How Top-Down Are We? Reconsidering the Gap Between Occupational Therapy's Identity and Practice

Abstract

Occupational therapy has spent more than a century defining occupation as its professional core. Yet studies across countries and settings show a recurring gap. Therapists value occupation-centered practice while often relying on impairment-focused assessment and intervention. This article argues that the profession may face a translation problem more than an identity problem. Biomedical service structures, standardized measurement, workplace culture, and professional socialization can pull reasoning toward body functions. Bottom-up methods are not inherently incompatible with occupational therapy; the problem arises when change in a component is treated as sufficient evidence of occupational success. Drawing on occupational therapy research, the International Classification of Functioning, Disability and Health, rehabilitation science, and disability rights, we argue that occupation and participation should remain the outcomes that organize assessment, intervention, and evaluation. Practical changes are proposed for clinical reasoning, outcome measurement, education, supervision, and service design.