Abstract
In the wake of sociopolitical movements to address health inequities and race-based violence in the United States, there have been calls to take up antiracist practices in the occupational therapy profession. This call aligns with Vision 2025 and requires intentional dialogue and instruction on racism and antiracism, beginning in occupational therapy academic programs. Although it is important to engage in discussions on racism and antiracism, it is equally imperative that members of the profession take action to ameliorate the consequences of racism. In this column, we argue for the need for occupational therapy educators to take immediate action. We provide specific recommendations and strategies to broach these topics, examples of classroom activities, and practical approaches for translating these skills to fieldwork settings. Continued work is needed to establish robust policies and practices to ensure that all occupational therapy program graduates enter the workforce prepared to promote health equity through antiracism.
This column offers specific recommendations and strategies for occupational therapy educators and academic programs to establish robust policies and practices to ensure all occupational therapy graduates enter the workforce prepared to promote health equity through antiracism.
In the wake of enduring health inequities among marginalized communities and sociopolitical movements to address race-based violence against Black people in the United States, calls rang from members of the occupational therapy community to be antiracist, culturally affirming, and intersectional in their practice (American Occupational Therapy Association [AOTA], 2021; Gibbs & Caracci, 2021). Representative bodies of occupational therapy practitioners dedicated time and resources to better understand the impacts of systemic racism and political hyperpolarization on the profession (AOTA, 2021); moreover, scholars of occupation challenged occupational therapy educators to confront systemic racism from a pedagogical standpoint, including addressing the lack of diversity in occupational therapy academic programs (Lucas & Washington, 2020). In this column, we advocate for the radical and systemic application of critical inquiry through the integration of antiracist instruction in occupational therapy academic programs and provide practical strategies to advance this work toward a realized Vision 2025.
Systemic Racism, Antiracism, and Occupation
Lucas and Washington (2020) defined systemic racism as a convergence of political and social structures that limit opportunity for participation on the basis of one’s minoritized group memberships. Lavalley and Johnson (2020) further examined the systemic construction of racism through occupation, describing the weaponization of occupation as a tool of social control and how inequities are sustained and reproduced. Juxtaposed to systemic racism, antiracism contends that racist policies and structures cause health and social outcomes to be predictable on the basis of racialized grouping, recognizing that all people, despite their racialized group membership, are equal (Kendi, 2019). Therefore, understanding the differences between racist and antiracist mechanisms (i.e., ideologies, policies, practices, and processes) calls occupational therapy educators, students, and practitioners to make sense of the racialized world in which they must intentionally provide antiracist occupational therapy pedagogy, fieldwork education, and services.
A Socially Responsive Profession
Discussions on the intersections of systemic racism, antiracism, occupation, and practice have become more prevalent (Mahoney & Kiraly-Alvarez, 2019; Suarez Balcazar et al., 2020). These discussions point to the profound need for the profession to implement antiracist and antioppressive policies at the national level as well as to institute strategic diversity, equity, and inclusion initiatives nationally and locally (e.g., mandatory antiracism training; intentional revision of program policies and procedures through an antiracist lens; targeted recruitment of minoritized students, faculty, and practitioners). We must advocate for and support the creation of toolkits for use in the classroom, clinic, and inclusive professional development, to name a few (AOTA, 2021; Gibbs & Caracci, 2021).
We contend that the profession must position itself to examine occupational concerns beyond individual factors and interrogate the social structures that sustain and perpetuate racism as well as marginalize and oppress participation (Lavalley & Johnson, 2020; Mahoney & Kiraly-Alvarez, 2019). Raising the political consciousness of occupational therapy practice requires that occupational therapy academic programs challenge their students to antagonize occupational injustice through political, social, economic, and other contexts (De Jongh et al., 2012). De Jongh et al. (2012) further asserted that occupational therapy academic programs institute socially responsive curricula. That is, occupational therapy curricula should value “whole person care, reflective practice, human rights and community development” (De Jongh et al., 2012, p. 16).
Sakellariou and Pollard (2013) argued that occupational therapy practitioners, educators, and students must lean into social and political participation to address occupational participation as a human right. They further recommended that occupational therapy academic programs provide learning opportunities that help occupational therapy students gain a critical understanding of the profession’s role in society apart from clinical settings and the role students play in that process. Occupational therapy educators and students must fulfill these responsibilities by working toward and co-constructing a transformational vision of a just society, even critically examining their conceptualizations of justice (Guajardo Córdoba, 2020). Johnson and Lavalley (2020) echoed these sentiments by calling on occupational therapy educators and researchers to enable transformative social change through “radical application of critical inquiry” in the classroom and beyond.
Promoting Positive Change to Address Systemic Racism
In this section, we offer strategies to implement antiracist pedagogy in occupational therapy academic programs. First, we provide suggestions for educators; then, we propose curriculum and fieldwork experiences that build understanding and knowledge of and practical skills for antiracist clinical practice.
Preparing for the Classroom: Understand and Be Able to Explicitly Discuss Your Experience and Positionality Within Racist Structures
Discussing racism requires deep honesty, directness, and a willingness to address White supremacy. Although many occupational therapy educators across all racialized groups are interested in enacting antiracist pedagogy and content, implementing these measures can be precarious. One such contributing factor is the lack of representation of faculty of color in occupational therapy programs. Although the latest workforce survey (AOTA, 2020) does not provide faculty statistics, deductively we know percentages have not significantly changed because the percentage of Black practitioners has decreased over time. This lack of representation has direct implications for how these issues are addressed in the classroom.
Educators of color may face backlash rooted in White supremacy and fragility, professionally or personally from colleagues or students in higher education systems (Pechenkina & Liu, 2018). White educators—who are disproportionately represented in the profession—are often not prepared for the necessary discomfort that comes with analysis and disruption of a privileged positionality within racial caste systems. Therefore, enacting antiracism in the classroom requires that educators first interrogate themselves to best understand their positionality and influence in the systems and work ahead (Johnson & Lavalley, 2020). This interrogation is never complete, but when earnestly and consistently undertaken, it can often cultivate comfort in moving forward with an honest and direct approach to antiracism in the classroom. We recommend that all occupational therapy educators consider the following strategies: Regularly spend time examining your own systemic positionality and biases (e.g., reading experiences and analyses from scholars of color, engaging in self- or group-reflection activities). Learn to examine and comfortably articulate how racism as a social structure permeates occupational therapy education and practice as well as the systems and institutions that practitioners operate within (e.g., health care systems). Incorporate feedback or surveys informed by diverse student, practitioner, and client experiences as well as culturally responsive literature and antiracist practices. Respect that White educators cannot speak to personal experiences of being an occupational therapy practitioner or client of color; however, they can explicitly speak to their position within systems of White supremacy and their work to address racism. Recognize that the work of an educator does not end at the classroom door. Building occupational therapy programs that enact antiracist initiatives effectively requires attention, energy, and coalition building. Educators hold power within these systems and consequently hold the responsibility to change them. Educators must connect with and build movement across hierarchies, disciplines, and administrations to transform the whole of the institution’s system. This process will facilitate a space and experience that is more welcoming and supportive to students, faculty, and staff from minoritized backgrounds.
In the Classroom: Guide Students to Develop a Firm Understanding of Their Own Social Position and Biases to Lay the Groundwork for Antiracist Practice
Occupational therapy academic programs should feature courses that incorporate critical perspectives of culture and occupation to examine the characteristics of social identity and the cycle of socialization (Laliberte Rudman, 2013). In these courses, students enter a reflective space to recognize their own social positioning and begin to gain and reframe their knowledge of systemic issues of oppression and marginalization on the basis of their intersections of identities. The following strategies can be used for this work: Seek out and amplify experiences of diverse practitioners and clients with determination and compensation. Not only must White educators be willing to seek out these other experiences but they must also be prepared to hold the space appropriately for guest speakers who have come to offer their lived experiences. Beyond merely discussing these topics, it is critical that students engage in active reflections and analyses of systemic issues in the literature, such as topics of racism (Lavalley & Johnson, 2020), transphobia (Dowers et al., 2019), ableism (Yañez & Zúñiga, 2018), classism (Beagan et al., 2018), and ageism (Friedman & VanPuymbrouck, 2021). Occupational therapy courses with a focus on antiracism should use experiential learning to introduce and contextualize diverse real-world settings. One way to achieve this goal is through student observation and reflective analysis of uncommon practice settings, such as a clinic dedicated to the provision of medical and mental health services for uninsured and underinsured clients of immigrant status; a state department of corrections center with a four-phase transitional program; or a lesbian, gay, bisexual, transgender, and questioning (LGBTQ) community center offering therapeutic support that prioritizes trans women of color.
As a component of their experiential learning, students benefit from being tasked with observation and reflective writing about the cultural and systemic underpinnings of the setting (e.g., philosophy and mission, the delivery of the service, environmental supports), the thoughts and feelings expressed by clients during the observation, description of the occupational engagement taking place and its relationship to structural and systemic factors (i.e., age, gender, race–ethnicity, disability, culture, language, interests), and the identification and description of the positive and challenging aspects of the experiential learning experience and implications for future practice. Through this analysis, students can apply and reflect on antiracist and culturally responsive concepts (Mahoney & Kiraly-Alvarez, 2019; Suarez Balcazar et al., 2020).
Thread Content About Racism and Discrimination Throughout Curricula
Although courses that feature in-depth discussions and reflection are important, it is essential that teaching explicitly incorporating culture and race not be housed only in one course or section of the curriculum. Every course should incorporate content-relevant information and opportunities for discussion and growth. The following examples can be used as guidance: When differences in diagnostic rates are discussed, occupational therapy educators should be explicit in linking these differences to racism and the downstream effects of structural discrimination. For some conditions (e.g., autism), rates are estimated to be lower in some minoritized communities because of systematic racism related to access to services. For other conditions (e.g., diabetes, suicidal ideation), rates are estimated to be higher in some minoritized communities because of systematic racism leading to disparities in physical and mental health. If these structural causes are not explicitly examined, students will incorrectly assume false biological differences. The impacts of racism in society and in students’ future work settings must be discussed. For instance, in courses covering pediatrics and school-based practice specifically, students must learn about and examine the immediate and long-term impacts of behavior management approaches on minoritized students.
Through these analyses, educators can then foster space for students to prepare to contend with and redress racist structures influencing their institutions and practices. Many times, this work is uncomfortable, and students benefit from opportunities to practice this advocacy in a learning environment.
In Fieldwork Education: Prepare Students to Effectively Advocate Alongside Clients With Bodies and Cultures That Differ From Their Own by Connecting Classroom Learning on Antiracism With Fieldwork Education
Occupational therapy practitioners’ failure to have cultural humility and to understand that occupations are culturally situated are factors contributing to the U.S. health care system’s lack of adequate care provision to minoritized populations (Brown et al., 2021). When occupations are taught without regard to cultural differences, students may rely on their own experiences to support their clients or completely avoid addressing the occupation because they realize their cultural knowledge is limited. During fieldwork, students learn to integrate what they have learned in the classroom into real-world practice. Therefore, it is critical that fieldwork educators are apprised of the antiracism content that students are learning. The following potential avenues can be used to connect classroom and fieldwork education: Provide antiracist education resources to fieldwork educators (e.g., videos, handouts, case studies) and emphasize their use as a priority in fieldwork education. Include discussions on systemic racism and antiracism and their impact on occupational therapy client experiences during prebrief meetings before fieldwork and debrief meetings after fieldwork. Learning about and enacting effective support for different ways of engaging in basic activities of daily living (ADLs) is critical. To illustrate, hair type and style differ by ancestry and ethnic heritage. To effectively prepare for practice, students must learn about hair care for a variety of hair types so that they can effectively support bathing and grooming occupations. This planning can also be extended to skin care, menstruation management, and sexual practices. Although students will never become fully versed in all ways that ADLs may be performed, opportunities to learn about various approaches and client needs will prepare them to be more adaptable and responsive throughout their careers. Model advocacy that addresses systemic racism at the organizational level. Demonstrate ways to hold colleagues, supervisors, policies, and processes accountable to antiracist principles. Support students in gaining practice and confidence in doing this sometimes uncomfortable work alongside clients. Examples include leading discussions in team meetings, asking for outcome data related to specific policies, or professionally educating colleagues in one-on-one conversations.
Conclusion
In this column, we have provided suggestions for occupational therapy educators and educational programs to begin to link together actions to make real change in the profession. However, this work is not easy. It requires educators and students to unlearn problematic patterns of thinking, challenge their beliefs, and work toward consistently learning and growing. This work is not achieved with one new course, one new reading, or one added guest speaker. Occupational therapy educators must reflect on their own positionality and experiences and provide consistent opportunities for student learning and reflection.
One existing barrier is the current educational standards guiding occupational therapy educational programs. The Accreditation Council for Occupational Therapy Education (ACOTE®) publishes guidelines that all occupational therapy programs must adhere to. The current guidelines frequently refer to “culturally relevant” practice; however, they do not require programs to include any content related to systematic racism or antiracism. Although we offer recommendations for occupational therapy educational programs here, the only way to ensure that all programs take the steps required to advance this work is through new or edited ACOTE standards. We hope that the suggestions we offer in this column provide a path forward for programs right now, but we acknowledge that internal advocacy is necessary to codify these recommendations into the profession-wide advances that are desperately needed.