© 2004 Pamalyn Kearney
RETURN
edited 1/15/05
Abstract
Occupational therapists have historically worked with patients within the medical system to not only assist in the recovery from illness and injury but also to facilitate the development of or return to meaningful roles and activities that have been disrupted due to chronic illness or disability. This attention to the lived experience of patients who cannot be "cured" has often resulted in a tension between the perspective of the occupational therapist and other members of the medical team. This tension can be traced to two competing paradigms in the history of occupational therapy; that of the moral treatment model and the medical model. The purpose of this paper is to trace the influence of these competing paradigms on the development of occupational therapy education during the twentieth century.
Introduction
The profession of occupational therapy concerns itself with the ability of people to fully engage in the activities necessary for participation in meaningful roles such as that of family member, community member, citizen, worker, student, and leisure participant. In this capacity, the occupational therapist works with individuals and groups who have limitations in participation due to physical, psychological, cognitive or social barriers to help identify strategies to enhance engagement in desired activities. The occupational therapist uses a wide variety of strategies, in collaboration with the client, to accomplish this. These strategies might include adaptive equipment, environmental modifications, cognitive retraining, client and family education, strengthening, social skills training, community education, and many others.
Although historians trace the roots of this profession back to the moral treatment movement in psychiatry during the nineteenth century, it is believed that the term "occupational therapy" was first coined by Mr. George Barton around 1910 (Definitions, 1940). Mr. Barton was an architect, who became interested in the use of occupation to restore health as a result of his personal experiences with tuberculosis, a left foot amputation, and a left hysterical paralysis (Reed & Sanderson, 1992b). Mr. Barton went on to found Consolation House, a school, workshop and vocational bureau for the disabled. It was at Consolation House that leaders of occupational therapy met in March of 1917 in what was the first effort in the United States (U.S.) to organize persons interested in the concepts of occupation and health. This meeting lead to the formation of the National Society for the Promotion of Occupational Therapy (Leaders, 1917; Reed & Sanderson, 1992b), later renamed the American Occupational Therapy Association (AOTA) (Reed & Sanderson, 1992a).
Prior to the formation of the National Society for the Promotion of Occupational Therapy, there were a few courses related to the use of occupations with the mentally ill at various sites in the U.S. The education of occupational therapists has changed greatly since this time. Today there are 158 programs in the U.S. offering entry level programs in occupational therapy with a mandatory progression to an entry level master degree by 2007 (AOTA, 2004). The purpose of this paper is to trace the evolution of occupational therapy education in the U.S. and the impact of two conflicting paradigms, that of moral treatment and the medical model, on its development.
Conflicting Paradigms
Moral Treatment
In order to consider the influence of moral treatment and the medical model on occupational therapy education, it is necessary to first define these concepts. Moral treatment as a method to respect and enhance the lives of individuals with mental illness was developed in modern history as a result of the work of Philippe Pinel in the late eighteenth and early nineteenth century in France and spread to England within a few years (Brigham, 1847). This concept was quickly adopted in American asylums (Whiteley, 2004). Practitioners who worked within the moral treatment paradigm believed that persons who were "mentally deranged" could best recover through engagement in typical daily routines that included activities such as crafts, gardening and games (Bockoven, 1971; Brigham, 1847) and that these treatments were of greater value than biomedical interventions (Brigham, 1847). There was a recognition and respect of human individuality and rights for the mentally ill as well as an acknowledgment of a basic human need to be engaged in creative and recreational activity as a member of a community (Bockoven, 1971; Whiteley, 2004). The value of engagement was also recognized for persons recovering from illness in hospitals during the nineteenth century (History, 1940). This philosophy, emerging from humanitarian trends of the 18th and 19th centuries, resulted in the creation of physical, temporal and social environments for the mentally ill with the goal of reeducation to correct attitudes and habits of living (Gillette & Kielhofner, 1979). In the decades following the end of the U.S. Civil War, moral treatment fell out of favor in the U.S. for a variety of reasons. First, there was a significant expansion of hospitals to treat the mentally ill and they became both overlarge and overcrowded. Second, there was a high degree of prejudice toward ethnic immigrants who made up a disproportionate percentage of patients in asylums. Third, there was a shift in understanding of the cause of mental illness from the belief that mental illness was due to moral-emotional factors to a perspective that mental illness was the result of abnormalities at the cellular level of the brain. With this changing understanding came the medical conviction that there was no cure for mental illness (Bockoven, 1971; Goldman, 1994). The shift toward a more Darwinian philosophy regarding mental illness combined with this increasingly pessimistic view of treatment to end the moral treatment approach to care by the late nineteenth century (Gillette & Kielhofner, 1979; Goldman, 1994).
Medical Model
At the same time that the moral treatment philosophy was fading into obsolescence in the U.S., the medical model was beginning to evolve. The medical model paradigm is based upon the perspective that the human body is like a machine that can be best understood and healed through greater understanding of the individual components of the system. This medical model developed as a result of a combination of factors including the industrialization of society, the move of medical education from an apprenticeship model to the research based university, and the resulting increase in understanding and use of research techniques to understand human processes and the impact of various interventions. The linkage of research to medical education began in the U.S. in the 1870s when Harvard, the University of Pennsylvania and the University of Michigan extended medical education to three years and added scientific and research courses to the curriculum. When the Johns Hopkins Medical School opened in 1893, with research as much of its mission as medical education, it became the model for medical education in the U.S. (Ludmerer, 1999a). In 1910 a report critical of the lack of scientific knowledge in medical education titled Medical Education in the United States and Canada and commonly known as the Flexner report was published, resulting in a definitive move toward scientifically based medical education with a commitment to research (Ludmerer, 1999a). As medicine and research developed in the twentieth century, this model became increasingly reductionistic and more entrenched in modern health care practices. This reductionistic approach to medicine lead to a focus on human functioning at the tissue and cellular level with little appreciation for the environmental, social or emotional contributions to health (Ludmerer, 1999b). The recognition in the latter third of the twentieth century that the medical model was not meeting the needs of significant groups of the population, particularly the chronically ill and/or disabled, has lead some in medicine to reexamine the influence of a wide variety of factors on health and to adopt a more holistic approach to care (World Health Organization, 2001). The medical model as a reductionistic paradigm is the perspective that will be utilized through the remainder of this paper.
Education in Occupational Therapy
Pre-standards Education
The idea of occupation as a curative and restorative medium reappeared with the reemergence of tenets of moral treatment in the early twentieth century (Gillette & Kielhofner, 1979). This coincided with a move toward "Americanization" of immigrants and of providing persons who were disabled with training in skills for social and industrial use (McDaniel, 1968). As early as 1906 there were courses for nurses, social workers and hospital attendants on the use of occupation for restoration. Susan Tracey, a nurse, wrote Studies in Invalid Occupations in 1910, leading to increased use of, and education in, occupations as a medical treatment (History, 1940). By 1916, anticipating U.S. involvement in World War I and aware of the use of occupation in the treatment of European soldiers, four institutions in the U.S. were teaching short, intensive courses in the use of occupation. A fifth institution would soon follow (History, 1940). At this time there were no standards for education in this area. In the spring of 1917 a group of physicians including the U.S. Surgeon General, neuropsychiatrists and orthopedic surgeons visited Europe and Canada to study their reconstruction programs for injured soldiers. When the U.S. entered World War I, occupational therapy became part of the U.S. military reconstruction program (McDaniel, 1968).
U.S. Army Standards
While the military had standards early on for who could function as a reconstruction aide (as the early occupational therapists were called), there were no standards for training or education until early in 1918 when the Surgeon General's office proposed specific standards to guide the war emergency courses and to separate training in occupational therapy from that of nursing. The initial standards called for a ten week, 385 hour course with 310 hours of training in handcrafts such as weaving, wood carving, basketry and leatherworking. The remaining seventy-five hours were to be spent learning about teaching invalids, understanding hospital routines and practice work (McDaniel, 1968). The influence of moral treatment concepts of the value of engagement in leisure and recreational crafts is clear. The need for reconstruction aides to have some medical knowledge was quickly identified and by September, 1918, the Surgeon General's office had revised the course outline to a 12-16 week course. This revised course included a total of 264 hours training in a variety of specified crafts, sixty four hours of lecture on topics such as methods of teaching, psychology, special problems of the handicapped, disorders of the central nervous system, and kinesiology, and an additional 24 hours of hospital practice (McDaniel, 1968). Although some medical foundation was included, the emphasis clearly remains on the occupations that would be utilized with injured soldiers. During this time there were also civilian courses that were not associated with the war emergency courses however these courses were unregulated and not well documented (McDaniel, 1968).
AOTA Initial Standards
AOTA approved the first educational standards for non-emergency war courses in 1923 (Kidner, 1923; Kramer, Seitz & Dickson, 2003; Reed & Sanderson, 1992a). At this time the minimum length of a course was twelve months with at least three months of hospital training (Reed & Sanderson, 1992a). The concern regarding the quality of education of future occupational therapists is evident in the AOTA Presidential Addresses during the early to mid 1920s. In 1924, President Kidner calls for the profession to limit entry to graduates of "regular training schools" or hospital programs with "real theoretical training" that accept graduates of arts and crafts schools. Kidner continues this theme in 1925 when he cautions against "so called training courses for occupational therapists in which two or three crafts are taught, but the indispensable theoretical work and medical lectures are conspicuous in their absence" (p. 410). Kidner goes on to recommend that training schools in occupational therapy be affiliated with centers of medical training rather than educational institutions such as normal schools and liberal arts colleges (Kidner, 1925). At this point it seems that occupational therapists were concerned that the education of therapists provide them with a balance of knowledge including the activity base of treatment that has emerged from moral treatment as well as the knowledge of the body from a biomedical perspective that the medical model is developing. By the end of the 1920s many occupational therapy schools had affiliated with a college or university (Woodside, 1971). Medical schools had made a similar move by the early 1920s with the closure of all proprietary, for profit medical training programs and the move to university based medical education (Ludmerer, 1999a).
AOTA tightened it's regulation of the education of occupational therapists by establishing a national registry of qualified occupational therapists in 1926, after several years of development (History, 1940; Kidner, 1929; Reed & Sanderson, 1992a). While accommodations were made for inclusion of therapists who were already in practice, the registry was limited to graduates of training schools that met AOTA's minimum educational standards (Kidner, 1929). The first registry was published in 1932 with 318 occupational therapists (Reed & Sanderson, 1992a).
AOTA approached the American Medical Association (AMA) in 1931 to request that their Council on Medical Education and Hospitals (CMEH) assume responsibility for the accreditation of occupational therapy educational programs, becoming the first organization to initiate this type of collaboration with the AMA (Reed & Sanderson, 1992a). It is difficult to determine the rationale for this decision based upon the written record. AOTA may have felt that, as a professional organization, it was unable to manage the accreditation process independently. At this time, AOTA had a small membership and may have lacked both people who could manage the accreditation process as well as the necessary financial resources. This affiliation may also have been due to the level of physician leadership in both the original founding of AOTA and the continued growth and development of the organization. Four of the first seven presidents of AOTA were physicians with their presidencies spanning fifteen of the first twenty-two years that AOTA was in existence (AOTA, 1967). Colman (1992) reports that the decision to request AMA involvement in occupational therapy program accreditation was to eliminate the possibility or appearance of bias that existed if AOTA was the accrediting body. In 1933 the AMA approved this request and began inspections (Kramer, Seitz & Dickson, 2003; Reed & Sanderson, 1992a). One AOTA publication states " ... the powerful American Medical Association came to the rescue ... " (p. 11, 1967), possibly indicating a strong desire on the part of the organization to ally itself with medicine to enhance its own standing. Revised "Essentials of an Acceptable School of Occupational Therapy" were developed as a result of these early inspections and adopted by CMEH/AMA in 1935 (Reed & Sanderson, 1992a). Occupational therapy education thus became closely linked with medicine, and the medical model of education. This relationship continued until 1994 (Kramer, Seitz & Dickson, 2003).
1935 Essentials
The Essentials of an Acceptable School of Occupational Therapy were published in the Journal of the American Medical Association in 1936. From a curriculum perspective, the Essentials required a minimum of one hundred weeks of full time training and were prescriptive in describing how this training should be structured. Programs were to provide no fewer than sixty-four weeks of technical work. Of this, at least thirty semester hours were to consist of didactic training in the biological sciences (fifteen semester hours minimum), social sciences (four semester hours minimum), occupational therapy theory (four semester hours minimum), clinical conditions (four semester hours minimum), and electives (three semester hours minimum). No fewer than twenty-five semester hours were to address activity training with the following specified: design, textiles, wood, metal, leather, plastic arts, recreation and miscellaneous. Clinical training was also specified to require no fewer than thirty-six weeks of hospital based practice in all of the following areas: mental hospitals, tuberculosis hospitals and sanatoriums, general hospitals, children's hospital or services, and orthopedic hospital or services. This curriculum seems to balance the science based curriculum one might expect of the medical model with the activity based courses that might be expected of the moral treatment model. Additionally, tenets of Dewey's progressive education model appear to be present in the heavy reliance on experiential training. It should be noted that the curriculum is much more substantial in both content and length than the early war courses were, possibly reflecting the alliance with medical education and/or the expanding body of knowledge in medicine.
1943 Essentials
The Essentials were revised in 1943 to reflect changes in expectations for technical training. At this time, technical training was revised to encompass not less than thirty semester hours of instruction in therapeutic activities. The Essentials allowed for flexibility in the emphasis of this training permitting an emphasis of one of the specified areas as long as survey courses in the other two were offered. The specified areas of technical training were: fine and applied arts including design, leather, metal, plastics, textiles and wood; special and adult education in home economics and library science; and recreation including music, drama, social activities, gardening and physical education (Essentials, 1943). In spite of the increase in the occupation based component of the curriculum, this revision appears to leave the balance between the medical model and the moral treatment influences roughly equal.
Preparation for World War II brought some relaxation of the interpretation of the Essentials in regards to the war emergency courses that the U.S. Army instituted once again, just as they had for World War I. AOTA actively negotiated with the U.S. Army during the planning of these courses to ensure that they met the content requirements of the Essentials, if not the time expectations. In exchange for increased Army status of occupational therapists to a professional rank, subsidized tuition and stipends for students in the war emergency courses, AOTA agreed to make graduates of these courses eligible for full registry (Colman, 1990). The World War II war emergency courses were only in place for two years and, thus, will not be examined further within the context of this paper. It should be noted, however, that a similar process occurred within medical education as part of the war effort. At Johns Hopkins the undergraduate curriculum was reduced to two years, the length of medical education was reduced as well as the duration and number of internships and length of residency (Ludmerer, 1999).
The impact of wartime needs on medicine had a significant impact on medical research and the medical model of care. World War II brought an increased valuation of medical research by the government for its impact on understanding the physiological impact of terrains such as desert and higher elevations on soldiers as well as the ability to treat diseases and injuries associated with wartime. The Committee on Medical Research was combined with the National Defense Research Committee to form the Office of Scientific Research and Development (Ludmerer, 1999). The increasing amounts of monies that the federal government provided to universities for scientific and technical research (Lucas, 1994) was also reflected in grants for medical research. The success of medical research during the war lead both the medical professions and the American public to continue to ignore the behavioral, environmental and social roots of illness and disability and to see medical research as the panacea to solve the challenges that both acute and chronic diseases and disabilities presented to society (Ludmerer, 1999).
The medical specialty of physical medicine and rehabilitation became a powerful force within rehabilitation by the end of World War II. Although the majority of occupational therapists practiced in mental health environments during the 1930s, World War II saw increasing numbers of therapists in rehabilitation settings. Physical medicine and rehabilitation, as a specialty, was trying to define its role within the AMA at this time and saw gaining control of occupational therapy education as well as occupational therapy departments as contributing to this process. From 1943 until 1952, leaders in physical medicine sought to gain control of occupational therapy education and to define occupational therapy as a specialty area under physical therapy. They attempted to accomplish their goals through the AMA, through AOTA and through approaching universities directly to have occupational therapy programs placed under the auspices of physical medicine. This resulted in much discussion as well as conflict within the AMA and within the profession of occupational therapy as to the professional versus technician status of occupational therapy, issues of specialization, autonomy and the relationship between AOTA and AMA. In the end, the relationship between AMA, CMEH, and AOTA did not change (Colman, 1992). The 1949 revision of the Essentials did, however, reflect this struggle. The Council on Physical Medicine and Rehabilitation was listed as one of the organizations concerned with occupational therapy education and a requirement was added that occupational therapy schools could only be located in medical schools with CMEH approval or colleges or universities with appropriate regional accreditation (Essentials, 1950).
1949 Essentials
The 1949 revision of the Essentials reflected the changes in medicine and the medical professions with changes to the curriculum requirements. The minimum number of semester hours in theoretical education was increased from thirty to thirty-nine and reflected the increasing scientific basis and the specialization that was emerging in medicine. The requirements for study of the biological sciences were increased from fifteen to eighteen semester hours. Study in clinical subjects increased from four semester hours to seven. Additionally, the specified subjects were changed to reflect previous as well as emerging medical specialties: general medicine and surgical, neurology, orthopedics, pediatrics, psychiatry and tuberculosis. To offset these increased semester hour requirements, the total time required for technical training in activities was decreased from thirty semester hours to twenty-five although the content requirements remained the same as they had been with the 1943 revision. The clinical training requirements were changed in regards to both areas of experience as well as expectations for duration of time spent in each setting. Students were required to complete at least twelve weeks of clinical training in psychiatry (increased from two months), at least eight weeks in physical disabilities (previously at least one month in orthopedics), four to eight weeks in tuberculosis (previous essentials mandated at least one month), four to eight weeks in pediatrics (previous mandate was at least one month), and four to eight weeks in general medicine and surgery (previously at least one month in general hospital) (Essentials, 1950). While the total length of time required for clinical training did not change with the 1949 Essentials, the categories of specialty areas did reflect changes occurring in medicine. The impact of medical specialization on the occupational therapy curriculum as well as the decreased requirements in training in activities reflected the growing strength of the medical model on occupational therapy education. This model would continue to strongly influence both occupational therapy education and practice for the next two decades.
During the 1950s and into the 1960s the profession of occupational therapy adopted the reductionistic paradigm of medicine and occupational therapists increasingly found themselves working in more specialized settings (Gillette & Kielhofner, 1979; West, 1965). This lead to tension between two groups of occupational therapists - those who felt occupational therapy education should be generalized and those who felt occupational therapy education should reflect the specialization present in practice. Welles (1958) observed that specialization existed in many professions including medicine, law and engineering because there was too much knowledge for anyone to be competent in even one aspect of it. She advocated for the development of education programs in areas of specialty. A few years later Moore (1963) criticized the profession for being unable to speak the language of medicine when trying to communicate with physicians because of training that is half science and half arts and crafts. She admonished the profession that it had not met the standards of medicine and would not until science based education was strengthened, even if it came at the cost of the loss of craft training. This growing movement toward specialization resulted in students who were ill prepared for specialized practice and therapists who were competent in their specific area of practice but who were also ill prepared to provide services in other areas of occupational therapy practice (Gillette & Kielhofner, 1979). Against this backdrop, the Essentials were once again revised.
1965 Essentials
The 1965 revision of the Essentials followed a curriculum study completed in the early 1960s. In an editorial published in the American Journal of Occupational Therapy in 1965, Gillette summarized the key recommendations of the curriculum study. First was a belief that occupational therapy practice can be described from the perspective of physical or psychosocial dysfunction. Second was a recommendation for increased emphasis of the behavioral sciences in the curriculum so that the time spent on them is more equal to if not greater that the time devoted to the biologic sciences. The third recommendation was for increased emphasis on clinical teaching concurrent with coursework. The final major recommendation was to de-emphasize traditional arts and crafts in the curriculum with an increased emphasis on methods to acquire the skills needed. The 1965 Essentials did reflect many of these recommendations. Key characteristics of these Essentials, relevant to this paper, include the first specification in the Essentials that a liberal education that includes a broad base in natural sciences, behavioral sciences and humanities is the strongest foundation for occupational therapy education. Additionally, these Essentials specified that the curriculum should serve to strengthen communication and understanding of both administrative principles and scientific methodology. Specific requirements outlined in this document included nine semester credits in biological sciences (down from eighteen in 1949), nine credits in behavioral sciences (up from four credits in social sciences in 1949), six credits in physical and psychosocial dysfunctions (down from seven credits in clinical subjects) and twelve credits in occupational therapy evaluation and treatment principles (an increase from eight semester house in occupational therapy theory). This category was further specified to include evaluation and treatment of the problems related to psychosocial dysfunction and those of physical dysfunction, appearing to follow the recommendations outlined by Gillette (1965). The new Essentials (1965) also called for nine credits in occupational therapy skills, which encompassed creative and manual skills, vocational and avocational activities, daily living skills and teaching methods. This was a significant decrease from the previously required twenty-five semester hours in technical training. Another significant change in the 1965 Essentials was a decrease in clinical experience expectations from thirty-six to twenty-four weeks with a specified period of three months each in a psychosocial setting and a physical dysfunction setting. In this arena, it appears that CMEH/AMA and AOTA did not follow the recommendations of the curriculum study. From a moral treatment and medical model perspective, these changes reflect the move in occupational therapy toward a more scientific based, specialized practice that used modalities that fit more easily into the medical model than the meaningful occupations described in the moral treatment model.
The trend toward specialized practice continued through the 1960s although leaders and educators in the profession began to question the direction that reductionism and the scientific medical paradigm was taking the profession (Schwartz, 2003). There was a heightened concern about the professional status of the profession. In 1970, Zamir called for a renewed focus on professionalization of the field and on finding the role of occupational therapy curriculum in higher education. Many felt that the profession had lost sight of the value and meaning of occupation, the concept that had lead to the creation of the profession, and that this had lead to role confusion and loss of identity for occupational therapists. Additionally, there was a growing realization in occupational therapy, medicine and society that reductionism was unable to solve all of society's medical problems (Gillette & Kielhofner, 1979; Ludmerer, 1999). This was particularly true of the issues faced by persons with chronic disease and disability where the problems were rooted in the environment and societal values and beliefs more so than in the component parts of the individual (Gillette & Kielhofner, 1979). Certain groups within the profession were beginning to believe that specialized practice and the medical model left the profession too dependent upon medicine for the development of the concepts to support occupational therapy practice with little to no attention being paid to the concepts of occupation and social adaptation (Gillette & Kielhofner, 1979).
1973 Essentials
Two actions occurred against this backdrop that have particular significance for this paper. In June, 1973, the CMEH/AMA approved revised Essentials (Essentials, 1975). This version of the Essentials drastically departed from previous ones in that there were no specified hours required for any area of coursework. Curriculums in occupational therapy were to be based upon a curriculum design developed by the individual program and were to include the following areas: basic human sciences, human development process, specific life tasks and activities, health-illness-health continuum and occupational therapy theory and practice. The continued influence of science and the medical model can be seen in the areas of human sciences, development and health-illness-health continuum. It is interesting to note that the human development process content was to include attention to the meaning of activity in relationship to competency and the development of an individual's potential. Within the area of life tasks and activities were expectations that students would be able to perform selected tasks and activities as well as be able to analyze activities that their patients may wish to engage in. In these sections one can see what may have been the influence of those members of the profession who were concerned that the profession was losing sight of its roots in occupation and engagement.
The second significant event was the formation in 1973 of the Task Force on Target Populations. AOTA's Delegate Assembly charged the Task Force with identification of the client populations that would benefit from occupational therapy intervention and to then rank these populations in order of priority. The plan was for this ranked order to then be used to influence association legislative actions and to develop program activities consistent with the priorities. The Task Force did not meet the charge it was assigned. In their report to AOTA, the Task Force wrote that although they perceived that the attachment to diagnostic categories may be an attempt by the Delegate Assembly to attempt to affiliate with stronger medical specialties to increase status and respectability, the Task Force believed that for occupational therapy to survive the profession needed the emphasis to be on the common core of practice, not specific diagnostic considerations. It was felt that the current trend toward specialization of entry level practice encouraged increased fragmentation of practice, moved the profession away from the goals of occupation and occupational behavior, resulted in more remedial treatment and increased competition with other professions including physical therapy, psychology and rehabilitation nursing. Therefore, the Task Force called for the educational process to return to a more generalized perspective, covering the common core of occupational therapy knowledge such as the meaning of occupation, the meaning of action in humans, the influence of the environment on occupation, assessment, and occupational therapy theory and intervention based upon occupational behavior (Johnson, et al., 1974). This report was one of several factors that helped to pave the way for an increased emphasis on the occupation base of the profession, on research and on theory development that had begun in the 1960s with the move toward more professionalism and continues to the present.
1983 Essentials
When the Essentials were updated in 1983 they included, for the first time, a definition of occupational therapy. The curriculum was required to be of sufficient length to meet the requirements of both the profession and the institution's requirements for the degree being granted. The 1983 Essentials added research and professional development (ethics, standards of care, continued learning of professionals and promotion of the profession) to the areas that were required within an occupational therapy curriculum. Clinical training expectations were divided between Level I and Level II fieldwork. Level I fieldwork was intended to be completed concurrently with coursework, providing the student with exposure to the concepts being taught in the classroom. It seems the Essentials finally achieved this recommendation from the curriculum study described previously (Gillette, 1965). Level II fieldwork was not changed from prior clinical training guidelines. While the addition of research may have been influenced by the medical model paradigm, it is my belief that the addition of both the research and the professional development requirements were an indication of the growing move to clearly define occupational therapy as a profession that is of value and worth to society.
Two other changes occurred with the 1983 Essentials that, while not pertaining directly to the curriculum, are worth noting. First, it was the AMA's Committee on Allied Health Education and Accreditation (CAHEA) that was the accrediting body at this time. Second, the 1983 Essentials did not require that the program director for an occupational therapy program be an occupational therapist. This action angered many educators and may have served as a seed of discontent that would ultimately result in a break from CAHEA a decade later (P. Kramer, personal communication, December 16, 2004).
1991 Essentials
The 1991 Essentials were the last Essentials to be approved by CAHEA and the AMA, although that was not the expectation at the time (P. Kramer, personal communication, December 16, 2004). The curricular requirements in these Essentials differed little from 1983. The definition of occupational therapy was expanded and management of occupational therapy services was added as a content area. Of note, the requirement that the program director be occupational therapists was reinstated. This was a time of growing unrest with the reliance of the profession on physicians and a belief, at least by the program directors, that as a profession occupational therapy should be doing its own monitoring and accrediting of educational programs (P. Kramer, personal communication, December 16, 2004). This did occur in 1994 when the AOTA Accreditation Committee changed its name to the AOTA Accreditation Council for Occupational Therapy Education (ACOTE) and was recognized by the U.S. Department of Education and the Commission on Recognition of Postsecondary Accreditation as an independent accrediting agency for professional programs in occupational therapy (AOTA, n.d.). At this time the Essentials were revised to reflect the change in accrediting body however no changes were made to the specified curricular requirements (Essentials, 1995). The events of this time period seem to indicate a continued move toward a professionalism paradigm and a deliberate distancing from the medical model. The 1991 Essentials, with the 1995 revisions, were the last Essentials to define occupational therapy education in the twentieth century.
Conclusion
This paper has traced the development of occupational therapy education from the inception of the profession through the close of the twentieth century with particular attention to the impact of two competing paradigms, the medical model and the moral treatment model. At the start of the twenty-first century, I believe that education continues to be shaped by these paradigms. While the profession continues to recognize its role in medical environments, there is a purposeful movement to educate therapists who practice from an occupation based perspective focused on those roles and activities that individual clients or groups find meaningful. There is also a growing movement within the profession as well as within medicine to recognize the role of the environment on health and wellness, as reflected in the World Health Organization's International Classification of Functioning, Disability and Health (2001). It may well be that the medical model paradigm is undergoing a paradigm shift of its own. The professionalism paradigm that began in the 1960s and 1970s continues to influence the development of the profession, particularly in the area of research and theory development. The influence of evidence based practice, which evolved from evidence based medicine, is another growing influence on occupational therapy practice in the twenty-first century. It is my belief that all four of these paradigms will continue to influence the profession of occupational therapy and the education of occupational therapists, to varying degrees, into the twenty-first century.
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