Abstract
The philosophical foundations of occupational therapy, originating in North America, primarily align with American philosophy, which leads to challenges when occupational therapy is applied in diverse cultural contexts. The occupational therapy profession needs to embrace multiple philosophical orientations to enhance cultural sensitivity. In this column, the authors use postcolonial theory to analyze colonial legacies and power dynamics within communities, highlighting the limitations of current Western-based adaptations in promoting diversity, equity, inclusion, justice, and accessibility. They argue that incorporating diverse philosophical orientations into occupational therapy can enrich the field by fostering adaptability and inclusivity. They also outline steps to integrate multiple philosophical orientations, including acknowledging historical influences and adopting practices that resonate with diverse values. Embracing multiple philosophical orientations signifies the profession’s commitment to evolving and responding effectively to the complex needs of individuals and communities, thereby promoting more equitable and just outcomes in occupational therapy practice.
In this column, the authors analyze colonial legacies and power dynamics within communities and highlight the limitations of current Western-based adaptations in promoting diversity, equity, inclusion, justice, and accessibility.
Occupational therapy discourse is dominated by the assumption that the value of occupation is primarily determined by the individual engaging in a particular activity (American Occupational Therapy Association [AOTA], 2017, 2020c; Christiansen, 1999; Reed et al., 2011). This assumption is based on the American philosophy of pragmatism, which serves as the core philosophical orientation of occupational therapy and influences all aspects of the profession (Taff & Putnam, 2022). In this column, we draw on Legg and Hookway’s (2021) conceptualization of pragmatism to define it as a philosophical orientation that emphasizes the practical consequences and personal effectiveness of beliefs and actions. We define philosophical orientation as the worldview, or a set of guiding assumptions, that shapes how one interprets reality, knowledge, and human existence. Although it is understandable that occupational therapy’s core philosophical foundation is based on American philosophy because of its origins in North America (Christiansen & Haertl, 2014), this also poses notable challenges to its fundamental applicability across diverse practice settings and client groups. Occupational therapy practice must evolve if it is to authentically meet the diverse needs of different groups and cultures.
The dominance of a singular Western philosophy makes implementing cultural sensitivity within the occupational therapy profession challenging. Cultural sensitivity is defined as using knowledge, understanding, consideration, and respect to make appropriate adaptations when interacting with persons or groups from diverse backgrounds while being mindful of one’s own and others’ perspectives (Foronda, 2008). Even in the United States, occupational therapy’s pragmatic foundational philosophy does not resonate with all modern-day Americans, especially indigenous peoples, Black Americans, immigrants, and other marginalized groups. Therefore, cultural sensitivity is relevant to occupational therapy practice everywhere. Across the globe, many Eastern and Southern philosophies, such as communitarianism, holism, feminism, spiritualism, Taoism, and Confucianism, are often sidelined and not thoroughly explored in current occupational therapy practice (Guajardo et al., 2015; Núñez, 2019). In recent years, the occupational therapy profession has answered calls to position itself as a transformative health field by using strategies such as advocating for cultural sensitivity among practitioners and emphasizing client-centeredness as integral to its professional philosophy (AOTA, 2020a, 2020b; Malfitano & Lopes, 2018). Throughout this column, we argue that incorporating multiple philosophical orientations into the profession further showcases its readiness to adapt to the diverse needs and contexts of persons and communities. Although the strategies that have been used to address cultural diversity within the profession have been beneficial—for example, establishing priorities related to diversity, equity, and inclusion for occupational therapy research (Johnson et al., 2024)—a crucial issue that goes unaddressed is the difference in philosophical orientations between different groups of people. As a consequence, even well-intentioned occupational therapy practitioners who practice cultural sensitivity and prioritize client-centeredness may inadvertently impose Western philosophy on clients with different philosophical orientations.
In this column, we argue that to ensure truly culturally sensitive practices, occupational therapy should embrace multiple philosophical orientations. Incorporating multiple philosophical orientations means creating space for practitioners to draw from various theories and perspectives that might be more resonant with or applicable to different cultural, social, or individual circumstances. Incorporating diverse philosophical perspectives beyond those of Western societies fosters ongoing learning and critical reflection and enhances the effectiveness of occupational therapy interventions (Kinébanian & Stomph, 2010). Furthermore, an openness to multiple philosophical orientations aligns with the evolving nature of the profession (Halle et al., 2018; Hasselkus & Dickie, 1994; Lawlor, 2021; Restall & Egan, 2021). As an evolving profession, the adaptability afforded by multiple perspectives will contribute to occupational therapy practitioners’ ability to respond to the complexities of human experiences and societal changes (Laliberte Rudman et al., 2019; Larsson-Lund, 2018; Schiller et al., 2023). In essence, embracing multiple philosophical orientations within occupational therapy signifies a commitment to growth, inclusivity, and responsiveness, positioning the profession on a path that aligns with the evolving needs and values of the persons and communities it serves.
Theoretical Framework
In this column, we incorporate postcolonial theory (Gandhi, 2018; Said, 1977) as an analytic lens through which we understand how historical power imbalances, such as colonialism, still affect people today. This framework allows us to critique the domination of Western ideologies and the marginalization of indigenous knowledge systems, highlighting how the ongoing effects of colonization continue to affect minority and marginalized groups. We assert that occupational therapy must be carefully integrated into the occupations of different cultures in a participatory manner that actively involves indigenous people. For example, an occupational therapist might work with an indigenous community to incorporate traditional healing practices into therapy rather than relying only on Western methods. The occupational therapy profession must embrace multiple philosophies that align with and respect diverse cultural perspectives to ensure that it remains relevant, accessible, and equitable in the United States (Taff & Blash, 2017).
The legacy of Western colonization continues to affect communities across the globe, including their languages, governances, and cultural practices, long after formal colonization ended (Césaire, 2010; Kortright, 2003; Mazrui, 2013). Changes in cultural features caused by colonization have directly influenced how occupations are carried out and the meanings that are ascribed to these occupations (Bolt et al., 2022; Ogbechie, 2018). For instance, enslaved Africans adopted Christianity under duress from British colonizers and missionaries, leading to substantial changes in their spiritual traditions. However, over time, this religion and its associated institutions became fundamental pillars of strength for the Black community in the United States (Allen, 2019; Gates, 2022).
Many indigenous groups have different ways of doing things yet share common beliefs and ideologies. For example, many African ethnic groups have shared ideologies, such as communitarianism (Idang, 2018; Molefe, 2020). According to the theory of Afrocentricity (Diop, 1989), shared ideologies may exist among people of African heritage, including Africans, African Americans, African Caribbeans, and other groups across the globe that originated in Africa. The Afrocentric philosophy of communitarianism differs from the Western philosophy of individualism. This difference in philosophical orientations may be reflected in the daily routines of different groups. Therefore, even when Western models are adapted, important cultural details are sometimes missed. For instance, a feeding intervention involving cutlery may not be comfortable for families who prefer eating with their hands. In many African cultures, eating together with the hands from shared plates is a tradition that strengthens unity and enhances food taste (Pan African Lifestyle, 2023). This reflects Afrocentric values, in which eating with the hands is often preferred. In contrast, Western cultures typically emphasize the use of cutlery and individual plates. As a result, incorporating cutlery into therapy interventions may not resonate with or be well received by people from Afrocentric backgrounds.
In this section, we have used postcolonial theory to frame how occupational therapy is dominated by Western frameworks, which often fail to meet the needs of non-Western populations. In the following sections, we explore how this dominance contributes to the shortcomings of current Western-based adaptations in addressing cultural sensitivity. We also discuss the need to incorporate into the field multiple philosophical orientations to drive efforts related to diversity, equity, inclusion, justice, and accessibility (DEIJA), and we outline the steps the profession must take to embrace diverse perspectives to achieve a more inclusive practice.
Current Western-Based Adaptations Do Not Suffice as Measures of Cultural Sensitivity
In this column, we challenge the assumption that existing cultural adaptations through DEIJA efforts effectively mitigate issues of cultural imposition. We assert that if cultural nuances are to be accommodated, diversity needs to be acknowledged at the philosophical level. Some occupational therapy scholars may argue that there is no need to criticize the profession’s philosophical foundation because many occupational therapy frameworks, models, interventions, and theories have been adapted to align with diverse settings outside their places of origin (Owen, 2014; Vermaak & Nel, 2016). Although we believe that existing frameworks, models, interventions, and theories have applicability in numerous settings, the fact remains that a lot of rigorous work is required to make them sensitive to cultural nuances (Goldstein et al., 2012). Research has found that despite efforts to tailor existing Western-originating models to various indigenous contexts, these adaptations do not quite fit in the contexts to which they have been adapted because they fail to address some of the cultural nuances embedded in different philosophical orientations (Akrofi et al., 2023; Jansen-van Vuuren et al., 2021). Researchers may not even consider what may be truly important for historically underrepresented groups given that they have previously not sought these groups’ perspectives. Therefore, it would be more appropriate to identify the philosophical orientations of target populations and tailor interventions accordingly (Whalley Hammell, 2015). Previous research has suggested that one reason occupational therapy practitioners struggle to establish the relevance of their profession and receive buy-in from their communities is the fundamental distinctions between Afrocentric philosophy and Western philosophy (Akrofi & Njelesani, 2024). Hence, we assert that without philosophical interrogation, constructs rooted in Western ideologies will remain insufficient when applied to non-Western societies.
Incorporating Multiple Philosophical Orientations to Promote Positive DEIJA-Related Change
By embracing various philosophical orientations, occupational therapy practitioners can accommodate multiple scopes of practice tailored to the unique philosophies of different communities or regions. For instance, practitioners from South America and Africa have developed social occupational therapy (Malfitano et al., 2014) and population-based approaches to occupational therapy (Correia et al., 2021; Watson, 2013), enriching occupational therapy practice. These approaches are rooted in philosophies of communitarianism and feminism and emphasize holistic understanding, community-centered approaches, strengths-based perspectives, advocacy of occupational justice, consideration of social determinants of health and public health perspectives, and the empowerment of individuals. The population-based approach advocated by Watson (2013) helps occupational therapy practice move beyond the individual and small-group therapy interventions that are typical of Western philosophy to interventions implemented at the population level. Similarly, social occupational therapy emphasizes interdisciplinary and intersectoral practices, bridging the micro and macro social dimensions across various contexts. Social occupational therapy, as articulated by Malfitano and Lopes (2018), involves politically and ethically framed professional practices that address the rights of individuals, groups, or systems disadvantaged by social conditions. These approaches signify a departure from the individual-centered focus often associated with neoliberal capitalism, which is prevalent in mainstream Western occupational therapy practices (Kumar & Hill, 2012); instead, they prioritize social transformation and development to address broader societal issues and advocate equitable access to meaningful occupations for all people. The incorporation of these approaches into occupational therapy practice is a pivotal stride toward recognizing diverse cultural and social contexts in defining the scope of occupational therapy, highlighting the imperative need for more inclusive and community-oriented approaches to the profession (Malfitano et al., 2021; Richards & Galvaan, 2018).
The Kawa model, developed by Iwama in 2006, is a prominent example of a non-Western model currently adopted in mainstream occupational therapy practice that has gained widespread acceptance in Western contexts (Iwama, 2006; Ober et al., 2022). Rooted in Eastern philosophies that emphasize holism and harmony with nature, this model has gained significant traction among occupational therapists across the globe (du Toit & Surr, 2012; Lape & Scaife, 2017; Naidoo et al., 2023; Newbury & Lape, 2021). It is frequently integrated with other models, frameworks, and practice guidelines (Ober et al., 2022). The Kawa model serves as an example of fostering culturally responsive practice (Iwama et al., 2009) and demonstrates how non-Western models, frameworks, and theories can effectively be assimilated into occupational therapy to address diverse cultural needs.
Steps the Profession Must Take to Embrace Multiple Philosophical Orientations
Sterman et al. (2022) identified strategies occupational therapy educators can use to promote DEIJA, including practicing reflexivity, advocating for the representation of minority groups, adjusting teaching methods, and building capacity for diversity and inclusion. These strategies are beneficial not only for educators but also for all occupational therapy practitioners. In this review, we acknowledge the limited literature on non-Western philosophical orientations in occupational therapy practice and urge further research to develop models that integrate diverse perspectives. We propose that an essential first step toward the adoption of multiple philosophical orientations is to provide training for occupational therapy practitioners that will help them cultivate critical reflection and cultural sensitivity through a process of critical reflexivity (McCorquodale & Kinsella, 2015). These trainings should go beyond the basic understanding and practice of cultural sensitivity to include exposure to different philosophical orientations from scholars with diverse cultural backgrounds (Sterman et al., 2022). For example, students might participate in case-based learning that compares occupational therapy practices rooted in Western theories with those based on Southern or Eastern perspectives. This approach will allow them to be exposed to and draw from a wide range of philosophical orientations. Promoting a culture of critical reflexivity within the profession should be approached systematically, beginning with a targeted focus on students enrolled in entry-level occupational therapy programs. By incorporating critical reflexivity into the educational curriculum at this foundational stage, we can cultivate practitioners who possess not only the requisite technical skills but also a heightened awareness of their own assumptions and perspectives (van der Merwe, 2019; Sterman & Njelesani, 2021).
Moreover, continuous professional development programs and workshops can be organized to enhance practicing occupational therapists’ awareness and knowledge of the multifaceted nature of their profession. These initiatives should foster an understanding of the dominant perspectives influencing occupational therapy practice and encourage practitioners to critically examine and challenge these perspectives (Mahoney & Kiraly-Alvarez, 2019). Occupational therapists must acknowledge that their positionality, lived experiences, perspectives, and biases shape how they understand the world and their clients (Vij & Webb, 2022). For instance, two occupational therapists may read AOTA’s (2020c) Occupational Therapy Practice Framework: Domain and Process and have entirely different understandings of what community participation as an occupation entails. More specialized training is needed to equip practitioners with critical skills, which will allow them to contribute to theory development and evidence-based practices rather than leaving this role to researchers and academics. For example, training in participatory research could equip practitioners to work collaboratively with clients and communities to develop culturally relevant models, directly enhancing theory and evidence-based practice.
Taking a postcolonial perspective highlights the critical and ongoing necessity to diversify the occupational therapy workforce (AOTA, 2007; Taff & Blash, 2017). It is imperative to ensure the representation of persons from diverse cultures within the workforce and to actively engage them in contributing their indigenous knowledge to building diverse philosophical orientations. There is insufficient representation of minority groups across occupational therapy practitioners, researchers, academics, administrators, and managers at all levels (Brown et al., 2021). This lack of representation unintentionally creates barriers that prevent many practitioners from minority backgrounds from contributing to the profession’s knowledge base. Moreover, occupational therapy educational programs predominantly emphasize knowledge generation at advanced or terminal degree levels, where minority groups are often underrepresented. This perpetuates a cycle that limits opportunities for these groups to shape and advance the field through their perspectives and experiences. In addition, practitioners from marginalized backgrounds who aspire to engage in knowledge generation may encounter financial or resource constraints that hinder their ability to participate in essential research and professional development activities (Akrofi & Njelesani, 2024). To effectively address these challenges, it is crucial to establish more grants specifically dedicated to promoting research and innovation related to DEIJA in occupational therapy. These grants should be intentionally designed to support initiatives that amplify the voices and contributions of minority and marginalized groups within the profession.
In academia, occupational therapy can embrace multiple philosophical orientations by expanding curricula to cater to the holistic and communal needs of all societies (Shahjahan et al., 2022). For example, in an African context this shift may involve moving beyond traditional individual-focused models to adopt community-centered approaches (Jansen-van Vuuren et al., 2020). The World Federation of Occupational Therapists’ (2016) standards on education particularly emphasize the need for occupational therapy programs to be culturally relevant, which should be a priority for educational institutions when establishing and running these programs. This approach includes integrating indigenous healing practices, traditional health knowledge, and local challenges into training, ensuring that occupational therapy practitioners are well prepared to meet the specific needs of their communities.
Furthermore, mentorship programs led by practitioners who embody cultural sensitivity are essential. These mentors can guide and support aspiring researchers without imposing their assumptions or ideologies, thereby fostering an inclusive and supportive environment for professional growth. An exemplary initiative in this regard is the American Occupational Therapy Foundation’s (2024) STRIDE Grant, which exemplifies a targeted effort to support DEIJA-related research and innovation in occupational therapy. Such initiatives not only advance the field but also cultivate a workforce that reflects and respects diverse perspectives, ultimately enhancing the quality of care and services provided to diverse populations.
The occupational therapy profession can also leverage the African philosophy of communitarianism. By embracing African communitarianism, occupational therapists can deepen community engagement and cross-cultural collaboration, ensuring that services meet the specific cultural needs of clients by involving families, communities, and stakeholders (Jansen-van Vuuren et al., 2020). A shift from client- to community-centered care integrates indigenous knowledge, transforming practitioners into active learners. This approach enhances therapeutic effectiveness, honors local traditions, and strengthens community well-being, advancing the profession and fostering inclusive, culturally diverse care (O’Brien et al., 2021).
We acknowledge that efforts to adopt multiple philosophical orientations may encounter resistance from practitioners because doing so may challenge the assumption of a universal scope of practice. Furthermore, this shift demands systemic changes in education, necessitating dedicated resources and institutional commitment. To address these challenges, systemic advocacy and funding for cross-cultural training programs are essential. Despite these potential challenges, we assert that such a transformation is not only timely but also imperative to fostering a profession that is truly relevant, adaptable, and responsive to the diverse needs of the populations we serve.
Conclusion
As occupational therapy strives for inclusivity, these recommendations can serve as a road map for practitioners to build an equitable, culturally responsive future. By embracing diverse philosophies and empowering minority groups, the profession’s scope expands beyond Western perspectives, addresses historical inequalities, and ensures equitable access to services. This transformative approach amplifies marginalized voices and fosters innovation, ensuring that practices are sensitive to diverse cultural needs.