How to Become an OT: Navigating Your Path to Occupational Therapy

Picture this: a seventy-year-old stroke survivor learning to button their shirt again, their face lighting up with triumph as trembling fingers finally succeed. Or a child with autism discovering they can actually tolerate the texture of Play-Doh after months of sensory work. These moments—small miracles wrapped in everyday activities—form the beating heart of occupational therapy. If you've ever felt that peculiar pull toward helping people reclaim their independence through the mundane magic of daily living, you might be wondering about the winding road that leads to those letters after your name: OTR/L.

The Reality Check Nobody Talks About

Let me be straight with you—becoming an occupational therapist isn't just about having a big heart and wanting to help people. I've watched plenty of well-meaning souls crash against the rocks of organic chemistry and neuroanatomy. The profession demands a unique cocktail of scientific rigor, creative problem-solving, and the patience of someone teaching their grandmother to use a smartphone for the hundredth time.

You'll need to fall in love with the science of human occupation. And by occupation, I don't mean jobs—I mean everything humans do to occupy their time and give their lives meaning. From brushing teeth to playing violin, from making love to making lunch, OTs study how people engage with their world when bodies and minds work perfectly, and more importantly, when they don't.

Educational Marathon: More Than Just Checking Boxes

The academic journey starts with a bachelor's degree, though honestly, your undergraduate major matters less than you'd think. I've known English majors who became brilliant OTs, though they had to hustle through prerequisite sciences. Most programs require anatomy, physiology, psychology, statistics, and often physics. Yes, physics—because understanding force vectors actually matters when you're figuring out the safest way for someone to transfer from bed to wheelchair.

Here's something the glossy brochures won't tell you: those prerequisite courses are where dreams go to die. Anatomy isn't just memorizing bones; it's understanding how the median nerve snakes through the carpal tunnel and why that matters when Mrs. Johnson can't grip her coffee cup anymore. Statistics isn't just numbers; it's learning to critically evaluate whether that trendy new treatment actually works or if it's just expensive snake oil.

The real commitment comes with graduate school. Since 2007, you need at least a master's degree to practice, though many new grads are opting for doctoral programs. The American Occupational Therapy Association keeps pushing for doctoral-level entry, which has sparked heated debates at every conference I've attended. Some argue it elevates the profession; others worry it creates barriers for diverse candidates who can't afford seven years of higher education.

Fieldwork: Where Theory Meets Reality (And Sometimes They Duke It Out)

Graduate programs include fieldwork—basically unpaid internships where you discover whether you actually like this job or just liked the idea of it. Level I fieldwork happens during your coursework, usually part-time observations where you shadow practicing OTs and try not to look completely lost. Level II fieldwork is the real deal: 24 weeks of full-time work where you're expected to gradually take on a full caseload.

I remember my first day of Level II fieldwork in an acute care hospital. My supervisor handed me a chart for a patient with Guillain-Barré syndrome, and suddenly all those textbook chapters felt woefully inadequate. Real patients don't present like case studies. They're scared, frustrated, sometimes angry at you for pushing them to do things that hurt. They have families hovering anxiously, insurance companies dictating treatment timelines, and bodies that refuse to follow textbook recovery patterns.

Some students thrive in the chaos; others realize they'd prefer the predictability of outpatient pediatrics or the slower pace of home health. That's the beauty of fieldwork—it's like speed dating different practice areas before committing to one.

The Certification Gauntlet

After graduation comes the NBCOT exam—the National Board for Certification in Occupational Therapy. This computerized beast adapts to your performance, getting harder if you're doing well, easier if you're struggling. It's four hours of clinical reasoning questions that test whether you can think like an OT, not just regurgitate facts.

The pass rate hovers around 80-85% for first-time test takers, which sounds reassuring until you realize that means one in five graduates fails on their first attempt. The exam costs over $500, and failing means waiting 45 days to retake it while your student loans start demanding attention and your job offer potentially evaporates.

State licensure follows certification, and every state has its quirks. Some require jurisprudence exams about state-specific practice laws. Others mandate background checks that scrutinize everything down to that underage drinking citation from freshman year. Moving between states later in your career means navigating this bureaucratic maze all over again.

The Money Talk Everyone Avoids

Let's address the elephant doing adaptive equipment training in the room: the financial reality. The median OT salary sits around $86,000 annually, which sounds decent until you factor in the average $70,000-100,000 in student loans from graduate school. Starting salaries in saturated markets might be closer to $60,000, while rural areas desperate for OTs might offer $90,000 plus signing bonuses.

The math gets trickier when you consider opportunity cost. Those seven years of education are seven years of not earning a full salary, not contributing to retirement, not building equity in a home. I've watched colleagues struggle with this reality, especially when their physical therapist friends—who do similar work—often earn slightly more, or when their college roommate who went into tech is pulling down six figures.

Practice Settings: Choose Your Own Adventure

The beauty of OT lies in its diversity. Hate hospitals? Try schools. Tired of pediatrics? Switch to hand therapy. Burned out on direct patient care? Corporate ergonomics consultants make bank teaching office workers how to not destroy their spines.

Each setting demands different skills. School-based OTs need to understand educational law and work within IEP teams. Hospital OTs must handle medical complexity and discharge planning pressures. Mental health OTs—an underappreciated subspecialty—need to tolerate ambiguity and understand psychosocial frameworks that many OTs barely touched in school.

I've bounced between settings myself, starting in acute care, moving to outpatient hands, dabbling in home health during COVID when everyone was desperate for therapists willing to enter people's homes. Each transition required humility—expertise in one area doesn't automatically transfer to another.

The Intangibles Nobody Measures

Beyond the quantifiable requirements lies the emotional labor of OT. You'll celebrate tiny victories that seem insignificant to outsiders—a dementia patient remembering how to fold towels, a veteran with PTSD managing a grocery store trip without a panic attack. You'll also absorb the grief of progressive conditions, the frustration of insurance denials, the heartbreak of seeing potential limited by socioeconomic barriers.

The profession demands creativity that can't be taught. When insurance allows three visits for a complex patient, you become MacGyver, cobbling together home programs and family training to stretch those sessions. When cultural differences mean your standard interventions won't work, you adapt on the fly. When a child refuses every sensory activity you've planned, you pivot and find what motivates them, even if it means incorporating their obsession with dinosaurs into every single exercise.

The Evolution of a Profession

OT is having an identity crisis, and honestly, it's about time. The profession started with arts and crafts in psychiatric hospitals, evolved through biomechanical models in physical rehabilitation, and now grapples with its place in an increasingly medicalized healthcare system. Young OTs push for recognition of occupational justice, arguing we should address systemic barriers to participation, not just individual deficits. Traditional OTs worry we're straying too far from our roots.

This tension plays out in education too. Programs increasingly emphasize evidence-based practice and research, but students graduate unable to analyze activities—the fundamental skill of OT. We can cite randomized controlled trials but struggle to explain why we're having patients fold laundry instead of using arm bikes.

Making the Decision

So should you pursue OT? If you're drawn to the intersection of science and humanism, if you see dignity in helping someone relearn to wipe their own bottom, if you can handle being confused with physical therapy for the rest of your career while maintaining professional pride—then maybe.

But don't romanticize it. This isn't a calling that transcends practical considerations. It's a healthcare profession with all the associated bureaucracy, documentation nightmares, and productivity pressures. You'll spend more time arguing with insurance companies than you'd like and less time with patients than you'd hope.

The rewards are real but subtle. They're in the moments when everything clicks—when your activity analysis, clinical reasoning, and therapeutic relationship align to create meaningful change. They're in the thank-you cards years later from patients whose names you'd forgotten but who never forgot you taught them to dress themselves after their amputation.

If you decide to take this path, enter with eyes open. The profession needs people who understand its complexity, who can advocate for its value while acknowledging its limitations. We need OTs who can straddle the art-science divide, who can document medical necessity while never forgetting the human story behind the diagnosis.

The journey to becoming an OT isn't just about meeting requirements—it's about developing a professional identity that can weather healthcare's storms while maintaining focus on what matters: helping people live lives they find meaningful, whatever that looks like for them.

Authoritative Sources:

American Occupational Therapy Association. 2018 Accreditation Council for Occupational Therapy Education (ACOTE®) Standards and Interpretive Guide. American Occupational Therapy Association, Inc., 2018.

Bureau of Labor Statistics, U.S. Department of Labor. "Occupational Therapists." Occupational Outlook Handbook, www.bls.gov/ooh/healthcare/occupational-therapists.htm.

National Board for Certification in Occupational Therapy. Certification Exam Handbook. NBCOT, 2023, www.nbcot.org/en/Students/get-certified#ExamHandbooks.

Schell, Barbara A. Boyt, et al. Willard and Spackman's Occupational Therapy. 13th ed., Wolters Kluwer, 2019.