Abstract
Inclusion and belonging are fundamental human needs and key to the engagement and well-being of occupational therapy practitioners, scientists, educators, and learners. Despite this, the profession has struggled throughout its history to act on its values as focused on wide-ranging perspectives of occupational engagement in diverse cultural contexts. Issues of diversity, equity, inclusion, justice, and accessibility (DEIJA) innervate contemporary discourse, but there is a real danger that these conversations remain at a superficial level and stop short of attempts at genuine disruption of the deeply rooted colonial systems that exist in the profession. In this column, we use Jacques Derrida’s concept of hos[ti]pitality to problematize DEIJA initiatives by asking whether occupational therapy can be genuinely inclusive or if minoritized persons will always be “guests” who are expected to reciprocate their presence. We then extend this theoretical approach to inform practical ideas to disrupt hos[ti]pitality in education, practice, and research, promoting antiracist and inclusive educational settings and deconstructing barriers to more authentic inclusion of marginalized identities. Although occupational therapy cannot be fully and unconditionally hospitable, we suggest that generative disruption at both the micro and macro levels can lead to a sense of solidarity that benefits the profession and the people and communities we serve.
In this column, the authors use Jacques Derrida’s concept of “hos[ti]pitality” to problematize DEIJA initiatives by asking whether occupational therapy can be genuinely inclusive or if minoritized persons will always be “guests” who are expected to reciprocate their presence.
The past decade has experienced a global renaissance in the Civil Rights era–like momentum to achieve equity and representation across race, ethnicity, sex, gender, socioeconomic status, age, ability, and religion, among other identities. Social movements and activism to increase diversity have sought to address systemic biases of access that took root centuries ago in slavery, and segregation in the United States has been reinforced over time through complex policies and legislation that centralize power to a few (Braveman, 2006). These efforts have been operationalized in constructs and resulting acronyms that attempt to capture increasing levels of specificity, including diversity, inclusion, equity, belonging, accessibility, justice, and antiracism, among others. Initiatives to address generational disparities and inequities have recently come under siege at federal and state levels for being discriminatory and prudentially hostile toward a White majority. As debates and discourse continue in various arenas, professional societies continue to grapple with the evolution of how to implement these essential concepts (Corsino & Fuller, 2021; Enders et al., 2021; Foy, 2021). Foundational in occupational therapy is the concept of diversity, equity, inclusion, justice, and accessibility (DEIJA), which embodies how we create, promote, and sustain feelings of belonging in all aspects of the profession. Belonging, closely related to inclusion, is a fundamental human need and refers to sustained acceptance by and respect from others in social contexts (Baumeister & Leary, 1995). In occupational therapy, belonging relates to how we create communities that welcome all identities and give a unique voice to the individual, and how each individual is consistently empowered to take an active and valued role in the profession’s future.
In this column, we problematize the recent, admirable professional endorsement and increased presence of DEIJA in occupational therapy. We are not questioning the obvious and imminent need for DEIJA but rather how the profession has worked toward addressing the natural barriers faced by people with minoritized identities through praxis or intentional action. Although undoubtedly well intended and sincere, we question whether professional statements or goals run deep enough to permeate and address systemic root causes or instead are administrative, superficial check boxes focused on optics, compliance, and unidimensional diversity. To this end, we pursue an applied theoretical path using the concepts of hospitality and hos[ti]pitality in the context of everyday lived experiences to explore whether we are building authentic spaces of belonging and, even further, question whether we can ever be genuinely inclusive. First, we discuss the theoretical and conceptual aspects of belonging as viewed through the lens of hospitality and its close counterpart, hos[ti]pitality. We then offer examples of the common hos[ti]pitalities that occur in the domains of education, practice, and research and problematize the ethical consequences of those hos[ti]pitalities in occupational therapy. Finally, we shift from the theoretical space to a more applied discussion of practical strategies the profession can take to disrupt hos[ti]pitality and sustain more just professional communities where we not only live with—but more so, for—each other.
Hospitality, Hostility, and Hos[ti]pitality
The concept of hospitality is ubiquitous and stitched into the social fabric across cultures globally. It is broadly defined as the act of being friendly and welcoming to guests and visitors (Fourshey, 2012; Heal, 1990). Hospitality originated from the Latin terms hospes (guest) and hostis (stranger or enemy; Lashley et al., 2007), which serves to highlight the close relationship between the two parties. Traditional philosophical discourse on hospitality has dichotomized the concept when thinking about implementation. Unlimited, unconditional, or pure hospitality has no restrictions, and the host welcomes visitors or strangers regardless of identity or status “to give the new arrival all of one’s home, all of oneself, to give him or her our own, without asking a name, or compensation, or fulfillment of even the smallest condition” (Derrida, 2000b, p. 77). In contrast, conditional hospitality is based on the expectation of reciprocity, whereby the stranger is obligated to act as a temporary visitor and affirm that the host retains control (Derrida, 2000b). Although there are universal elements of hospitality, there are also cultural variations and perceived ethical obligations that shape how hospitality is expressed and experienced at various levels (e.g., individual, community, institutional, nation–state, and international).
Hospitality from a Northern/Eurocentric lens is portrayed as noble or ethical, but in reality this is a lens of false purity because every hospitable action is transactional and involves the expectation of reciprocation in some form (Bolzoni, 2022). This conditional hospitality always involves a host and a guest; the host must welcome the guest, or “foreigner,” but implicitly makes it clear they are not welcome to stay. Hospitality is “an asymmetrical social relation” because “we want to honor the guest and keep him/her at a distance at the same time” (Gotman, 1997, p. 7). From a power dynamics point of view, the host is often in control, and the guest must conform to the rules and norms of the house. Although there can be fluid relationships whereby the guest can disrupt established norms and hierarchies, hospitality typically involves “investigating” the guest, thereby acting as a culturally powerful social control mechanism (Lynch et al., 2011).
French philosopher Jacques Derrida (2000a) deconstructed the traditional concept of hospitality, noting the contradiction that “hospitality always in some way does the opposite of what it pretends to do” (p. 14). This led to Derrida coining the portmanteau hos[ti]pitality to highlight that there exists a discernible measure of hostility in every act of hospitality. Hos[ti]pitality, therefore, reveals that hospitality “always brings within itself . . . exclusion, unfairness, a certain degree of violence, or even perjury” (Kakoliris, 2015, p. 149). Hos[ti]pitality is echoed in Paulo Freire’s (1970/2000) notion of false generosity, which addresses symptoms—often with good intentions and perhaps some positive impact—but preserves underlying oppressive structures/systems and disincentivizes true change:
A psychoanalysis of oppressive action might reveal the “false generosity” of the oppressor as a dimension of the latter’s sense of guilt. With this false generosity, he attempts not only to preserve an unjust and necrophilic order, but to “buy” peace for himself. (p. 146)
Exploring hos[ti]pitality thus helps unmask the deceptive nature of a so-called hospitality framed as ethical and virtuous but that in reality is an illusion that maintains the status quo and offers the impression that actual, ethical change is occurring.
Hos[ti]pitality in Occupational Therapy
The rapid, seismic shift of DEIJA and other acronymic variations resulted from national spotlights on social movements like Black Lives Matter, the murder of George Floyd, #MeToo, LGBTQ+, and minoritized groups differentially affected by the 2019 coronavirus pandemic. The combined public pressure demanded legal and regulatory changes in the federal government’s executive and legislative branches, accountability from conglomerate and multinational corporations, demographic changes in employees to be reflective of their communities where a particular business resides, ethical treatment in higher education and medicine, and an overall generational shift in values. Regrettably, the breadth and depth of this social amplification for change have been interpreted as a formulaic diatribe lecture reduced to mandatory courses, typically a one-hour lecture about the importance of diversity and recognizing implicit bias.
The practice of commercialization and commodification is not new to any industry, particularly in the hospitality space. The shift to centralize diversity and inclusion across institutions at its core embodies the tenets of unconditional hospitality. However, the products resulting from the past 5 years yield an inauthentic message underscored by political correctness that has engendered a performative, commodified, and controlled movement; it embodies conditional hospitality (Weeks et al., 2024). To achieve cultural shifts across corporate, academic, governmental, and social spheres, majority-run institutions have attempted to add dimensions of diversity but do not follow through on the inclusivity part of the promise. This is hos[ti]pitality.
Occupational therapy has accepted aspects of hospitality (e.g., client-centeredness, student orientation and support programs, human subjects research protection policies) as fundamental to its ethics and codified it in how we practice. In occupational therapy (and most other medical disciplines), the expected return from marginalized identities (the “guests”) may take various forms, including expecting unquestioned compliance with/acquiescence to policies, procedures, and hidden curricula that are not as inclusive as they appear to be; being interrogated; being judged as to one’s worthiness; continually being asked to prove oneself; tokenization; not being allowed to be authentic; pressure to conform to dominant cultural and intellectual norms; and myriad other manifestations of minority taxation (Kamceva et al., 2022). These “paybacks” are the price of admission for people with marginalized identities, and together they constitute a hostile environment where dealing with bias, assimilation, and microaggressions is a necessary part of the transaction. Recognizing these power dynamics and the inequalities inherent in hospitality relationships introduces a novel mechanism of social control, reinforcing hierarchies and exclusions based on race, class, sex, gender, immigrant, or refugee identities. Additional examples of hos[ti]pitality include using the few minoritized learners frequently in print and electronic media and websites, expecting marginalized identities to represent all people in their group, strict dress codes, implicit and hidden curricula, moving goalposts, bias in assessments, rigid attendance and makeup policies, and supposedly equitable education without taking into account uneven starting points and potential necessary supports (Hammond et al., 2019; Muñoz et al., 2023; Taff et al., 2024).
Having outlined the fundamental theoretical and ethical issues inherent to hos[ti]pitality in the profession, we now turn our attention to suggestions for intentional action, or praxis, toward disrupting and minimizing the harm caused by this always-present but little-noticed dichotomy.
Disrupting Hos[ti]pitality in Education, Practice, and Research
Practical Solutions: Supporting Students and Faculty
Education is the epicenter of hos[ti]pitality in occupational therapy. It is where DEIJA initiatives have the most deceiving facades despite genuine intent. Many occupational therapy programs seem to pledge aspirational mission and vision statements, vow to foster bias-free and inclusive learning spaces, and venture into antiracist pedagogies. Some programs may opt to shift to holistic admissions, nurture student advocacy groups, and establish DEIJA committees or task forces. Although all these efforts are gravely needed, failure to deliver tangible outcomes and lasting impacts around these promises can compromise students’ academic well-being, diminish their sense of belonging (Aldridge et al., 2023), and eventually undermine their potential professional success. In addition, if done poorly, DEIJA initiatives may be illusory to prospective students, who may come to realize that these learning environments are far from welcoming to people with marginalized identities, hence perpetuating the limbo of belonging in the profession and evoking the very definition of hos[ti]pitality.
Furthermore, DEIJA initiatives for faculty, instructors, and teaching assistants tend to be an afterthought. Data show that faculty with minoritized identities are less likely to receive tenure and promotion, receive funding, publish scholarly work, or receive professional development support (Wright-Mair & Museus, 2023). Federal and foundational funding is rarely dedicated to addressing DEIJA issues in occupational therapy education and practice. These exclusionary patterns may perpetuate the noninclusive climate of minoritized communities in academia, research, and professional development, preserving the long-lasting experience of hos[ti]pitality. Challenging these exclusionary patterns will require sustained efforts at the macro level (e.g., institutional and organizational involvement) and micro level (e.g., individual educational programs and faculty members). On the basis of common challenges in the profession (as gathered through anecdotal experiences, peer- reviewed literature, and expert opinions), we propose several practical strategies to create environments that foster a true sense of belonging (Allen et al., 2021) and ensure effective measures toward supporting DEIJA issues in occupational therapy education.
Macro-Level Strategies: Institutional, Organizational, or Multifaceted
The following strategies suggest grand shifts at a large scale that may require time and resources from institutions, community partners, and other stakeholders. If authentically and consistently implemented, these strategies may create an atmosphere of a genuine rather than performative sense of equity, inclusion, and social justice that can eventually disrupt hos[ti]pitality. 1. Revise institutional policies and procedures to actualize effective DEIJA practices and support minorities and underprivileged communities of faculty, staff, and students. Examples include establishing equity-based policies and procedures for admission, hiring and recruiting, promotion and tenure, professional advancement, campus support, and culturally relevant resources (Brotherton et al., 2021; Brown et al., 2021; Ford et al., 2021). 2. Establish interprofessional collaboration across schools, units, and teams to create DEIJA-infused practices from different professional perspectives (e.g., collaboration between occupational therapy practitioners and public health professionals to promote inclusive occupational therapy services in rural areas, or collaboration with engineering schools to promote accessibility solutions to persons with limited income or access to assistive technology). 3. Establish community-oriented programs and initiatives that can create educational opportunities for students, faculty members, and researchers on DEIJA- related issues such as social drivers of health, equity-based care, and social justice (e.g., service learning trips to bolster students’ understanding of population-based needs, especially those in underserved and rural areas).
Micro-Level Strategies: Program, Local, or Individual
These strategies are meant to be implemented at a smaller scale that requires a sense of commitment and a DEIJA-oriented mindset.
Curriculum
1. Intentionally design or revise curricula to center antiracism practices (e.g., include modules that address bias, racism in health care, and social drivers of health). Antiracist principles challenge the hos[ti]pitality of hidden curricula by emphasizing the need for genuine reflection on daily practices and their impact on minoritized populations (Sterman et al., 2022). 2. Center marginalized perspectives on occupation (e.g., include readings and texts written by authors of color or of marginalized groups). Centralizing these perspectives welcomes authors of diverse backgrounds to tell the story themselves instead of having privileged authors tell the story on their behalf (i.e., hos[ti]pitality of perspective). 3. Reduce default Eurocentric theoretical foundations in curriculum design and delivery (e.g., teaching models and frameworks that value co-independence, family- oriented independence, collectivist rather than individualistic functioning (Hoyt et al., 2023; Pereira, 2017), and culturally diverse assessments and interventions. In addition, connect DEIJA constructs to the American Occupational Therapy Association’s (AOTA’s; 2020) Code of Ethics within the curriculum design to enhance an inclusive culture of learning and teaching (e.g., connect core values to cultural humility in all clinical courses). By establishing the link between ethical practice and a deep understanding of DEIJA issues, we emphasize the notion that performative care is unethical and hence promote genuinely inclusive practices.
Classrooms
1. Implement inclusive teaching guidelines (e.g., follow the principles of universal learning design and inclusive classrooms). This means starting from the point of universal design instead of reacting via accommodations (Fornauf & Erickson, 2020). By creating learning spaces that welcome all learners and cater to their diverse learning styles and needs, we nurture a true sense of belonging and reduce the possibility of a hos[ti]pitable environment. 2. Train in and intentionally use transgressive instructional strategies (Braa & Callero, 2006) and metacognitive monitoring to enhance faculty and learner skill in evoking edutentionality (Taff, 2024) in learning activities. Edutentionality involves developing a mindset of continuously problematizing and mentally disrupting the colonial entanglements of education; recentering marginalized and oppressed identities as starting points for instruction; and framing knowledge, skills, and attitudes toward equity, belonging, and rehumanization. Such instructional practices can help disrupt hos[ti]pitality by unmasking hidden curricula and making clear implicit biases. 3. Establish a programmatic DEIJA strategic plan, or identify a core DEIJA strategic goal and train faculty on DEIJA principles with a documented professional development agenda that serves the DEIJA strategic plan and goals (Muñoz et al., 2023). Programs’ strategic plans must be connected to institutional plans, and systems for accountability must be established.
Student Support
1. Establish a student advisory board to weigh in on programmatic DEIJA needs. If applicable, select a proxy (e.g., an elected student advocate or staff member) who can advocate for student needs in faculty meetings. This will require oversight and accountability because the power dynamics behind hos[ti]pitality are entrenched and can minimize authentic feedback and action. 2. Establish a confidential feedback mechanism (e.g., an anonymous reporting system) whereby students can provide feedback and input on DEIJA needs and clearly act on the information provided. This allows students to feel that their feedback and concerns are in fact taken seriously and helps mitigate conditional hospitality. 3. Establish DEIJA-related standards in student handbooks (e.g., include bias-free language as an expectation in standards for student conduct). Including such language in a program’s official documents reflects the program’s commitment to DEIJA issues, which can create a welcoming environment for students and faculty. Shared, expected language can help identify when elements of hos[ti]pitality creep into policies, practices, and procedures. 4. Plan budgetary and financial support for DEIJA initiatives (e.g., to support speakers on DEIJA). This may include providing seed funding for research or community-based initiatives on social justice and advocacy to support their scholarship agenda.
Practical Solutions: Supporting Fieldwork Educators and Practitioners
Making tangible changes on issues related to DEIJA is more challenging in clinical practice than education, for various reasons. For example, although the core values described in the profession’s Code of Ethics (AOTA, 2020) call for Equality when providing clinical care, equitable care delivery is not a key performance indicator in terms of work evaluation or professional development for occupational therapy practitioners. The principles in the Code of Ethics also call for Justice in clinical practice by promoting “equity, inclusion, and objectivity in the provision of occupational therapy services” (AOTA, 2020, p. 4).
However, practitioners and fieldwork educators (FWEs) are not required to reflect fair and just treatment to diverse groups of clients in their daily practice. Practitioners are simply not held accountable for not showing cultural humility, inclusive practices, or equitable treatment, thus allowing hos[ti]pitality to remain unchallenged. The terms may not even be common language in clinical settings, and other reductionist terms (e.g., cultural competence) may be adopted (Grenier, 2020). Hence, many students may not be exposed to such values during their clinical education because FWEs may not explicitly model or reflect these values while supervising them in Level I or II fieldwork. In addition, initiatives to enhance issues related to DEIJA in fieldwork education are limited to local academic institutions rather than being a nationwide requirement (Grenier et al., 2020). Some of the examples of DEIJA in fieldwork include national or international service trips and community-based services, which may not be viable options for most occupational therapy programs.
Hos[ti]pitality can be best detected in clinical practice, where cultural humility (as a relevant trace marker of DEIJA) is seldom encouraged, let alone enforced. Although practitioners are the gatekeepers to client-centered care, they have less control over clinical practice in terms of policy, accountability, procedures, and other aspects of daily practice. This is one of the reasons why explicitly preparing students for their transition into a practitioner role while in occupational therapy school is imperative.
That said, there are a few practical strategies that can be used by AOTA, private practice owners, clinic directors, and other leaders to deliver antiracist practices. Implementing these practices reinforces the mindset of genuinely supporting DEIJA-related issues in clinical practice. When students see that DEIJA issues are addressed not only in their educational program but also later, in their fieldwork education and clinical practice, a true sense of inclusion emerges. We can challenge hos[ti]pitality if we collectively implement these (or similar) strategies and consistently implement them across various areas of practice. The following are a few examples. 1. Encourage FWEs to explore didactic content on DEIJA (e.g., readings on cultural humility, social justice practices, accessibility) that is offered to students before they begin fieldwork, to be cognizant of the gap between education and fieldwork practice with respect to issues related to DEIJA. 2. Establish a collaboration between the academic institutions and FWEs to foster informed communication on DEIJA issues in fieldwork education (e.g., antiracist education and practice, addressing power dynamics in therapeutic relationships). 3. Invest in and provide free DEIJA-centered continuing education activities (e.g., bias-free interviewing skills). 4. Seek and use culturally relevant assessment tools or intervention approaches for various cultural practices (e.g., explore diverse ways of assessing toileting, hair care, and meal preparation). 5. Train FWEs to bridge DEIJA education to practice by expecting students to learn through a DEIJA lens (e.g., ask students to find best practices on cultural humility and apply them in their clinical education).
Practical Solutions: Supporting Researchers and Scientists
The research macrosystem is a complex ecological intersection of researchers/scientists, peer reviewers, academic institutions, funding agencies, and the public, all engaged at different levels. The empirical body of science from the research macrosystem serves as the foundation for supporting effective evidence-based treatment in medicine, especially occupational therapy, but has largely been built on White, educated, industrialized, rich, and democratic (WEIRD) samples (Henrich et al., 2010). By excluding a diversity of participants, research efforts in medicine and the social sciences have been responsible for perpetuating health disparities without equitable solutions. The narrow research space could not support the diversity that resulted from different socioeconomic strata, education (years and quality), sex, gender, race, ethnicity, nationalities, languages, and geographic residence (Babulal, 2020). This is often done implicitly through inclusion and exclusion criteria that may have selection bias, often unintentionally, and analytical models that result in valid findings but with a focus constraint that severely limits generalizability to other groups and the larger population (Babulal et al., 2022; Franzen et al., 2022). These standardized research practices are under scrutiny and being critically examined by funders to ensure that representation of a diverse sample exists in prospective and retrospective studies as well as clinical trials. Many academic journals are also revising their editorial boards to have more diverse and representative members and reviewers. There is also a concerted effort to implement new peer-review criteria to include standards to evaluate the WEIRD sample composition of a study and encourage authors to directly address in their papers restrictions relating to the sample. DEIJA serves as a tool to help break two cycles of hos[ti]pitality—(1) creating more entry points for broader participation of underrepresented populations in an enterprise that is safely guarded and policed by outdated values and (2) providing access to research participation by underrepresented groups—thereby strengthening equity in research and evidence-based outcomes.
The following are some practical strategies to ensure effective measures toward supporting the inclusion and success of diverse research in occupational therapy. 1. Research studies should be fundamentally designed to welcome and embrace diverse groups, ensuring that all individuals’ health issues and needs, in particular those from marginalized communities, are not only acknowledged but prioritized. This approach leads to genuinely equitable health care solutions and policies that more unconditionally honor the dignity and humanity of every participant who commits their time and body for the sake of research. 2. Researchers should embody DEIJA principles in their laboratories and programs as an ethical imperative, actively dismantling inequalities and addressing the needs of marginalized groups with intentionality and respect. This commitment fosters an unconditionally hospitable research environment that welcomes all individuals and actively works against the structures of exclusion and oppression (Lafferty et al., 2024). 3. Doctoral programs can transform their educational infrastructures to unconditionally welcome and support diverse individuals in pursuing research opportunities. This transformation should prioritize recruiting that is based more on life experiences and innovation than on academic metrics and creating an environment that actively seeks out and nurtures a wide range of talents and viewpoints, thereby enriching the scientific community through genuine inclusivity and representation. 4. Funders have an ethical obligation to create and expand grants and scholarship opportunities that support diverse researchers and their projects, especially in the early career stages. This commitment should reflect a deep understanding of the structural barriers these researchers face and aim to dismantle those barriers to ensure equitable access to resources and opportunities. 5. Researchers should be rigorously trained in cultural humility, enhancing their ability to partner with and conduct research within diverse communities with deep respect and without expecting reciprocity. This training must encompass a comprehensive understanding of history, social implications, cultural nuances, ethical considerations, preferred communication and dissemination methods, and fair remuneration, reflecting an unconditional commitment to hospitality and respect. 6. Comprehensive training on bioethics, various forms of bias in research, and the structural and social determinants of health should be integrated into research-focused academic programs. This training should also focus on the ethical recruitment, enrollment, and retention of diverse groups in research, ensuring that all practices reflect a profound commitment to sustained inclusivity and a moral responsibility for creating a space that welcomes participants as partners. 7. The definition of what is considered viable evidence should be expanded, and hierarchies of research should be reframed to include more nontraditional sources, such as open innovation/science, gray literature, and blogs (Beck et al., 2022; Bonato, 2018; McQuaid et al., 2023). Such radical paradigm shifts must be considered if the systemic foundations of hos[ti]pitality are to be disrupted. 8. Robust networks and mentorship programs for underrepresented researchers, designed to provide unconditional guidance, support, and opportunities for collaboration and professional growth, should be developed and sustained. These programs should be structured to dismantle barriers to inclusion and the power dynamics of control and should actively foster an environment of hospitality in research at the local, regional, national, and international levels.
Conclusion
Addressing DEIJA in occupational therapy is not merely about achieving representational diversity but about dismantling systemic barriers and fostering belonging if the profession is to evolve and remain relevant. Although commendable progress in incorporating DEIJA principles has been made, the risk of falling into conventional training of superficial compliance is high. The concept of hos[ti]pitality highlights the inherent tensions and hidden hostilities that can persist within ostensibly inclusive practices that can quickly become obscured by statements, policies, and mandates that are influenced by social forces that want to maintain the status quo. Genuine hospitality is aspirational and almost ethereal to grasp; however, we can endeavor to move to solidarity as a profession by authentically engaging with DEIJA. To move beyond performative gestures, occupational therapy must transparently embrace accountability and commit to actionable, sustainable changes. This involves rethinking educational curricula, enhancing support for minoritized students and faculty, and ensuring that research practices genuinely reflect and serve diverse populations. By embracing these strategies, the profession can create an environment in which all individuals are not only included but also empowered to thrive, ultimately leading to more equitable and effective health care outcomes.