Justice and U.S. Occupational Therapy Practice: A Relationship 100 Years in the Making

Background

Despite discourse on occupational justice having been mostly nurtured outside the United States, Wood, Hooper, and Womack (2005) suggested that “many beliefs and principles inherent in the ethic of occupational justice arguably constituted the moral premises that first gave rise to occupational therapy in the United States in the early 1900s” (p. 379). Other authors have made similar declarations, noting that the profession’s roots in the Settlement Movement and Progressive Era (Bethke Elshtain, 2002; Breines, 1995; Frank & Zemke, 2009; Schwartz, 1992) planted seeds for a moral philosophy (Frank, 2012) and a justice-focused professional identity. Between the first and most recent decades of the profession’s history, U.S. occupational therapists focused their efforts on securing their place within the medical establishment (Friedland, 1998; Kielhofner & Burke, 1977; Yerxa, 1992), resulting in a framework that moved away from justice-related issues. By relying on a biomedical model, occupational therapy adopted a perspective that framed health as an individual phenomenon, obscuring the effects of social and political structures that can foster injustice and ill health (Wilcock & Hocking, 2015). Given this historical trajectory, the profession’s current emphasis on occupational justice is often interpreted as a return to its origins rather than the rise of a novel undertaking.

Links to the profession’s ethos notwithstanding, U.S. occupational therapy practitioners have not taken up the idea of occupational justice comfortably or en masse. Concern that the concept is not distinct from the notion of social justice (Braveman & Bass-Haugen, 2009; Durocher, Gibson, & Rappolt, 2014; Stadnyk, Townsend, & Wilcock, 2010) fuels dissent among scholars and practitioners who place the pursuit of justice outside the “traditional” occupational therapy practice arena. The question of whether justice falls within occupational therapy’s purview is often answered relative to two topics: the continued predominance of biomedical health care systems as a practice setting (Durocher, Rappolt, & Gibson, 2014) and the benefits and costs of framing occupational therapy as a political profession (Pollard, Kronenberg, & Sakellariou, 2008). Some scholars and practitioners see no room for pursuing justice beyond high-level advocacy in reimbursement-driven practice environments; others argue that the political and justice-oriented nature of occupation and occupational therapy spans “traditional” and “nontraditional” practice settings. A 2014 discussion (Farias, Laliberte Rudman, & Magalhães, 2014) among members of the International Society for Occupational Science (ISOS) illuminated this contention about occupational justice: Far from showcasing uniform agreement that “occupational justice is occupational therapy’s implied social vision” (Whiteford & Townsend, 2011, p. 69), the ISOS discussion illustrated that some U.S. practitioners view the push toward occupational justice as symptomatic of a particular liberal political agenda that hampers practitioners’ diversity and freedom.

Rationale for a Stronger U.S. Voice in Occupational Justice Discourse

Debates about the role of justice in U.S. occupational therapy practice have had a moral overtone. In other words, occupational therapy practitioners question whether they should consider the pursuit of justice as part of their practice domain. We argue that this question is, perhaps, not the best one to ask. We suggest that the provision of occupational therapy services inherently promotes justice—just as occupation itself is an intrinsically political phenomenon—because it enables occupations for people who face external barriers to participation in everyday life (Pollard et al., 2008). In this view, the political nature of occupation relates to the power dynamics that shape everyday life instead of solely invoking governmental parties and their activities. There is no question that societal power dynamics shape occupational engagement. Thus, instead of asking whether occupational therapy should promote justice, we believe that a better question to answer is, “Why is it important for U.S. occupational therapy practitioners to conceptualize their practices more strongly as justice-oriented endeavors?”

Following the biomedicalization of occupational therapy’s domain in the mid-20th century, there have been efforts to reclaim the profession’s activist roots. These efforts parallel global calls for occupational therapy practitioners to serve populations such as immigrants and refugees, people experiencing homelessness, and communities affected by poverty (Ruth Watson, as cited in Frank & Zemke, 2009). The importance of resuming a focus on these populations and broader justice-related issues rests on the link between today’s social, political, and economic circumstances and those of our profession’s founders. Schwartz (2009) noted in her Eleanor Clarke Slagle Lecture that “similar to today, the United States faced many problems at the beginning of the 20th century, including war, immigration, industrialization, exploitation of workers, poor schools, and inadequate medical care” (p. 682). In occupational therapy’s 99th yr, the United States continues to be plagued by vast health and socioeconomic inequities that preclude well-being and foster social unrest.

These problems are not going away, and the work of U.S. occupational therapy practitioners intersects with these problems simply because this is the country where they work. Practitioners continue to work with veterans who are returning to civilian lives after war. They also work with immigrants, refugees, unemployed workers, and people who have not had the benefit of adequate access to education or health care. Current global perspectives of occupational justice explore these and other issues, and U.S. scholars and practitioners have no shortage of parallel examples to add to the dialogue.

Occupational therapy practitioners must engage in global conversations about justice to offer their distinct perspective on current issues. Today, nearly 50 million people in the United States live in poverty (U.S. Census Bureau, 2015), which limits access to not only basic needs but also leisure, education, and social interaction. Each year, roughly 1 million immigrants are granted legal U.S. citizenship, and an additional 50,000–75,000 are granted asylum (U.S. Department of Homeland Security, 2013). They must work to not only meet their basic occupational needs but also to renegotiate their cultural roles after international relocation. Occupational therapy practitioners have the knowledge and skills to work with these “new Americans” as well as other communities both within and outside the traditional health care arena.

Occupational therapy’s role in matters of justice is not to simply align with notions of social and procedural justice but to contribute to the understanding of the inherent need for occupation (Reilly, 1962), particularly how supporting occupation helps achieve a just society where people can live meaningful lives through their contexts. Occupational therapy’s professional vision cannot be achieved without further inquiry into occupational injustices in the United States and how they can be addressed in everyday practices (Bailliard & Aldrich, 2016). Remaining silent on issues of injustice not only leaves a hole in international dialogue about occupational justice but also “risks that we are complicit in maintaining the status quo as we fail to challenge, or foster changes in, the social structures that create and sustain marginalization and health inequities” (Gerlach, 2015, p. 247).

Future Directions

Townsend and Marval (2013) identified a lack of social practice and a lack of critical consciousness of injustices as barriers to enabling occupational justice. Hocking and Townsend (2015) explained that issues of justice are rarely taught in occupational therapy curricula and that professionals seldom “[assert] the need to challenge the inequitable access to occupation” (p. 70) that some populations face. Following these and other authors’ recommendations, we suggest that reimagining approaches to occupational therapy education and practice will facilitate greater U.S. engagement with the global discourse about occupational justice. Part of that reimagining involves returning to the influences that brought our profession into being.

As a reformer in the Progressive Era, Jane Addams's work immensely influenced the founders of occupational therapy (Schwartz, 2009). Hamington (2004) described Addams's thoughts on community engagement and justice as grounded in “a proactive care that involves certain habits of interaction” (p. 104). Addams urged people to “seek out the unknown other” (Hamington, 2004, p. 105) and asserted that “we cannot begin to have a democratic, caring, helping community without experience of one another that lets us better understand the plurality that exists among us” (Hamington, 2004, p. 107). Addams's emphasis on these habits of interaction mirrors current conversations about cultural humility in occupational therapy education and practice. Cultural humility “emphasizes the need to respect and be open to clients’ culturally based understandings of their lives and the impact of structural inequalities on their occupational opportunities and well-being” (Hammell, 2013, p. 230). Occupational therapy practitioners’ valuation of cultural humility can be interpreted as a desire to engage and seek justice with each person in accordance with particular desires and needs as identified through client-centered care (Bailliard & Aldrich, 2016).

Valuing others is an inherent aspect of occupational therapy practice, and its intrinsic relation to justice can be underscored to both students and practitioners. Bailliard and Aldrich (2016) suggested “encouraging occupational therapists to view their practices as pursuits of justice” (p. 91) and assuming “a more explicit focus on rights” to “habituate students to embody considerations of justice and care in every aspect of their reasoning” (p. 93). Providing classroom spaces for occupational science and occupational therapy students to grapple with and apply knowledge about occupational injustice may plant seeds for their pursuit of justice beyond educational activities (Aldrich, White, & Conners, 2016). The Participatory Occupational Justice Framework emboldens occupational therapy practitioners to “explicitly identify and name occupational issues of inequity or the absence of occupational rights” so that documentation can serve as “justification to reallocate resources for occupational justice initiatives” and allow “[engagement] in continuous quality improvement with conscious attention to reduce ongoing injustice” (Whiteford & Townsend, 2011, p. 72).

Habituating students and practitioners to considerations of inequities and injustices may help forestall problematic or unintended consequences that can accompany the pursuit of justice. Thibeault (2013) described a situation in which foreign students’ well-intentioned service project translated into occupational deprivation for residents in a Nicaraguan community, leaving many people unemployed, starving, and suffering fatal pressure sores from donated wheelchairs. To avoid such a fate for justice-promoting efforts, Thibeault outlined a community-building process that began with “befriending”—through collective occupational engagement—the person or people for whom justice is being promoted. Within this community-building process, practitioners can examine their own values and motives, adopt an occupational lens, and establish partnerships within the communities experiencing injustice. Although this kind of community building can take a long time, these principles and processes, along with Addams's habits of interaction, can give practitioners guidelines for how to promote occupational justice while minimizing unintended consequences.

Conclusion

Given occupational therapy’s intentions to “help people across the lifespan participate in the things they want and need to do” (American Occupational Therapy Association, 2016), occupational justice can be seen as a core component of professional endeavors. Yet, even outside the United States, where the dialogue about occupational justice has predominantly developed, occupational therapy practitioners may still see justice as something external to or beyond everyday practice (Galvin, Wilding, & Whiteford, 2011). However, the political nature of occupation and occupational therapy (Pollard et al., 2008) can be capitalized on (Bailliard, 2016) to help practitioners consider their everyday practices in a new light (Bailliard & Aldrich, 2016). From founding ideals to recent scholarly writings, occupational therapy practitioners and students are well positioned to cement a focus on justice for the profession’s next 100 yr, and now is the time to put that focus into action.