rule.

Listen to the CMS Comment here:

This wasn’t my introduction to advocacy.

It was another iteration of the question I have been carrying across my life and career:

What kinds of care are our systems actually making possible?

My comment addresses therapy coding and valuation, clinical reasoning, care coordination, interdisciplinary overlap, complexity, technology, mobile and home-based care, staffing and productivity pressures, access, and the risks of both overutilization and systematic underutilization of rehabilitation.

But underneath the 12 recommendations is something larger.

Some of the most consequential clinical work does not fit neatly inside the minutes spent performing a discrete intervention.

We review records.

We synthesize information.

We recognize changes in function and risk.

We communicate with caregivers and other clinicians.

We modify plans.

We coordinate transitions.

We connect pieces of someone’s life that the healthcare system has separated into different disciplines, encounters, codes, and records.

That work matters.

And writing the comment brought me back to an idea that has become increasingly important in my scholarship:

Payment systems are implementation systems.

Payment policy eventually becomes staffing.

Workflow.

Caseload.

Documentation.

Technology.

Service availability.

Interdisciplinary communication.

What clinicians have enough capacity to notice.

And eventually:

Policy becomes occupation.

Because people don’t experience healthcare as a collection of codes.

They experience a life.

The question I ultimately asked CMS was:

Does the payment system create the conditions for beneficiaries, caregivers, and clinicians to participate meaningfully in developing, coordinating, and adapting care around the realities of everyday life?

I want you to read the comment.

Not because you have to agree with me.

Read it as a practitioner.

What gives language to something you have experienced?

Where do you disagree?

What does your practice setting allow you to see that mine doesn’t?

What assumptions have you been treating as policy?

What would you have said differently?

What do you know because you have actually been there?

And notice if another question appears:

Wait. Am I allowed to have an opinion about this?

That question matters.

Your experience doesn’t automatically make your interpretation correct.

Authorship is not certainty.

It is learning to understand what you know, how you know it, what you don’t know, what conditions are operating around you, and where you can responsibly participate.

That is where From Adaptation to Authorship begins

I cannot make the administrator disappear.

I cannot change your district for you.

I cannot guarantee your facility will suddenly include you in discharge planning.

I cannot eliminate hierarchy, reimbursement pressures, productivity expectations, or institutional politics.

What I am interested in is something different.

I want us to become better at walking into the same Tuesday afternoon and locating ourselves differently inside it.

Someone says your client doesn’t need OT.

Instead of immediately collapsing into anger, silence, self-doubt, or an exhausting internal argument, maybe we learn to ask:

What is actually happening here?

What authority does this person hold?

What is genuinely policy?

What is interpretation?

What is simply “how we’ve always done it”?

What do I know?

How do I know it?

What does the client want?

What can I document?

What can I question?

Who could I collaborate with?

Where is there room for negotiation?

What is genuinely immovable today?

What am I willing to risk?

What am I not willing to risk?

And what is not mine to carry home?

That is the transformation I care about.

Discernment where there used to be diffuse powerlessness.

Sometimes authorship is speaking.

Sometimes it is documenting differently.

Sometimes it is asking the question nobody has asked.

Sometimes it is bringing the client back into a conversation happening around them.

Sometimes it is reading the policy instead of accepting “that’s just how we do it.”

Sometimes it is finding an ally.

Sometimes it is trying a small experiment.

Sometimes it is deciding:

This is not the hill I am going to die on today.

And sometimes:

Actually, this one is.

Sometimes authorship is staying.

Sometimes it is leaving.

Sometimes it is recognizing that the problem was never yours to solve individually in the first place.

But either way, I want us to understand the conditions and costs well enough that our choices can become more genuinely our own.

You do not have to abandon yourself in order to belong. And authorship does not require you to stop belonging.

This is part of why I built the Evolved Living Collaborative

I have become increasingly interested in what happens when practitioners have somewhere to think together outside the pressures of productivity, institutional hierarchy, professional performance, and the demand to immediately arrive at the correct answer.

The Evolved Living OT/OS Collaborative is the space I am building for that.

It is a free community for occupational therapists, occupational therapy assistants, students, educators, researchers, occupational scientists, and interdisciplinary collaborators who want to think more deeply about occupation, practice, knowledge, power, participation, and what becomes possible when we take our own professional reasoning seriously.

It is not therapy.

It is not clinical supervision.

It is not a place where I tell you what to think or what to do.

It is a place where we can practice asking better questions together.

Inside the Collaborative, I am building an evolving library of resources around occupational science, occupation-centered practice, professional autonomy, critical knowledge translation, reflective practice, and the questions underneath essays like this one.

There are journal clubs, conversations, community gatherings, educational resources, recordings from consenting participants, and opportunities to encounter ideas that may never fit neatly inside a productivity unit, continuing education checkbox, or institutional training module.

I think of it increasingly as an epistemic quilting guild: a place where different forms and lineages of knowledge can be brought into relationship without pretending they are identical.

A place to examine not only what we know, but how we know it, where that knowledge came from, whose knowledge has been privileged, what has been excluded, and what happens when knowledge meets the complexity of actual practice.

Because authorship requires provenance.

And none of us develops that kind of discernment entirely alone.

You are welcome to come think with us

If something in this essay has been sitting with you, you are welcome to continue the conversation with us.

The Evolved Living Collaborative is free to join, and I intend to keep the core community, educational resources, and journal club recordings from consenting participants accessible there.

If community participation is not what you are looking for right now, you can also subscribe to my Substack, where I continue writing about occupational therapy, occupational science, professional autonomy, critical knowledge translation, implementation, and the strange gray spaces where policy meets actual human practice.

My hope is to keep creating places where practitioners can encounter ideas, question assumptions, find collaborators, deepen their own discernment, and participate more intentionally in the systems we inhabit.

Because the system may still be there.

There will be load-bearing pieces we cannot move alone.

There will be places where we need protection.

There will be people we can work with.

There may be doors we did not recognize before.

There may even be places where we begin building something adjacent.

But we do not have to keep abandoning our own perception just to survive the room.

This is happening around me, but I no longer have to let it author me.

If that sentence landed somewhere deep, come find us.

Bring what you are noticing.

Bring what you are questioning.

Bring what you know.

Bring what you are no longer sure you know.

We can start there.

Josie

Dr. Josephine Jarvis, PP-OTD, MA-OTR/L, BA, BSOccupational Therapist | Applied Occupational Scientist | Educator & Scholar-PractitionerEvolved Living

From adaptation to authorship.

This Substack is reader-supported. To receive new posts and support my work, consider becoming a free or paid subscriber.

What happens when the people delivering healthcare actually participate in deciding how that care is valued?

Right now, we have an opportunity to do exactly that.

CMS is accepting public comments on the CY 2027 Medicare Physician Fee Schedule proposed rule, and the deadline is September 14, 2026.

If you are a U.S.-based occupational therapist, physical therapist, speech-language pathologist, or another rehabilitation or allied health provider, this is a moment to pay attention and participate.

Read the CMS CY 2027 Medicare Physician Fee Schedule proposed rule

Submit a public comment through Regulations.gov

Search for CMS-1848-P when submitting your comment.

Why this matters

Payment policy is about much more than reimbursement rates. It influences what healthcare systems prioritize, how services are structured, what work is considered valuable, and what kinds of care are realistically available to patients.

For rehabilitation providers, there can be a significant gap between the work that actually produces meaningful outcomes and what can be easily represented through a billing code.

Think about what goes into a complex rehabilitation encounter. There is the assessment itself, but also the clinical reasoning behind it. There is communication with caregivers and other providers, environmental analysis, education, risk management, adapting interventions to the individual, coordinating care, and making decisions based on information that may not be captured by a single diagnosis or procedure code.

For many of us, these are not extras added onto the work.

They are the work.

That makes this comment period important.

Rather than simply saying that reimbursement is too low, we have an opportunity to explain what current payment structures fail to capture and what that means for patients, providers, and the healthcare system.

What is changing?

The CY 2027 proposed rule includes changes and requests for input related to how Medicare services are coded and valued, including the Practice Expense methodology and aspects of care management and remote monitoring.

These are technical policy issues, but the questions underneath them are surprisingly practical:

What does it actually take to provide good care?

What resources are required?

What kinds of clinical work happen outside the most visible portion of an encounter?

How should payment systems recognize complexity, coordination, clinical reasoning, and the resources required to manage patients over time?

These are questions rehabilitation providers have direct experience answering.

OT Potential’s Sarah Lyon and colleagues have been particularly active in bringing OT and PT perspectives into this conversation. Their proposed recommendations include better differentiation in reimbursement for evaluation complexity and consideration of non-time-based therapist management codes to recognize some of the ongoing clinical work that occurs throughout an episode of care.

You do not have to agree with every recommendation to see the value in participating.

In fact, this is one of the things I appreciate about the public comment process. It gives us an opportunity to respond to what is actually being proposed, identify what we think is missing, describe unintended consequences, and offer alternatives based on what we see in practice.

Start with Sarah Lyon’s episode

If you want some context before diving into the policy language, I recommend starting with Sarah Lyon’s recent OT Potential episode on this issue.

Listen to the OT Potential episode on YouTube

The episode provides a useful overview of the current opportunity and the work underway to bring rehabilitation perspectives into the Medicare payment conversation.

OT Potential has also created a 2027 CMS Comment Template for OT and PT care, which makes the process considerably easier if you are staring at Regulations.gov wondering where to begin.

Access the OT Potential CMS Comment Template

The template provides language you can adapt, along with references and guidance for submitting your comment. I would encourage you to personalize it rather than simply submitting the exact same language as everyone else.

Your own experience is what makes the comment valuable.

What can you contribute?

Start with the part of the system you know.

Maybe you work with patients whose needs are more complex than the evaluation code adequately communicates. Maybe much of your clinical expertise involves adapting care to cognition, environment, caregiver capacity, health literacy, routines, transportation, safety, or other contextual factors.

Maybe you spend substantial time coordinating with other disciplines and caregivers. Maybe your work involves preventing a problem rather than treating the consequences after it happens.

Maybe you have watched a patient avoid an emergency department visit because someone identified a risk early. Maybe you have helped a family safely manage a transition home. Maybe your interdisciplinary team caught something that would have otherwise resulted in a complication or readmission.

These experiences matter.

They help illustrate something that can get lost when healthcare policy is discussed primarily through codes, utilization data, and reimbursement formulas: healthcare is delivered by people making decisions in complex environments with other people.

If a payment methodology does not adequately account for the resources required to do that work well, policymakers need concrete examples of what is being missed.

Don’t underestimate the value of your clinical perspective

You do not need to be a healthcare economist to submit a meaningful comment.

You do not need to write a 20-page policy analysis.

You do not need to represent your entire profession.

A useful comment can be fairly straightforward. Identify the issue you are responding to. Describe what you see in practice. Explain why it matters. Give a concrete example. Then tell CMS what you think should be considered.

Instead of simply saying, “OTs need to be paid more,” you might explain how comprehensive occupational therapy assessment requires consideration of cognition, environment, routines, caregiver capacity, safety, equipment, participation, and other factors that may not be adequately represented by the existing valuation structure.

Instead of simply saying, “care coordination should be reimbursed,” describe what happens when coordination does not occur. Explain who has to do the work, what information has to be exchanged, what decisions are made, and what can happen to the patient when that work is missing.

The more concrete we are, the more useful our comments become.

This conversation belongs to all of rehabilitation

Although OT Potential’s template focuses on OT and PT, I think there is a larger opportunity here.

OTs, PTs, SLPs, and other allied health professionals all see different pieces of the same system. We work across hospitals, outpatient clinics, home-based care, post-acute settings, schools, and community environments. We see where care coordination works and where it breaks down. We see the consequences when payment structures reward one part of the care process while making another part difficult to sustain.

That perspective is worth bringing into the conversation.

This does not have to become another debate about which profession deserves more.

The more useful question is:

What does the patient actually need, who has the expertise to provide it, and does the payment system support that care?

That is a question worth asking across the healthcare continuum.

We have until September 14

We spend a lot of time talking about healthcare payment.

We talk about productivity. We talk about coding. We talk about documentation. We talk about access. We talk about burnout. We talk about care coordination. We talk about the disconnect between what patients need and what healthcare systems can realistically provide.

This is an opportunity to move some of that conversation into the policymaking process.

CMS is asking for public input.

We have resources to help us understand the proposal.

We have templates to help us get started.

And we have our own professional experiences.

So take an hour. Listen to the episode. Read the relevant sections of the proposed rule. Use the template if it helps. Add your own examples. Submit your comment.

Comments are due September 14, 2026.

Read the proposed rule

Listen to the OT Potential episode

Use the OT Potential comment template

Submit your comment

And then share this with another clinician.

We cannot expect payment systems to recognize the complexity of our work if we never tell policymakers what that work actually involves.

Now is the time to put our clinical experience on the record.

I wrote this piece in response to some discourse I was tagged in around OT’s role in sports medicine and supporting high performance athletes.

The reflection is specifically in response to this three-part LinkedIn series:

Part 1: What OT Adds to Sports MedicineRead the original post on LinkedIn

Part 2: Collaboration and Professional RolesRead the original post on LinkedIn

Part 3: Advocacy, Scope, and the FutureRead the original post on LinkedIn

Much of the discourse in the comments was centered on concerns of overlap with athletic trainers and presumptions that what OT is offering would be essentially duplicative and disrespectful to more traditionally prominent members of the sports medicine ecosystem.

I had to modify my response on LinkedIn to match their character limit, so I thought I would publish the full response here. It covers content that feels relevant to much of the endless discourse that is largely driven by shorthand misinformation, presumptions, and various insecurities that get stirred when our focus is on eliminating rather than expanding possibilities for care and innovation.

Why occupational science literacy matters

A big part of why I am a proponent of increased occupational science literacy for OTPs worldwide is to encourage us to use our own distinct lens and concepts when communicating about the innovations, roots, and foundations of our practice so we can get out of this trap of being reduced to limited paradigms and understandings of other professions in bad faith.

First, we tend to be undermined for possibly not having the same competencies as another discipline or profession. Then, when we reveal that we do have the same competencies, or we catch up, we are framed as essentially duplicative or redundant and not unique.

This is why communicating about our identity and skills from our own foundations and core terminology, including our cosmological, philosophical, epistemic, and emerging practice developments, on our own terms, alongside the formal policy developments that have shaped our practice from the beginning, is so important.

Especially if we do so with pride in our unique integrative foundations rather than shame or presumed incompetence, very often this pattern is deeply rooted in the internalization of structural sexism and misogyny as it relates to female-dominated health care professions and integrated care approaches overall.

OTPs need to start recognizing that when we are met with such suspicion and accusation, it can actually be a sign of our strength and competence as a threat rather than a sign of our own incompetence or need to prove or defend ourselves where we typically already currently belong.

We keep de-skilling each other

It’s so interesting how often in this type of discourse we default to pigeonholing and limiting all skilled providers to the bare minimum of responsibilities in institutional settings.

For example, often between OT and PT the discourse can reduce both professions down to upper extremity versus lower extremity, even though we all know both disciplines in the real world are full-body therapists.

With the discourse around athletic trainers, it seems like we’re reducing all professions to the most basic elements of those responsibilities, rather than exploring nuanced conversations about strengths, weaknesses, opportunities, gaps, and intersections that could lead to more comprehensive care.

Unlike competitive athletics, health and human services are not competitive sports.

When providers compete, our clients are always the ones who lose out on comprehensive care.

I also think this pattern of discourse has consequences beyond any single profession. When we continually reduce skilled professions to their bare foundations and then treat overlap at that level as evidence of duplication, we can inadvertently create conditions that discourage innovation and advancement across health and human services.

The bare foundations are the floor of professional capacity, not necessarily the ceiling.

If we treat the floor as the ceiling, then every advancement into an emerging specialty, every new application of foundational knowledge, and every development in professional reasoning has to first defend itself against the existence of something another profession already does.

That creates a very different condition for professional development than asking what becomes possible when skilled professionals build beyond their foundations.

Overlap is not duplication

Overlap between providers is not new and never has been new. It’s actually essential to communication and efficiency for there to be essential overlap.

One profession having a specific body area or modality in their scope does not mean that it is somehow unlawful or an automatic restriction or duplication for another provider to be skilled and competent in those areas. It simply means more than one profession has core competencies to perform a specific function.

It means there are options rather than a basis for exclusion.

For example, just about everyone in the hospital performs vitals, and we want it that way, to optimize saving everyone’s lives.

The issue, then, is not simply whether competencies overlap. The more important question is what happens beyond those foundations.

Nearly every skilled profession has foundational competencies that overlap with other professions. Those foundations establish what a profession is capable of doing. They do not necessarily define everything that profession can become.

The floor is not the ceiling.

This is also why I think it is important to distinguish overlapping competencies from professional identity.

AOTA’s scope statement describes OT as a dynamic and evolving profession responsive to consumer and societal needs, system changes, and emerging knowledge and research. Its scope is organized around the domain and process of occupational therapy rather than around a single body region or a fixed list of procedures.

Professional differentiation can therefore exist even when foundational services overlap.

It can emerge through what a profession has developed beyond the foundation: its theories, epistemics, cosmology, professional reasoning, specialized knowledge, emerging practices, methods, populations, contexts, and approaches to delivering services.

It can also emerge through the way even some of the same foundational services are understood and integrated into a person’s actual occupational life.

Two professionals may provide something that looks similar on the surface while asking very different questions about the person, their environment, their goals, their occupations, their identity, their routines, and what meaningful participation looks like to them.

That is not necessarily duplication.

That is professional differentiation.

And those differences can be meaningful to clients.

A client may choose between qualified providers not simply because one profession possesses an activity that another profession is forbidden or unable to perform, but because of the way a practitioner understands their needs, the populations or contexts they specialize in, how they approach collaboration, how they conceptualize their goals, and how their services fit with the client’s preferences and priorities.

Our clients are not choosing between completely separate universes of intervention.

They are choosing people, approaches, relationships, areas of expertise, and ways of understanding and responding to their needs.

The more generative question is therefore not simply whether another profession can perform the same foundational task.

It is what each profession has developed beyond the foundation and how that development creates additional possibilities for care.

OT has always been more than hands

Much of what distinguishes occupational therapy exists in what is often regarded as largely unseen realms in physical medicine. Our internal, subjective experiences of navigating changes in body, mind, spirit, and environment are rarely fully appreciated through physical medicine methodologies alone.

Occupational therapy emerged through the moral treatment and arts and crafts movements, advancing the right to engage in self-directed activity as restorative to body, mind, and spirit, and as foundational to human rights-affirming living for people wherever they live, work, and play.

Occupational therapy is the belief that engagement in self-directed, integrative activity can regenerate health, integrating body, mind, spirit, and especially hands, but never reducing occupation simply to hands, because every occupation requires a full body to execute.

This is where Elizabeth J. Yerxa’s work on occupational science becomes especially relevant.

In her 2000 article, Occupational Science: A Renaissance of Service to Humankind Through Knowledge, Yerxa argued that occupational science could help occupational therapy develop and define its own knowledge base and scope through scholarship. She centered the human as an occupational being whose relationship with occupation unfolds across development, environment, culture, learning, and agency.

That matters because our foundations are not simply historical ideas to preserve. They give us a way of knowing and reasoning that can continue to generate new possibilities for practice.

That is also why I am excited that our September Evolved Living Collaborative Journal Club is returning to Yerxa’s article. More than 25 years later, her questions give us an opportunity to consider what occupational science can still contribute to how we understand occupation, knowledge, and the future of occupational therapy.

Those foundations are still relevant, but they are also a starting point for what comes next.

📚 September Journal Club

Saturday, September 26 at 1:00 PM Pacific

Our first Journal Club was moved from August to September so we could give ourselves more time to read and engage with the article.

This month we are returning to Elizabeth J. Yerxa’s 2000 article, Occupational Science: A Renaissance of Service to Humankind Through Knowledge.

Article Freely Available Here

More than 25 years later, Yerxa’s questions still give us plenty to think about. We will explore the emergence of occupational science, its relationship with occupational therapy, and what kinds of knowledge about occupation might continue to serve humanity.

Inside the Collaborative, you will find an article summary, reflective prompts, and additional resources to help you engage with the reading. You do not have to read every word of the original article to participate.

The Journal Club will be recorded for anyone who cannot attend live.

Join Evolved Living Collaborative Here

What could OT offer a high-performance athlete?

With any client receiving occupational therapy services, which could include a high performance athlete, our services are determined by their unique occupational profile and disruptions.

We receive the referral, either from a medical provider or, if not medically related, it could be pursued through a coaching model by a client themselves.

We develop an occupational profile looking at activities, engagement, and development at different stages of life.

I’ve characterized this as a person’s Pokemon card that looks at the ways in which occupational balance is experienced throughout days, weeks, months, years, and how routines can be optimized and adapted to accommodate different injuries and precautions, while still being able to have quality meaningful access and participation in one’s daily and weekly routine.

This includes not just one’s role as a high performance sport athlete, but also as a mother, father, student.

This is very consistent with the profession’s own contemporary description of practice. OTPF-4 defines occupational therapy as the therapeutic use of everyday life occupations with persons, groups, or populations to enhance or enable participation, emphasizing the transactional relationship among the client, their engagement in occupations, and context (AOTA, 2020).

And there is now emerging literature specifically supporting this way of thinking about athletes. A 2025 scoping review of occupational therapy in athletics and sports identified OT contributions across physical, emotional, and social rehabilitation, participation, recovery, performance, quality of life, and psychosocial well-being. The authors explicitly describe sport as a meaningful occupation associated with identity, mastery, and well-being (Bulan et al., 2025).

One of my colleagues is currently providing occupational therapy supports for neurodivergent medical students. In that work, they’re looking at how to adapt and relate to assignments and routine organization that is specific to accommodate neurodivergent medical students, which could be analogous to high performance athletes.

I think the important point here is not that medical students and high performance athletes are interchangeable populations. It is that occupational therapy can look at how the demands of a person’s particular role interact with their cognitive, physical, emotional, environmental, and occupational needs.

That kind of occupational lens is relevant to high performance athletes because the role of the athlete is not simply the performance of a physical skill.

It exists within a network of routines, relationships, environments, expectations, recovery demands, identity, education or employment, family roles, sleep, leisure, and other occupations.

And we have direct research demonstrating why this broader occupational lens matters in sports. Douglas et al. (2024) found that high school athletes recovering from concussion experienced disruptions not only in sport, but also in ADLs, school performance, sleep, mental health, driving, social participation, and identity. The authors concluded that occupational therapists can assist with individualized treatment plans supporting athletes’ return to meaningful occupations.

The point is not that OT has to invent a completely different physical activity every time we work with someone.

The distinction may be in what we are trying to understand, what we are trying to support, how we are reasoning about the person’s occupations and context, and how we integrate foundational services into the larger occupational life of the client.

Tim Dionne’s work offers a useful example of this kind of occupationally grounded thinking. In The Neuroscience of Everyday Life: An Applied Guide for Health Sciences Students, Dionne contributed a chapter on ADHD and task completion that uses an everyday activity as the context for understanding how neurological differences affect participation. The book as a whole is explicitly organized around connecting neuroscience with people’s everyday activities and participation (Dionne, 2025).

Tim also writes What Counts, where he shares contemporary OT perspectives and applied reflections.

That kind of occupational lens is relevant to high performance athletes as well. The role of the athlete is not simply the performance of a physical skill. It exists within a network of routines, relationships, environments, expectations, recovery demands, identity, education or employment, family roles, sleep, leisure, and other occupations.

The distinct psychology of a high performance athlete and the requirements of their role, similar to the role that occupational therapists play in the high-performance athletics of our military, focus on optimizing sleep routines and creating customized habits and life hacks that are particular to those soldiers and their various nuanced roles.

Firefighters offer another example

I have seen this same occupational science-informed approach emerge in work with another population whose demands can be remarkably analogous to those of high performance athletes: municipal firefighters.

In 2023, I was involved in developing a capstone direction connected with the University of Washington that asked occupational therapy students to engage with community stakeholders and regional fire departments through an individual, micro, and mezzo lens informed by occupational science.

The purpose was not simply to identify biomechanical injuries and then develop biomechanical interventions for the individual firefighter.

The larger question was how occupational therapy could support wellness, recovery, and burnout prevention by examining the occupational ecology in which firefighting actually occurs.

A firefighter’s performance does not happen in isolation from the fire station, shift structure, staffing patterns, routines, physical spaces, social culture, recovery opportunities, sleep, or the way activities are organized throughout a shift.

A purely impairment-centered approach might identify the shoulder, back, knee, or other biomechanical problem affecting role performance and then treat the injured body part.

An occupational science-informed approach can ask a different set of questions:

What is happening in the environment that is contributing to this occupational disruption in the first place?

How are activities being organized?

What routines are making recovery easier or harder?

How are the physical spaces of the fire station supporting or constraining wellness occupations?

Where are there opportunities to reorganize activity, routines, environmental affordances, and social supports before an injury or burnout becomes an individual clinical problem?

This is where the individual, micro, and mezzo levels become particularly important. Instead of isolating services to the individual and their biomechanical impairments and client factors, OT can also examine the organization of occupations within the team, the fire station, and the broader work environment.

The University of Washington’s 2024 MOT capstone project, Sleep, Stress, and Shift Work: An Occupational Therapist’s Investigation into Firefighter Wellbeing and Culture, provides a concrete example of this emerging approach. The student team examined environmental, social, personal, and physical factors affecting firefighters’ occupational lives and identified intervention opportunities at individual, meso, and systemic levels. Their work included literature and media review, key informant interviews, six firefighter interviews, and two fire station visits. I was one of the community mentors for the project.

This is exactly the kind of work I mean when I talk about occupational science creating possibilities for OT that cannot be reduced to biomechanical treatment.

The project did not begin with the assumption that a standardized intervention already existed and simply needed to be delivered to firefighters. It engaged firefighters and community stakeholders in understanding the occupational ecology of their work and identifying where wellness and participation could be supported.

And importantly, this does not mean OT needs to become the profession that treats every physical injury a firefighter experiences.

A firefighter with a biomechanical injury may appropriately benefit from physical therapy, medicine, athletic training, occupational therapy, or other specialized services.

The occupational therapy contribution can be understanding what that injury means within the person’s occupational life and what changes to routines, environments, roles, habits, recovery opportunities, and participation might support the person and the larger system.

Occupational therapy’s involvement in this population is still an emerging area. We do not necessarily need to wait five decades for a fully mature literature base before occupational therapists are allowed to recognize an emerging occupational need and begin responsibly developing, evaluating, and refining services.

We do need to distinguish between claiming that an intervention has been proven effective and responsibly engaging in program development, community-based inquiry, practice-based learning, and evaluation.

Those are not the same claim.

Occupational science gives us tools for asking questions about occupations in context while bodies of evidence are still developing.

We can begin with the occupation.

We can listen to the people who live it.

We can examine the environment in which it occurs.

We can identify disruptions and opportunities across individual, micro, mezzo, and macro levels.

We can collaborate with the professions that have complementary expertise.

And we can develop and evaluate responsive interventions without pretending that a standardized protocol from another population is automatically the best answer.

This is another example of what occupational science-informed OT can provide that is genuinely different from simply developing another biomechanical intervention for another biomechanical impairment.

And importantly, the differentiation does not depend on claiming that no other profession can address sleep, wellness, injury, performance, environment, or routines.

The differentiation can emerge from how OT brings these pieces together through its own occupational foundations, epistemics, professional reasoning, and developing practice.

That is what advancement can look like.

We do not need to define each other

I don’t think any of us that are specialized clinicians are in a good position to accurately reflect at a high level any other credential that is not our own, to be able to say exactly what the precise differences are between different providers.

It is much more refined when we get to know each other and those who seek to be of support to these populations, to get to know each other as individuals and our individual zones of expertise and excellence.

We need to move beyond a scarcity mindset and allow all professions to advance beyond the bare minimum stereotypes or distinctions, because our clients benefit from access to as many choices as possible, as well as autonomy and agency in how they develop their personal care team.

It’s not up to us to police or limit the progression of other providers.

It’s on us to show up to the call and advance and innovate into new terrain that has not yet been touched.

I think this is also where our professional discourse can either facilitate or constrain advancement.

If every new contribution has to first establish that it is completely separate from every existing contribution, we create a system where overlap becomes something to eliminate rather than something to build from.

That is not how most skilled professions actually develop.

Advancement often happens at the intersections.

A profession develops new knowledge, new applications, new specialties, new methods, and new ways of delivering services from a foundation that may already overlap with other professions.

The existence of shared foundations can actually make interdisciplinary advancement possible.

The goal should therefore not be to eliminate overlap.

It should be to understand it well enough that we can recognize where our foundations intersect, where our professional developments differentiate, and where collaboration creates something none of us could provide alone.

We’re not going to evolve into the future by constantly reproducing conditions of the past or blocking the developments of other providers, as has been the history of the United States healthcare system, which I’ve outlined in a workshop on the text Witches, Midwives, and Nurses in my online learning community.

Who gets to choose?

It’s really not up to any of us as allied providers who our clients choose to work with.

It’s up to our clients.

I think we will have much more productive discourse if we take on good faith learning from advanced clinicians and the clients that receive their services about how they can complement and enhance care rather than only seeing fear of duplication.

This does not mean that every provider should do everything, or that professional boundaries and legal scope do not matter. They do. AOTA explicitly notes that state law defines the scope of practice for OTs and OTAs and that practitioners must comply with applicable statutes and regulations.

The point is that professional boundaries are not the same thing as rigidly assigning every competency to only one profession.

Multidisciplinary care can contain overlapping knowledge and skills while still retaining meaningful differences in professional education, philosophy, reasoning, and purpose.

The existence of overlap is therefore not, by itself, evidence of duplication.

And this matters for client autonomy.

If multiple qualified professionals can provide a foundational service, that does not mean the client has no meaningful basis for choosing among them.

Their choice may be shaped by the practitioner’s specialization, professional lens, theoretical orientation, communication, relationship, experience with a particular population, approach to care, or ability to connect the service to the occupations and environments that matter most to them.

Sometimes the foundational service may even look similar.

The experience of receiving that service, the reasoning behind it, what it is connected to, and what the practitioner sees as possible beyond it may be very different.

That difference can be meaningful.

And clients should have room to decide which approach is most consistent with their own preferences, priorities, and goals.

Why I keep coming back to Occupational Science

A big part of why I am a proponent of increased occupational science literacy for OTPs worldwide is because I believe we need to be able to communicate about our identity, skills, innovations, and possibilities from our own foundations.

If we only communicate about OT through the language and boundaries of other professions, we will continue getting caught in the same cycle.

We need to be able to articulate what occupational therapy brings to the table without first having to prove that we can do something another profession already does.

And we need to be able to recognize that overlap does not erase distinction.

Occupational science can help us better understand what exists beyond the foundational floor.

It gives us language to examine occupation not only as something we intervene in clinically, but as a field of inquiry involving human experience, meaning, identity, participation, environment, culture, systems, and the conditions that enable or constrain what people are able to do and become.

That matters because the future of professional practice cannot be built only by repeating the foundational services that already exist.

We need professions capable of developing.

We need practitioners capable of thinking beyond inherited categories.

We need epistemic flexibility that allows us to recognize knowledge emerging from practice, communities, lived experience, interdisciplinary collaboration, scholarship, and places that established systems may not yet have fully recognized.

And we need professional discourse that makes room for that development rather than treating every new possibility as a threat to someone else’s territory.

Our clients are not territory.

Our professions do not have to be in competition for one profession to advance.

We can have different areas of expertise, overlapping competencies, distinct lenses, and collaborative relationships at the same time.

We can provide some of the same foundational services while developing very different ways of understanding and applying them.

We can develop emerging practices without pretending that the foundational professions that came before us have become irrelevant.

And we can allow clients to choose among qualified providers based on what is meaningful to them.

That is a much more interesting future to me than continually arguing about who is allowed to do what.

Subscribe to this substack to access the free OS 101 Guide

Continue the conversation

If you enjoy conversations like this and want to gain more Occupational Science literacy and gain the terminology to help advance understanding and application of cutting edge and foundational integrative OT, I would love for you to subscribe to my Substack.

This is where I am making room for the longer conversations that do not fit inside a LinkedIn character limit, including conversations about Occupational Science, OT history, professional identity, policy, scope, interdisciplinary collaboration, and emerging practice.

And if you want to continue these conversations with an international community, I would love to have you join the free Evolved Living Collaborative.

There are an abundance of free OS 101 resources and opportunities to engage through craft nights, journal club, daily discussion, and ongoing conversations about how we can expand our understanding and application of occupational therapy.

Join the free Evolved Living Collaborative:

And subscribe to the Substack to receive the longer-form essays:

If you came here from one of the LinkedIn posts above, thank you for following the conversation here.

I hope this longer version gives us more room to move beyond shorthand definitions, professional insecurity, and scarcity toward more nuanced conversations about what becomes possible when we allow skilled providers to develop, collaborate, specialize, and innovate.

References

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. doi:10.5014/ajot.2020.74S2001.

American Occupational Therapy Association. (2021). Occupational therapy scope of practice. American Journal of Occupational Therapy, 75(Suppl. 3), 7513410020. doi:10.5014/ajot.2021.75S3005.

Bulan, P. M. P., Villalino, C. K., Gutierrez, M. S. Y., & Evardo, M. K. S. (2025). Occupational therapy in athletics and sports: A scoping review. American Journal of Occupational Therapy, 79(6), 7906205020. doi:10.5014/ajot.2025.051180.

Dionne, T. (2025). Peter wants to build a playhouse for his siblings and has ADHD: Neuroscience facilitates our understanding of task completion. In W. Dunn, T. J. Wolf, L. G. Richards, & D. M. Nilsen (Eds.), The neuroscience of everyday life: An applied guide for health sciences students. Routledge.

Dionne, T. (n.d.). What Counts. Substack.

Douglas, R., McConnell, C., Abbott, A., Bare, G., Cleave, S., Crum, T., Kirkpatrick, M. A., & Kuenzli, M. (2024). Occupational therapy’s role in return to occupations post-concussion in high school athletes. Physical & Occupational Therapy in Pediatrics, 44(4), 542–553. doi:10.1080/01942638.2023.2299033.

Kielhofner, G. (1982). A heritage of activity: Development of theory. American Journal of Occupational Therapy, 36(11), 723–730. doi:10.5014/ajot.36.11.723.

Neal, A. E. (2026). Addressing sleep health in the fire service: A sleep hygiene education program. University of Nevada, Las Vegas.

Oh, H.-J., Sim, C. S., Jang, T.-W., Ahn, Y. S., & Jeong, K. S. (2022). Association between sleep quality and type of shift work in Korean firefighters. Annals of Occupational and Environmental Medicine, 34, e27. doi:10.35371/aoem.2022.34.e27.

Schemm, R. L. (1994). Bridging conflicting ideologies: The origins of American and British occupational therapy. American Journal of Occupational Therapy, 48(11), 1082–1088. doi:10.5014/ajot.48.11.1082.

University of Washington Division of Occupational Therapy. (2024). Sleep, stress, and shift work: An occupational therapist’s investigation into firefighter wellbeing and culture [Graduate capstone poster].

Here is a voice-over of the article for those who prefer audio

Hi everyone! I’m thrilled to share this episode with you today.

If you’ve been following this podcast since it started in 2023, you might know it grew out of my doctoral capstone project during my time in the University of Utah’s Post-Professional Clinical Doctorate program from 2019 to 2023. This journey unfolded during the challenges of the COVID-19 pandemic, which highlighted the global impact that devaluing public health initiatives has had on collective on health and well-being, and made deeply evident the barriers and costs to humanity created by maintaining dynamics of scientific elitism, and the lack of accessible frameworks for translating impactful health interventions and knowledge from the academy to the field, especially frameworks informed by disability and occupational justice.

After navigating two stalled capstone projects due to pandemic-related challenges, I shifted my focus to creating resources for field clinicians to develop occupational science literacy for direct practice. Over three years, I poured my heart and all my spare time into building a fully virtual introduction to occupational science, using innovative online learning tools and best practices in adult education. If you’re curious, you can explore this project at engage.evolvelivingnetwork.com, and just by subscribing to this Substack, you can get free access to the OS 101 guide, which includes a glossary of all foundational occupational science terminology.

My journey back into occupational therapy higher education began after feeling disillusioned during my first two years of clinical and school-based practice as a travel therapist. I was searching for a space where I could thrive using holistic approaches that integrated mental and physical health. Initially, I hoped to work in pediatric and school-based settings, but I quickly encountered policy limitations that narrowed the focus of occupational therapy to handwriting and fine motor skills. This was disheartening, especially since my master’s research centered on executive dysfunction supports for adolescents and assistive technology in schools, areas that were largely controversial for occupational therapists in traditional settings at the time.

These challenges revealed deeper issues within the field, including limited access to occupational science developments and foundational frameworks like the “Occupational Therapy Practice Framework Fourth Edition.” I realized through my my more in-depth study that these barriers were tied directly to historical inequities, such as structural sexism in higher education and healthcare leadership sourcing all the way back to the 1500s. This understanding fueled my passion for creative problem-solving and building community around these issues. I have a free training in the evolved living collaborative skool community on how Occupational Science is integrated with the Occupational Therapy Practice Framework Fourth Edition for anyone who is looking to get caught up on out latest practice guidence updates.

After graduating, I launched this podcast to raise awareness about Occupational Science and my capstone course. Later, I collaborated on a textbook chapter proposal for the “Occupational Therapy Without Borders” third edition, exploring innovative ways to circulate knowledge beyond traditional academic institutions. While the chapter ultimately missed the publication deadline, the experience taught me valuable lessons about resilience and navigating academic challenges.

Since then, however, I have been challenged in relation to this podcast by writer’s block, perfectionism, shame around missing the deadline, and a lack of direction without the structure of a prompt, deadline, or institutional affiliation to prove the value of my work to or rebel against. I’ve been on a personal journey of healing and rediscovery, exploring the roots of occupational therapy in the moral treatment and arts and crafts movements, and deepening my understanding of decolonial healthcare frameworks. This has included honoring the wisdom of indigenous and folk healers whose contributions have often been suppressed or commodified by modern healthcare systems. To support my own recovery, I created a podcast and community called “Rewilding the Mythic Self,” where I’ve been reconnecting with creativity, spirituality, and interdisciplinary collaboration outside of formal institutions. Over time, however, I have come to realize that fracturing out these parts of myself wasn’t really possible and was actually disconnecting me from the type of integrative work I am passionate about reviving in Occupational Therapy practice throughout the world and thank goodness I am not alone in this mission!

One of the most transformative moments in this journey recently has been discovering the work of Libby Lamb an occupational therapist and poet (Author of the Acacia Project) based in UK and Australia who powerfully integrates spirituality and creativity into her personal life and practice. Participating in Libby’s writing workshop this past July has helped inspire me to revive this podcast and explore in community how occupational therapists can reconnect with their creative and spiritual selves while navigating the demands and restrictions of traditional practice settings. Her insights have been invaluable in addressing my own creative blocks and building confidence to embrace my full self in both my persional and professional practice.

Together, Libby and I have been exploring themes around the “witch wound”, the historical legacy of suppression and violence against women healers, and its relevance to contemporary occupational therapy. In relation to our discussion, Libby wrote an incredible article on the complexities of navigating one’s identity as an OTP while also making space for one’s own spirituality and creative expression for our own wellbeing and holistic fulfillment. I highly recommend reading this article and subscribing to her work here: Libby Lamb

Find Libby on instagram: @OTandbiscuits and @wordswithlibby and join her free facebook for OT’s Reclaiming Craft here:

These conversations have deepened my appreciation for the power of occupational science in addressing systemic barriers and promoting inclusive healthcare practices. I encourage you to check out Libby’s work, including her poetry book and coaching program, “Duality,” which supports occupational therapists worldwide (US-based OTPs are invited to participate in her creative writing offerings through words with libby however she is currently unable to offer 1:1 coaching for OTPs in the USA at this time.)

This past fall I also explored simliar themes in a reflexive intergenerational workshop on the concise classic text: Witches, Midwives, and Nurses by Barbra Enenrich and Deidre English on the historic orgins of the American Medical Association and the ties between imperial and colonial Western biomedical models and the formal exclusion and suppression of women, people of color, the global south, and criminalization of folk medicinal practices that are foundational to the fear and apprehension many of us continue to hold up into this day inspite of OT inseperable tie to the arts and crafts, mornal treatment, and spirutality through and self determined engagement in meaningful and purposeful activity in context. This powerful workshop is currently freely available in the Evolved Living Collaborative Skool Community Classroom.

This legacy has persisted until this day in the podcast I referenced Drs. Vivian Tatiana Camacho Hinojosa and Bolivian midwife who trained in the west as surgeon before returning to ancestral practices and fighting with her community to protect and expand access to water, food, and traditional medicine world wide. Her powerful work has helped advance protections for folk medicinal practices and keep sacred midwifery practices alive with broad coalitions internationally. She is currently facing political persecution and encourages us to reconnect to honoring life and finding health in connection to life affirming community and protection and collaboration with nature as warriors for life and protection of its most tender expression.

Quality outcomes from access to Midwives in childbirth: https://pmc.ncbi.nlm.nih.gov/articles/PMC9584105/

Here is the reference article on how weavers made Apollo Space Mission possible: https://www.sciencenews.org/article/core-memory-weavers-navajo-apollo-raytheon-computer-nasa

Along with the powerful science of knitting:

There are some amazing resources available that I plan to read and review on this Substack this year and possibly host discussions on in the Evolved Living Collaborative:

I’ve come to realize that true liberation lies in integration, bringing together my creative, spiritual, and professional identities to build coalitions and navigate challenges collectively. This perspective has guided my recent collaborations, including sharing my folk arts and crafts experiments with the Canadian Society for Occupational Science and the American Occupational Therapy Association, and attending the Decolonizing Healthcare Knowledge Summer School Institute in Mexico City.

For those interested in joining these conversations, I invite you to explore the Evolve Living Collaborative platform, where we host free workshops like “Witches, Midwives, and Nurses,” weekly craft nights, coffee and co-occupation sessions, and a monthly journal club focused on foundational occupational science articles and emerging interdisciplinary books. Together, we can revive the optimistic origins of occupational therapy, celebrate the power of meaningful activity, and create spaces for healing, creativity, and connection.

Direct Link: https://www.skool.com/evolved-living-collaborative-6395/about

Thank you for being here, and I hope you enjoy this episode!

Thanks for reading! Subscribe for free to receive new posts and support my work.

Why this Occupational Science series matters

If you are an occupational therapy practitioner in the United States, chances are you are already using occupational science.

You just might not have been given the words for it yet.

That gap is part of why I created this Occupational Science Alphabet Series, a public learning series designed to make occupational science more accessible and more visible in everyday life and traditional practice settings.

This first composite series begins with A for Occupational Apartheid.

Recording Timestamps:

00:00 “Occupational Apartheid Analysis”

06:01 “Occupational Apartheid Challenges”

16:11 “Systemic Barriers in OT”

18:04 “Enhancing Accessibility through Advocacy”

25:20 “Defining Occupational Apartheid”

33:06 “Occupation and Systemic Inequality”

39:23 “Advocating Equity in OT Practice”

45:04 “Occupational Therapy for Healing”

48:04 “Advancing Occupational Justice”

54:55 “Occupational Ethics Evolution”

58:50 “Occupational Apartheid Ethics”

01:03:58 “Justice and Veracity”

01:10:17 Healthcare Bias and Scientific Integrity

01:15:59 “Addressing Maternal Health Disparities”

The phrase can feel intense at first.It should.

Because it names something real.

It gives language to the ways people are systematically denied access to meaningful participation in everyday life, not simply because of individual impairment or diagnosis, but because of how social, economic, political, and cultural systems are organized.

And that matters deeply for occupational therapy.

Because when we only look at barriers inside individual bodies, we miss the wider context shaping participation.

We miss the insurance policy.The school policy.The zoning code.The inaccessible architecture.The transportation gap.The labor condition.The funding cap.

Occupational science helps us see those patterns clearly.

And once we can see them, we can respond more ethically and more effectively.

The Secret of Occupation

One of the most powerful insights of occupational science is that occupation always transcends the individual.

Yes, participation includes personal capacity, motivation, and health status.

But occupation is also shaped by:

environmentculturepolicyhistoryeconomicssocial relationships

When occupational therapists work with clients, we are rarely working with bodies alone.

We are working with people in systems.

Occupational science simply gives us a language to describe those systems more clearly.

Why Occupational Apartheid Matters

The concept of occupational apartheid helps us name situations where social systems restrict access to meaningful participation in everyday life.

Frank Kronenberg describes occupational apartheid as:

“systematically enacted negations of humanity that divide and subjugate collectives of people to the benefit of some at the expense of others.”(Kronenberg, 2018)

These restrictions can occur through intersecting social mechanisms such as:

racismclassismsexismableismxenophobiaeconomic inequality

These forces shape who has access to resources that sustain dignified living.

They shape who can participate fully in everyday life.

And they show up in everyday occupational therapy practice more often than we might initially realize.

When Systems Become Habit

One of the most profound insights connected to occupational apartheid comes from the concept of occupational consciousness, developed by Elelwani Ramugondo.

Occupational consciousness invites us to examine how systems of power become embedded in everyday activity.

Because the truth is:

Systems do not reproduce themselves automatically.

They reproduce themselves through what people do every day.

Policies become habits.Beliefs become routines.Social hierarchies become normalized through everyday actions.

Over time, these patterns become so familiar that they operate below the level of conscious awareness.

This is where occupation becomes incredibly important.

Occupation is the point where ideas turn into action.

And when those actions become automated habits, they can quietly reproduce systems of inequality, even after the laws that created them have been formally abolished.

When Systems End but Patterns Persist

History shows us that oppressive systems rarely disappear completely when policies change.

Segregation in the United States was formally dismantled decades ago.

Apartheid in South Africa was officially abolished in the 1990s.

And yet racial disparities, inequities in access to housing, healthcare, education, and safety persist in both societies today.

Why?

Because systems do not only exist in policy.

They exist in everyday occupations.

They exist in patterns of:

where people livewho receives serviceswho gets referred to carewhose needs are believedwho feels welcome in public spaceswho has access to transportation, education, and healthcare

These patterns often persist through habits and assumptions that operate subconsciously.

Occupational consciousness asks us to notice those patterns.

Occupational apartheid helps us name their structural origins.

Rehumanizing the Collective After War

Another important dimension of occupational apartheid is its relevance to collective recovery from war, violence, and social division.

Many of the social systems that shape our institutions today were forged in contexts of conflict, colonial expansion, and geopolitical competition. Even when wars formally end, the habits, infrastructures, and relational patterns shaped by those conflicts often remain embedded in everyday life.

Occupational apartheid helps illuminate how the aftermath of war can continue to shape participation in subtle ways, through segregation, displacement, institutional distrust, unequal resource distribution, and inherited patterns of fear or exclusion.

If left unexamined, these patterns can reproduce division across generations.

Occupation is where these patterns are maintained, but it is also where they can be transformed.

Through shared activities, community participation, creative practice, caregiving, education, and everyday collaboration, people rebuild relational life.

Occupational therapy historically emerged in part from this very context, helping individuals and communities reconstruct meaningful life after the disruptions of war and institutionalization.

Engaging with occupational apartheid and occupational consciousness today invites us to continue that tradition.

Not by reproducing new forms of division or tribal harm, but by helping cultivate conditions where people can participate in humanizing, compassionate, and sustainable forms of collective life.

In this way, occupation becomes a pathway toward healing.

Not only individual healing.

But collective healing.

Occupation as a Tool for Liberation

If occupation can reproduce systems of injustice, it can also help dismantle them.

Because occupation is also the place where change becomes possible.

When we change everyday patterns of doing, we change systems.

This is why occupational therapy has always been connected to movements for human dignity and social participation.

From the moral treatment movement to disability rights advocacy, occupational therapy has been concerned with helping people return to meaningful life within their communities.

Occupational science expands that mission.

It invites us to see how everyday activities can either reinforce systems of harm or help create environments where people can live with dignity, belonging, and agency.

Why This Perspective Strengthens Occupational Therapy

Understanding occupational apartheid and occupational consciousness does not weaken clinical practice.

It strengthens it.

When therapists understand the systemic barriers affecting participation, they can:

design more realistic interventionsadvocate for appropriate equipmentcollaborate with community resourcesidentify policy barriersdocument environmental constraints clearly

It also helps us articulate what makes occupational therapy distinctive.

Our profession studies human beings as occupational beings.

That means we look not only at physical function, but at how environments and systems shape the possibilities for everyday life.

This perspective integrates insights from:

health sciencessocial sciencescritical social sciencescommunity knowledgedecolonial scholarship

Together, these perspectives create a robust and integrated understanding of participation.

What This Series Explores

This Occupational Science Alphabet Series explores concepts that help illuminate the broader context of occupation, including:

occupational apartheidoccupational consciousnessoccupational justicecollective occupationsecological approaches to health

Each concept will be translated into examples from real-world practice contexts.

The goal is simple:

To help occupational therapists, students, and the public better understand the unique scientific foundation of our profession.

Subscribe for OS 101

If this conversation resonates with you, I invite you to subscribe to this Substack.

Here I share:

Occupational Science 101 explanationspodcast conversationsinterdisciplinary scholarshipreflections on ethics and policyexamples from everyday clinical practice

My hope is to make occupational science more accessible so that occupational therapy can be better understood both within our profession and by the broader public.

Stay tuned for the Forthcoming Learning Community

I am also building a forthcoming Skool community where free OS 101 content will be hosted.

This space will include:

introductory occupational science coursesa journal and book clubcommunity discussion forumsreflection spaces for practitioners and learners

Together we will explore how occupational science can support:

collective liberationecological balanceoccupational wellbeinghumanizing care across the lifespan

Closing Reflection

If you have ever felt that occupational therapy is bigger than the narrow boxes it is often placed in, you are not imagining that.

If you have sensed that participation barriers often arise from systems rather than symptoms, you are not imagining that either.

Occupational science gives us the language to understand those realities.

And occupational therapy gives us the tools to transform them.

This series is an invitation to explore that together.

Primary Sources

📚 Ramugondo, E. L. (2015). Occupational consciousness. Journal of Occupational Science, 22(4), 488–501.https://doi.org/10.1080/14427591.2015.1042516https://www.tandfonline.com/doi/full/10.1080/14427591.2015.1042516

📚 Kronenberg, F. (2018). Everyday enactments of humanity affirmations in post-1994 apartheid South Africa: A phronetic case study of being human as occupation and health (Doctoral dissertation, University of Cape Town).https://open.uct.ac.za/handle/11427/29441

References

Hammell, K. W. (2019). Building globally relevant occupational therapy from the strength of our diversity. World Federation of Occupational Therapists Bulletin, 75(1), 13–26. https://doi.org/10.1080/14473828.2018.1529485

Kronenberg, F. (2018). Everyday enactments of humanity affirmations in post-1994 apartheid South Africa: A phronetic case study of being human as occupation and health (Doctoral dissertation, University of Cape Town). https://open.uct.ac.za/handle/11427/29441

Kronenberg, F., Pollard, N., & Sakellariou, D. (Eds.). (2011). Occupational therapies without borders: Towards an ecology of occupation-based practices (2nd ed.). Elsevier.

Ramugondo, E. L. (2015). Occupational consciousness. Journal of Occupational Science, 22(4), 488–501. https://doi.org/10.1080/14427591.2015.1042516

Wilcock, A. A., & Hocking, C. (2015). An occupational perspective of health (3rd ed.). SLACK Incorporated.

Evolved Living Podcast with Dr. Josie Jarvis OT

Global Conversations: Cross-Discipline Collaboration in Epidemiology, Occupational Science, Disability, and AIwith Emmanuel Ampomah Boadi

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Episode Overview

In this episode of the Evolved Living Podcast, Dr. Josie Jarvis welcomes Emmanuel Ampomah Boadi, a Ghana-based researcher working at the intersection of occupational science, epidemiology, biostatistics, rehabilitation, and disability studies. Their thoughtful, wide-ranging conversation explores how participation in daily life is shaped by social, structural, and systemic forces far beyond individual clinical encounters.

Dr. Josie Jarvis opens the episode by reflecting on her diverse clinical background, spanning home health, schools, memory care, and acute and orthopedic rehabilitation. Her journey—deepened by doctoral work amid the COVID-19 pandemic—led her to occupational science as a discipline uniquely equipped to investigate barriers to participation at the population (not just individual) level.

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Key Topics Discussed

- What is Epidemiology?

Emmanuel Ampomah Boadi grounds the discussion by defining epidemiology: the study of how health, disease, and disability are distributed across populations, and the factors influencing those outcomes. He emphasizes that "it is the backbone of public health," using stories from Ghana and references to public health icons like John Snow and John Graunt to illustrate epidemiology’s roots in mapping, measurement, and understanding the interplay between environment and human behavior.

- Bridging Disability Studies and Occupational Science

Emmanuel Ampomah Boadi describes how his academic journey—spanning disability/rehabilitation studies and biostatistics—inspired him to explore the overlap between occupational science and population health. He highlights the importance of looking not only at medical conditions but also at social and environmental context, power imbalances, and race—reminding us that “everybody has some form of disability” and that “there is nothing like normal.”

- The Role of Data and AI

The conversation explores the need to “quantify” our observations to strengthen advocacy. Emmanuel Ampomah Boadi sees artificial intelligence as an assistive technology—valuable, but ultimately limited. He urges clinicians and researchers to retain the clarity and accountability of human interpretation, using AI as a support rather than a replacement for nuanced judgment.

- Ethics, Equity, and Systemic Barriers

The episode doesn’t shy away from difficult truths. They discuss well-known ethical breaches in research history (Tuskegee Syphilis Study, Nuremberg Code violations) and highlight how, without active attention to equity and ethics, scientific progress can deepen injustice. Dr. Josie Jarvis and Emmanuel Ampomah Boadi both reflect on their lived experiences of systemic inequity—from global vaccine access to the design of research and public health interventions.

- Cultural Humility and Community Engagement

Emmanuel Ampomah Boadi shares a poignant research anecdote from Ghana: an infrastructure project failed because outsiders did not consult the community, ultimately building a water borehole atop a sacred space. The lesson: knowledge translation is only possible with true cultural humility and partnership, not top-down assumptions.

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Concepts Explained

Occupational Science:

A discipline that examines human participation (“occupation”) in everyday life, considering both individual and system-level factors—policy, environment, economics, and history—that enable or restrict engagement.

Epidemiology & Biostatistics in Rehab:

Not just tools for infectious disease, epidemiology provides frameworks for understanding disability, health disparities, and the structural determinants of participation. Biostatistics helps quantify these patterns and decipher root causes, moving advocacy from anecdote to evidence.

Occupational Apartheid & Social Models of Disability:

The episode contextualizes “occupational apartheid”—a situation where social, economic, or policy barriers systematically exclude groups from meaningful participation in everyday life. Emmanuel Ampomah Boadi distinguishes between the medical, social, and biopsychosocial (ICF) models of disability, urging listeners to see how “systemic barriers” create or intensify disability.

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Practical Wisdom for Listeners

- Integration is Key: Solutions come from teamwork—integrating medical science, social science, community wisdom, and policy. “You need to involve the community—what you believe to be the best solution may not fit their real needs.”

- You Belong in Science: Dr. Josie Jarvis and Emmanuel Ampomah Boadi both stress that occupational science and health advocacy are not reserved for those with doctorates or prestigious affiliations. Efforts—however imperfect—matter.

- Share and Connect: The conversation encourages clinicians, students, and community members to participate, share ideas, question systems, and “be on LinkedIn” or join organizations like CSOS (Canadian Society for Occupational Scientists), which prioritize international access and virtual participation.

- Respect, Humility, and Effort: Growth and social change depend on respecting all perspectives, continuous effort, and humility when things don’t go as planned.

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Why This Matters

Occupational therapy and science are poised to lead in bridging the gap between STEM and social science, between evidence and ethics, between theory and grassroots reality. Episodes like this demonstrate—in clear, accessible language—why the work of linking occupation, policy, data, and advocacy is both urgent and hopeful.

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How to Engage Further

- Resources Mentioned:

- Occupational Science 101 Guide

- OS Alphabet Series (on TikTok, Instagram, Facebook, and LinkedIn)

- CSOS membership and virtual events

- LinkedIn and Substack for new episodes and reflections

- Get Involved:

Bring occupational science ideas into your practice, classroom, or community—even if you’re new to the concepts. Connect for further conversations, share your efforts, and don’t wait for perfect conditions.

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Final Thought

As Emmanuel Ampomah Boadi shares: "Don’t be afraid that you’ll get it wrong. If you don’t get it wrong, you never know what to do to make it right." Occupational science—and a just health system—needs all voices, including yours.

Connect with Emmanuel on LinkedIn here: https://www.linkedin.com/in/emmanuel-ampomah-boadi-08b4241a4/

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For more episodes, resources, and to keep the conversation going, follow the Evolved Living Podcast on Substack and connect on social media platforms. Let’s keep collaborating across borders, backgrounds, and disciplines—the future of well-being depends on it.

When I first learned about evidence-based practice, I remember staring at that glossy triangle, the research hierarchy pyramid, with meta-analyses gleaming at the top like sacred scripture.

It was comforting at first. Finally, a clear map of what counts as truth.But once I entered practice, that tidy hierarchy started to crumble under the weight of real people’s lives.Human beings aren’t controlled variables, and occupation doesn’t fit neatly into double-blind trials.

The Trouble with the Old Pyramid

The traditional Evidence-Based Practice (EBP) pyramid was built for biomedical and pharmaceutical research, where the goal is to test isolated variables across large populations (Duke University Medical Center Library, n.d.).

That works beautifully when you’re measuring how a medication lowers blood pressure.But occupation is not a pill… it’s a process.It’s meaning, context, motivation, and environment woven together.

In OT, our “data set” is often one person at a time, a life lived in context.Trying to flatten that into a universal protocol often means losing what makes our work effective and human.

The Tomlin & Borgetto Research Pyramid: A Model That Fits Our Field

In 2011, George S. Tomlin and Brandon Borgetto published Research Pyramid: A New Evidence-Based Practice Model for Occupational Therapy in The American Journal of Occupational Therapy (Tomlin & Borgetto, 2011).

They didn’t just redraw the pyramid, they reimagined what evidence could look like.Their four-sided model includes:

* Descriptive research: defining and observing occupational phenomena (the foundation).

* Experimental research: asking causal questions under controlled conditions.

* Outcome research: measuring effectiveness and impact in practice settings.

* Qualitative research: exploring lived experience, culture, and meaning.

Each side contributes uniquely to a full picture of occupational reality.Rather than stacking these methods into a hierarchy, Tomlin and Borgetto framed them as mutually reinforcing, like the faces of a pyramid that meet at the top…where evidence becomes practice.

“Rather than ranking designs by hierarchy, the research pyramid encourages practitioners to evaluate rigor based on the type of question being asked.”- Tomlin & Borgetto (2011, p. 190)

Why This Matters in Practice

In home health, I’ve seen firsthand how rigid hierarchies undervalue the evidence that actually drives change.An RCT can tell me which exercise statistically improves shoulder flexion …but not whether my client can now garden with her grandchildren, or return to painting without pain.

Occupational therapy lives where biology meets biography.To serve people well, we need research frameworks that make room for both.

The Critiques That Strengthen Us

Scholars such as Whiteford and Wright-St Clair (2004) argue that the old hierarchy often silences the very forms of knowledge that make OT powerful- narrative, context, creativity.When we measure success only by quantitative control, we risk missing the human story.

Occupational science reminds us that people are meaning-making beings.Our science must be capable of holding that complexity.

How I Apply the Tomlin & Borgetto Pyramid

* For mechanical reliability, I turn to experimental studies.

* For real-world effectiveness, I consult outcome research.

* For understanding experience, I value qualitative inquiry.

* And at the root of it all, I rely on descriptive studies to ground my reasoning.

Each approach has a place.Evidence becomes less about hierarchy and more about harmony, a dynamic ecosystem of knowing.

Reclaiming Evidence as a Living Practice

Embracing this model isn’t about lowering standards; it’s about broadening the lens.It validates community programs, arts-based methods, trauma-informed care, and culturally grounded interventions that might never fit into traditional RCTs.

When we expand what counts as evidence, we expand what’s possible: for our clients, our profession, and the world we’re helping to rebuild.

🌿 Learn More: Foundations of Occupational Science for U.S.-Based OTPs

If this conversation sparks something in you, the urge to better understand why occupational therapy feels different from other disciplines and how to ground that difference in research and policy… I invite you to join me inside Foundations of Occupational Science for U.S.-Based OTPs.

This self-paced capstone learning experience bridges theory and practice, guiding practitioners and students to:

* Decode the real meaning and application of the Tomlin & Borgetto Research Pyramid.

* Integrate occupational science concepts into documentation, advocacy, and program design.

* Reclaim OT’s creative and psychosocial roots while navigating contemporary U.S. systems.

* Build confidence in articulating the full scope of practice, in language policymakers, payers, and interdisciplinary teams understand.

You can explore the course and all current offerings here:👉 engage.evolvedlivingnetwork.com

Together, we’re building a movement of practitioners who see evidence as a living, liberatory practice…one that honors both the science and the soul of occupation.

References

Duke University Medical Center Library. (n.d.). The evidence-based practice pyramid. Retrieved from https://guides.mclibrary.duke.edu/ebmtutorial/ebp_pyramid

Tomlin, G. S., & Borgetto, B. (2011). Research pyramid: A new evidence-based practice model for occupational therapy. American Journal of Occupational Therapy, 65(2), 189–196. https://doi.org/10.5014/ajot.2011.000828

Whiteford, G., & Wright-St Clair, V. (2004). Occupation and practice in context (1st ed.). Churchill Livingstone Australia.

I have been thinking a lot about the history of care and what becomes possible when we take the time to remember the people and practices that came before our modern healthcare systems.

That was the focus of a recent book circle and art-making session inside the Evolved Living Collaborative, where we explored Witches, Midwives, and Nurses by Barbara Ehrenreich and Deirdre English through an occupational therapy and occupational science lens.

The live gathering has already happened, but the recording and classroom materials are now available inside the community so you can explore the conversation at your own pace.

This is one of those topics that I think deserves more than a single conversation.

A Forgotten Lineage of Occupation

Long before occupational therapy became a profession, people were using everyday occupations to care for themselves, their families, and their communities.

Growing food, preparing remedies, weaving, sewing, making pottery, caring for children, attending births, preparing meals, and gathering around shared work were not necessarily separated into the categories we use today to describe healthcare, leisure, productivity, or self-care. They were simply part of living.

These occupations helped people survive, connect with one another, pass knowledge between generations, and create meaning within their communities.

Witches, Midwives, and Nurses gives us an opportunity to look at what happened when many of these community-based traditions of care came into conflict with increasingly professionalized and institutionalized systems of medicine.

Women healers and midwives were not simply forgotten as modern medicine developed. Their knowledge and authority were challenged, restricted, and displaced in ways that were deeply connected to gender, class, and institutional power.

That history raises questions that still feel relevant today.

Who gets recognized as a legitimate knowledge holder? Whose knowledge becomes evidence? Who gets paid for care? What happens to forms of care that do not fit neatly into professional or institutional structures?

These are not just historical questions.

So What Does This Have to Do With Occupational Therapy?

For me, this is where the conversation becomes especially interesting.

Occupational therapy emerged alongside movements that recognized the therapeutic potential of meaningful activity, including the moral treatment movement and the arts and crafts movement.

There was an understanding that doing matters. Making matters. Connection matters. The environments in which we live matter.

Human beings are not simply bodies carrying diagnoses. We are people living through occupations, relationships, communities, environments, routines, and meaning.

And yet, within modern healthcare, many of the things that make occupational therapy distinctive can become difficult to see.

Our craft-based roots can become secondary to productivity metrics. Relational work can become difficult to quantify. Psychosocial and community-based occupations can be pushed aside when healthcare systems prioritize what is easiest to measure.

Sometimes I think we have become so accustomed to explaining occupational therapy through the language of the medical system that we forget how unusual some of our roots actually are.

That is one of the questions I wanted to create space for in this classroom session.

What might happen if we became more familiar with the histories of care, craft, community knowledge, and everyday occupation that existed before our profession had a name?

Why Revisit This Now?

This feels particularly important at a time when so many people are experiencing burnout and disconnection from the systems that are supposed to support health.

Clinicians are being asked to do more with less. Communities are struggling with access to care. Insurance structures can make meaningful services difficult to obtain. Healthcare workers are navigating staffing shortages, productivity expectations, and systems that do not always leave much room for relationship or creativity.

At the same time, people continue to care for one another outside of formal institutions.

People cook for their neighbors. They grow gardens. They make art together. They share skills and knowledge. They create mutual aid networks. They teach one another traditional practices. They gather around tables and find ways to make life a little more livable.

None of this replaces regulated healthcare when regulated healthcare is needed.

But I think it is worth paying attention to the fact that people have always created ways of caring for one another, particularly when formal systems have not been able to meet every need.

Occupational therapy has an interesting place within this conversation because occupation connects individual health with the environments, relationships, communities, and everyday activities that make up a person’s actual life.

What We Explored Together

In the 90-minute classroom session, we used Witches, Midwives, and Nurses as a starting point for thinking about the relationships between women’s knowledge, folk practices, craft, community care, and the development of occupational therapy.

We also created art together.

The Window Between Worlds activity invited us to think symbolically about the people, practices, and forms of knowledge that may have been pushed outside of official histories of healthcare, while also considering what knowledge we might want to carry forward.

The session includes reflections on selected passages from the book, connections to occupational therapy history, conversation about relational and community-based knowledge, and an opportunity to consider what reclaiming meaningful occupations might look like in our own communities.

You do not need to have read the entire book to engage with the session. You also do not need to arrive with a particular interpretation or a perfect understanding of the history.

The classroom is meant to be a place to think, question, make, and explore together.

Access the Classroom Inside the Evolved Living Collaborative

The recording and classroom materials from Reclaiming the Roots of Care are now available inside the Evolved Living Collaborative.

Once you join, you can access the links to the text and audio versions of Witches, Midwives, and Nurses, along with the workshop recording and the creative activity we explored together.

The community is also becoming a place for ongoing connection around occupational science, occupational therapy, creativity, and meaningful occupation.

We are hosting weekly craft nights, Coffee & Co-Occupation gatherings, and a monthly Journal Club, along with other conversations, workshops, and opportunities to learn together.

I created this community because I wanted a space where occupational therapists, students, educators, researchers, occupational scientists, creatives, and interdisciplinary collaborators could explore ideas together without everything having to become another formal course or professional development requirement.

Sometimes we need to study something.

Sometimes we need to talk about it.

Sometimes we need to make something with our hands while we think.

And sometimes we just need other people who are curious about the same questions.

The Evolved Living Collaborative is free to join. You can join the community here.

Want to Go Deeper?

If you are interested in tracing the threads of occupation across generations, I also explored some of these ideas in my podcast episode, Weaving the Threads of Our Occupation.

That conversation gets into why I have become so interested in intergenerational occupational histories and in looking beyond the official timelines we are often given when we learn the history of our profession.

Because I do not think our professional history begins when someone first wrote down the words “occupational therapy.”

The story is much older than that.

There are threads connecting us to the people who made, cared, taught, gathered, adapted, and passed knowledge from one generation to another.

I think there is something powerful about remembering those threads.

A Closing Reflection

The history of care is not only found in hospitals, universities, and professional textbooks.

It can also be found in kitchens, gardens, workshops, homes, community gatherings, and in the hands of people teaching other people how to do something that matters.

Occupational therapy has a complicated history, and I am not interested in romanticizing that history or pretending that everything that came before modern healthcare was inherently better.

I am interested in asking what we might learn when we widen the story.

What knowledge was preserved?

What knowledge was lost?

Who was allowed to become an expert?

Who was excluded?

And what might we want to reclaim without simply recreating the past?

For me, that is where this conversation becomes exciting.

Maybe remembering our roots is not about going backward.

Maybe it gives us more possibilities for imagining what care could become.

🌿 The classroom session is available now inside the Evolved Living Collaborative, along with the book and audio resources and opportunities to keep exploring these questions together.

Last week I reacted live to a powerful post shared by Bill Wong in our community. The article in question — “Occupational Therapy and the ‘Seat at the Table’ Fallacy” by ABC Therapeutics — suggests that the push for higher credentials in OT (e.g., mandatory OTD) has been mis-directed:

“A degree doesn’t grant influence. Credentials open doors, but they don’t dictate what happens once you step through them … A ‘seat at the table’ means very little if the table itself was built by someone else.” ABC Therapeutics

It’s a critique worth hearing. But it’s also an invitation—not to retreat—but to re-vision how we approach our profession.

The core tension

The article argues:

* Many OTD programs replicate existing content under new credentials, without generating genuine contribution. ABC Therapeutics

* Visibility campaigns (hashtags, social media posts) risk being “toothless” when they lack scalable frameworks or evidence. ABC Therapeutics

* We have long sought a seat at others’ tables rather than designing our own tables.

You’ll hear echoes of that critique in my video: I reflected on how OT education, biomechanics-dominated models, and reimbursement systems have siloed us—and how that matters for people with disabilities, for social justice, and for innovation.

My take: Let’s build AND sit

1. Building our own tables

Yes—the article is right: credentials alone don’t guarantee influence. But I take that as a call to action. We need to:

* Design models where OT is not just invited, but indispensable (policy, systems, community, creative arts)

* Co-create the future with interdisciplinary, cross-cultural, and justice-oriented partners

* Use our degrees (OTD or otherwise) to contribute—not just credential-inflate

2. Recognizing the invisible tables people actually built

OT’s lineage includes folks who built their own tables: moral treatment movement, arts & crafts interventions, community-based rehabilitation, disability justice activism. In my video I referenced how we’re responding to human rights crises, climate, trans / disability access barriers—these aren’t “outside” OT—they’re core.

3. Expanding practice beyond the “biomechanical king of the castle”

The article critiques that OTD programs default to clever “hobbie” capstones (“OT in football”, hashtag activism) without rigor or depth. My sympathy to the students who poured their hearts and best work in to their first major OT project. Perhaps some encouragement and support for the potential of their future work is also in order. I can’t tell how much more difficult contributing to the advancement of one’s field without the support or encouragement or belief in possibilities from one’s elders also want to offer what depth and rigor can also look like:

* Confronting systems of oppression (transphobia in toileting access, disability justice, policy literacy)

* Measuring participation, identity, belonging—not just ROM, strength, task time

* Using community arts, folk craft, cross-generation dialogue as legitimate knowledge translation pathways

Why this matters—especially now

* People with disabilities face occupational deprivation, systemic barriers, and need OT thinking that goes beyond physical rehab.

* The U.S. health-human services system is stressed; OT’s value-add includes bridging discipline silos, addressing context, and enabling participation.

* New generations (Gen Z, Gen Alpha) bring fresh epistemologies. If we insist on “sit at the table”, we risk boxing their potential. My mantra: “Make room for the next table-builders.”

An invitation to you

If you resonate with any of these questions:

* How might OT design a new table rather than merely trying to sit at one?

* What kind of praxis (not just theory) can we commit to that spans social justice, policy literacy, community arts, and cross-cultural collaboration?

* Can we mentor and co-create with newer cohorts, rather than gate-keep?

Then join me. Let’s build Evolved Living OT/OS Collaborative as a space for these conversations and creations.

Reference

ABC Therapeutics. (2025, October 17). Occupational Therapy and the ‘Seat at the Table’ Fallacy. Retrieved from https://abctherapeutics.blogspot.com/2025/10/occupational-therapy-and-seat-and-table.html