The Fight That Never Ended: OT's First Identity Crisis (1920–1939)

Episode Description

Have you ever sat through a faculty meeting, a conference presentation, or a social media debate about whether OT is too medical or not medical enough — and wondered why the profession is still having this conversation?

The answer is in this episode.

The years between 1920 and 1939 were the first time occupational therapy looked in the mirror and asked what it actually was. The profession was barely three years old when the forces pulling it apart became impossible to ignore. Medicine was growing more scientific, hospitals more structured, rehabilitation more measurable — and OT found itself caught between the values that created it and the system it was trying to join. Meaning, purpose, identity, creativity, and participation on one side. Measurement, standardization, efficiency, and medical legitimacy on the other.

Both sides were right. At the same time. And that is exactly what made it so hard.

This is Part 3 of Occupation Under Pressure, and it covers the two decades that gave the profession its first formal organizational structure, its first educational standards, and its first open internal division. In 1921 the National Society for the Promotion of Occupational Therapy became AOTA. In 1935 AOTA partnered with the American Medical Association to establish educational standards — a move that brought credibility and recognition and immediately raised new questions about how much medicine should shape a profession built on something medicine had historically struggled to measure.

Out of that tension came two identifiable camps. The Diversionists, who believed crafts and meaningful occupation were therapeutic in themselves — restorative of identity, purpose, and agency. And the Therapists, who argued occupation was primarily a vehicle for improving measurable function, strength, endurance, and performance. The profession was not divided over whether occupation mattered. It was divided over why it mattered. And that distinction, Michelle argues, is the fault line that every subsequent OT debate has been running along ever since.

The episode also places this identity crisis inside its full historical context — the height of the American eugenics movement, the beginning of the Tuskegee Syphilis Study, segregation embedded throughout healthcare and education, and the forced closure of OT's first school for training African American practitioners. While occupational therapy was fighting to define itself, it was doing so inside a society actively debating whose lives were worth valuing. That context matters for understanding both what the profession was up against and what it was fighting for.

The Hard Take challenges the framing of the entire debate. Michelle's argument is not that OT should choose between science and meaning, between the medical model and the social model, between function and participation. Her argument is that the false choice itself is the problem — and that OT was never designed to pick a side. It was designed to bridge. The profession's future, she contends, depends on becoming more rigorous and more scientifically precise while refusing to trade away the thing that made it irreplaceable in the first place: the capacity to see a person's whole life and help put it back together.

The weekly challenge asks you to find one place in your practice where you have accepted a false choice — and build a bridge instead.

In This Episode

• How occupational therapy transformed organizationally between 1920 and 1939 — from NSPOT to AOTA, from emerging practice to national profession
• The 1935 AOTA-AMA partnership: what it gave OT and what it cost
• The emergence of the Divertionist versus Therapist divide — and why the debate was never really about crafts
• Why the question was never which side was right but how to bring both sides together
• The eugenics movement at its American peak — Carrie Buck, forced sterilization, and the broader context of whose lives were considered worth supporting
• The Tuskegee Syphilis Study, segregation in healthcare, and the closure of OT's first school for African American practitioners
• The Hard Take: OT's greatest threat was never medicine or measurement — it was uncertainty about its own identity
• Why Michelle does not think OT was ever supposed to be anti-medical — and what the founders were actually trying to build
• The false choice that has followed OT for a century: medical model or social model, function or meaning, science or occupation
• Why the future of OT depends on refusing to separate rigor and humanity
• OT's mental health scope of practice reality: recognized in every state, formally credentialed in almost none
• The precision rehabilitation argument: why OT should be leading those conversations, not running from them

Key Figures and Organizations

Eleanor Clarke Slagle, American Occupational Therapy Association (formerly NSPOT), American Medical Association

Key Events and Concepts

1921 — NSPOT becomes AOTA 1932 — Tuskegee Syphilis Study begins 1935 — AOTA-AMA educational standards partnership The Divertionist versus Therapist divide The American eugenics movement at its peak Buck v. Bell and forced sterilization Segregation in OT education

Your Challenge This Week

Find one place in your practice where you have accepted a false choice. One intervention, one patient, one session. Build a bridge. Use a meaningful occupation and measure it. Address mental health while targeting function. Combine participation with objective outcomes. Combine meaning with measurement. Then ask yourself: what happened when I stopped choosing and started integrating? Document it. Reflect on it. Because that is exactly what OT was trying to figure out in the 1920s and 1930s — and the answer still matters today.

Series Context

This is Part 3 of Occupation Under Pressure, an eight-part series on the real sociopolitical history of occupational therapy.

Part 1 covered 1790–1899: the philosophical roots of occupation before the profession existed. Part 2 covered 1900–1919: the forces and founding moment that made OT a formal profession. This episode covers 1920–1939: the first identity crisis — and the debates that never really ended.

Next episode: the world hands OT another defining challenge. War returns. And the question is no longer what kind of profession OT wants to be — it is whether the profession can prove its value fast enough to survive what is coming.

The wheel of change moves slowly. It always has. But it only moves because someone is willing to push it.

Connect and Continue the Conversation

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