We cannot hang our hat on occupation alone.

The Guide to Occupational Therapy Practice by Moyers (AJOT, 53[3], 247–322) is an attempt to define the general scope of occupational therapy for practitioners, health care professionals, teachers, reimbursement organizations, and policymakers. The document, however, raises a major concern about what truly is our profession’s scope of practice. There is an overriding emphasis placed on occupations throughout the document that seriously limits our profession’s domain of concern, body of knowledge, and tools for practice. Though occupation is a cornerstone of our practice, there are many other aspects of our profession that were not clearly identified in the document. Narrowing the scope of practice to occupations alone may have a significant impact on the way in which outside audiences understand, interpret, and pay for our services. First, occupations is the label predominantly used to identify and describe many different concepts throughout the document. Outside of occupations, other key concepts such as performance areas, performance components, and therapeutic activities are not adequately identified or defined. In general, the conceptual level and the essential characteristics of each concept are not identified, which makes it difficult to distinguish between concepts. Additionally, concept labels are, at times, used interchangeably, making it difficult to determine the full meaning of each concept in different contexts. For example, occupations are defined as the everyday things that people do. Occupations are also identified as being a part of a performance area. And still, occupations are used synonymously with therapeutic activities, indicating their potential use as a tool of practice. By not clearly identifying and defining key concepts critical to occupational therapy, the document sends the message that the scope of practice is limited primarily to occupations. “Occupations,” in the areas of activities of daily living, work, and leisure, are emphasized as the profession’s domain of concern. The document does not adequately identify or define performance areas or performance components (American Occuaptional Therapy Association [AOTA], 1994) as areas of human experience with which occupational therapists have expertise and offer assistance. By narrowing the profession’s domain of concern to occupations alone, the profession runs the risk of losing key areas of expertise in practice and gives other professions the opportunity to take on traditional areas of our domain of concern as their own. In addition, the document does not clearly describe the process of problem identification. According to the document, the primary mode of evaluation is that of a person’s occupations and occupational performance through interview and observation. There is little mention of the way in which an occupational therapist assesses abilities in one of the performance areas (AOTA, 1994) or the way in which an occupational therapist assesses the performance components (AOTA, 1994) or environmental influences that may affect a person’s performance. The document merely states that an occupational therapist develops “hypotheses” (p. 265) about the person’s performance in any of these areas. It is not clear from the document how an occupational therapist develops these hypotheses. By not clearly identifying ways in which an occupational therapist assesses a person’s abilities and limitations, and by focusing primarily on occupations in the problem identification phase of treatment, specialized areas of evaluation seem to be nonexistent. In turn, outside audiences, such as reimbursement organizations, may not recognize our skills in assessing areas other than occupations and, thus, may stop reimbursement for such services. According to the document, the practice of occupational therapy is based on nine principles of occupations. There is no mention of the frames of reference that have been developed and are used by occupational therapists to identify and remediate problems. Many of our frames of reference are based not on the principles of occupation, but on biological and behavioral sciences such as neurology, physiology, psychology, and sociology (Levy, 1993b). For example, an occupational therapist working with a person with a physical illness or injury may use a biomechanical frame of reference (Dutton, 1993a), which is based on the principles of increasing joint range of motion, strength, and endurance, to assist in problem identification and remediation. Additionally, an occupational therapist working with children may use the sensory integration (Simon, 1993) or neurodevelopmental (Dutton, 1993b) frames of reference, which focus on underlying neurological and sensorimotor issues. Further, an occupational therapist working with a peson with a mental illness may use a behavioral frame of reference (Levy, 1993a), which focuses on learning new, or adaptive, behaviors that promote independence for the person. By not mentioning the frames of reference used in occupational therapy, key areas of our expertise are eliminated. As a result, outside audiences, such as our referral mechanisms, may not recognize interventions that are based on frames of reference, other than the nine principles of occupations, as being part of our repertoire and may begin referring traditional occupational therapy clients elsewhere. Finally, the document seriously narrows the scope of practice by limiting the tools of practice to the use of occupations. Outside of the use of occupations, there is little or no mention of tools of practice, such as therapeutic use of self, activity groups, assistive technology, and physical agents, all of which are a part of occupational therapy (Mosey, 1996). By limiting the tools of practice to the use of occupations, the value and use of other tools may be lost. Additionally, outside audiences may have difficulty viewing the use of such tools as a part of our practice. The Guide to Occupational Therapy Practice is an attempt to define the general scope of occupational therapy. The document has instead limited the scope of practice to occupations as the area of human experience addressed by occupational therapists, as the set of principles that guide the practice of occupational therapy, and as the tool used in the pracLetters to the Editor