Over 20 years ago Gary Kielhofner DrPH wrote in "Functional Assessment: Toward a Dialectical View of Person – Environment Relations" (The American Journal of Occupational Therapy, March 1993, Volume 47, Number 3):
"Functional Assessment or the determination of what a person is capable of, sits at the politically loaded juncture between the individual and surrounding institutions. Along with a range of other evaluative procedures such as certification exams, driver tests, literacy evaluations, and court judgements, functional assessment is often used to determine what freedoms a person will and will not have, what roles he or she may take on, what activities he or she may do, and what benefits or resources he or she will receive. Moreover, functional capacity increasingly has legal and moral connotations"...
Link to functional competence
Gary Kielhofner goes on to say "That functional competence is intimately linked to moral worth. Judgments of functional capacity rank alongside evaluations of moral integrity in forming social opinion about the worth of particular persons."
Ability to function tied to society
"The ability to function in one’s daily occupations carries this tremendous social, moral, and legal weight because it is tied in essential ways to society. Functional ability in occupations is linked to success and perpetuation of social and cultural ways of life."
"In this context, the problem of functional assessment is not merely a problem of accuracy or efficiency. The issue is embedded in the distribution of power and shaped by the visions with which we identify problems experienced by our clients, which are of concern to the human collective."
So what about the Case of Work Assessment?
"Conventional wisdom and professional ideology suggest that to work is positive both for the individual, who gains economic, psychological, and social resources by working, and for society, which prefers taxpayers to consumers of tax-supported social assistance. In an ideal world, the good of the individual and the good of the social group converge. Decisions may be made in the best interest of both. However, the convergence of individual and social needs is often unclear, and outright antagonism sometimes exists."
So what about the instances when there are problems in the workplace?
"If these problems are indeed present in the workplace is it not reasonable that some persons would wish to escape a particular workplace or work altogether? Moreover, when a person is disabled or injured, the functional assessment problem is to determine whether he or she should return to work. Embedded in this question is a deep moral issue that must center on several complex problems. Can the person do the work? Does the person want to work? Is the work environment a place in which any reasonable person would have incentive to work? Is the work good for this person?"
Are issues present?
"Issues of environment, workplace conditions and incentives (or disincentives) are largely ignored. Rather we commonly assume that the problem resides in the individual. In fact, the worker who does not wish to work, or whose behavior suggests disincentive to work, is socially identified as malingering."
Thoughts on the words by Dr. Kielhofner
As I ponder these words by Dr. Kielhofner, how are we as clinicians determining work ability or functional capacity? I bring up the case example of John Doe. What about John's fears and worries about recovery from his injury and his ability to return to his job?
Do we focus on the physical injury and ignore the rest after all it is a back injury! Or do we identify the underlying fears and worries that are impacting his rehabilitation?
Whose job is it to determine the barriers and move John forward in rehabilitation... John, or the clinician who is the "expert in enabling occupation"?