This is a shortened version of the first Hanneke van Bruggen lecture, presented by the author at the 17th Annual Meeting of ENOTHE in Ghent, Belgium (2011).
As an enthusiastic traveller, I observe that occupational therapy is recognisably the same profession in every country I have visited, but it also differs in the ways that it is taught and practised, reflecting diverse cultural norms and expectations. Through discussions with colleagues around the world, I have learned to appreciate just how flexible and adaptable occupational therapy can be, when we have the skills and confidence to set goals and deliver our services in ways that are culturally and socially relevant to diverse settings.
What is diversity?
Diversity means difference, variety and being unlike each other (Shorter Oxford English Dictionary 2002). For example, the term biological diversity, or biodiversity, means 'the variability among living organisms from all sources… and the ecological complexes of which they are part; this includes diversity within species, between species and of ecosystems’ (UN 1992). We know that biodiversity is essential to life on earth because:
It is the combination of life forms and their interactions with each other and with the rest of the environment that has made Earth a uniquely habitable place for humans. Biodiversity provides a large number of goods and services that sustain our lives. (Secretariat of the Convention on Biodiversity 2000)
Homosapiens is itself a diverse species, with people differing from each other along a huge number of dimensions: gender, race, age, height, intelligence, religious beliefs, emotional resilience, sociability, creativity, ambition, energy, physical fitness, pain tolerance, health, longevity, style of dress and culture, to name just a few. The commonalities we share with others contribute to the fulfilment of a deep need for belonging and community, but it is the differences between people that give us our sense of personal identity and agency. Each of us needs to know that we can make a unique and valuable contribution to the development and wellbeing of our communities (Nixon 2012).
Diversity is essential to human survival and wellbeing, because it is not the similarities between people that drive development, innovation and adaptation, but the differences. The Universal Declaration on Cultural Diversity states:
As a source of exchange, innovation and creativity, cultural diversity is as necessary for humankind as biodiversity is for nature. In this sense, it is the common heritage of humanity and should be recognized and affirmed for the benefit of present and future generations. (UNESCO 2001)
How this paper is organised
This paper addresses the issue of diversity in occupational therapy. It argues that the profession started with a predisposition to acknowledge and accommodate diversity, that has not been fully realised in practice. The role of the human rights discourse in promoting diversity is considered, highlighting that recognising a person’s rights is not the same thing as valuing their individuality. The paper then addresses three challenges the profession faces in moving towards greater diversity: the composition of the workforce; access to occupational therapy services, and professional education. The paper finishes with a summary of why diversity is an important issue for occupational therapy.
Diversity and occupational therapy
When the profession of occupational therapy was founded, at the beginning of the 20th century, the concept of diversity did not appear in the literature, although an implicit acceptance of human differences can be inferred from the writings of the first practitioners. For example, a paper on occupational therapy, delivered at the Glasgow Royal Mental Hospital in 1924, suggested that ‘instead of thinking in groups, we must develop a more individual touch than has ever previously characterized mental hospital organization’ (Henderson 1925, p. 64). Elizabeth Casson, who started the first school of occupational therapy in the UK, in 1930 (Paterson 2010), wrote that ‘even in cases of physical illness [occupational therapy] is primarily psychological’ (Casson and Foulds 1955, p. 113) and, as such, ‘must be applied to each patient as an individual’ (p. 123).
A practice that is tailored to the needs of the individual is able to accommodate diversity.
Despite this positive beginning, by the early 21st century it was found that ‘despite the occupational therapy profession’s declared allegiance to client-centredness, there has been little effort to enable the perspectives of diverse client groups to infiltrate theories of occupation’ (Hammell 2009, p. 11). Today, throughout the world, some occupational therapists employ the same theories, models, processes and techniques with all clients, without critical evaluation of their social, cultural and personal relevance. An example of this is shown in Box 1.
BOX 1: Using a universal approach
An occupational therapy service manager in the UK decided to introduce her chosen model for practice across the whole service, rather than encouraging staff to find appropriate ways of working with diverse needs and preferences.
The impetus… to choose a service-wide model was in part driven by the need for the profession to establish its identity and clarify its contribution in the current healthcare marketplace… advances in the profession sometimes require a more collective or corporate approach, in which professional members come to use a shared language, along with a common toolbox of structured assessment tools and intervention resources. (Wimpenny et al 2009, p. 514)
The manager quoted in Box 1 uses the language of business to justify the adoption of a single model for practice: marketplace, corporate approach, common toolbox. Yet, a Nobel prize winning economist has argued for greater diversity of models:
'We need a variety of alternative forms of economic organisation. We… have focussed too long on one particular model.' (Stiglitz 2010, p. 46)
In 2020, the death of a young, black man being forcefully restrained by police in the USA led to widespread protests under the banner of ‘Black lives matter’. The World Federation of Occupational Therapists (WFOT) published a statement of support for the movement, stating that ‘systemic racism needs to be addressed as a global priority’ (WFOT 2020). It will be interesting to see what actions the profession takes in support of this priority during the next few years.
As stated in the introduction, diversity is not an option in the modern world but is essential to drive development, innovation and adaptation, whether in economics or healthcare. However, this perspective was not prominent in the human rights discourse of the second half of the 20th century.
The publication of the United Nations’ Universal Declaration of Human Rights in 1948 acknowledged the need to recognise and appreciate diversity. Article 2 of the Declaration states that:
Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Furthermore, no distinction shall be made on the basis of the political, jurisdictional or international status of the country or territory to which a person belongs, whether it be independent, trust, non-self-governing or under any other limitation of sovereignty. (UN1948)
This means that diversity in any characteristic should not exclude a person from enjoying the same rights and freedoms as everyone else in the world. Many governments have enshrined the principles of the Universal Declaration of Human Rights in law so that there is not only recognition but also protection of the rights of vulnerable groups, such as women, children and disabled people.
Over the past 70 years, the language of human rights has permeated society, including the education, health and social care systems of many countries. Health and social care personnel are expected to work within a human rights framework that includes respect for all persons. For example, the WFOT Code of Ethics requires that:
Occupational therapists approach all persons receiving their services with respect and have regard for their unique situations. They will not discriminate against people on the basis of race, colour, impairment, disability, national origin, age, gender, sexual preference, religion, political beliefs or status in society.’ (WFOT 2016)
In 2010, the WFOT published a position paper on diversity and culture, which stated ‘that every person is unique in the way they combine the dynamic interplay between cultural, social, psychological, biological, financial, political and spiritual elements in their personal occupational performance and participation in society’. To state that every person is unique ‘implies that we acknowledge that a diversity of people represents a diversity in values [and suggests] a deep responsibility at the heart of occupational therapy, which entails the practice of respect for people’s differences’ (Kronenberg et al 2011, p. 2).
The United Nations and WFOT positions on human differences emphasise the right of all people to full participation in society rather than stressing the vital necessity of maintaining and fostering diversity. We tend to think that inclusivity is to the benefit of disadvantaged people without necessarily recognising that it benefits all of us equally. As occupational therapists, we have a responsibility to ‘incorporate diversity and culture in [our] daily practices… educational programmes, occupational therapy research and the WFOT’ (Kinebanian and Stompf 2009, p. 18), but do we understand that diversity is not optional but necessary, as stated by UNESCO (2001). Diversity is not a problem to be solved, or even a right to be upheld, but is an essential component of human survival and wellbeing.
Challenges for occupational therapy
The Brazilian occupational therapist, Sandra Galheigo (2011, p. 62), spoke of ‘the risk of producing conformity, instead of emancipation’. Perhaps the greatest risk to occupational therapy at the present time is that we become so conformist we lose the capacity to adapt to rapidly changing social, political and economic conditions. In many countries throughout the world, the practice of occupational therapy is already falling short of what it could be and there is a danger that we will not survive as a profession unless we remain true to our values.
At its best, occupational therapy practice reflects a humanistic, person-centred, non-discriminatory ethos that grew from our founding philosophies and continues to absorb new influences, including a human rights perspective. This has enabled the profession, for over 100 years, to match services to the needs of the populations we serve. But, if we are to continue to thrive, more effort must be made to increase the diversity of the occupational therapy workforce, the people who access our services and our professional education.
The occupational therapy workforce
How diverse are occupational therapists? The first practitioners were young, educated, white women from relatively affluent families (Paterson 2010), not representative of most of the populations they served. Does the present composition of the profession better reflect local demographic profiles, or do we select students to be as much like ourselves as possible: mostly young, educated, predominantly white, mainly female and relatively affluent?
In the United States, the Sullivan Commission (2003) on minorities in the health professions identified five principles for increasing diversity in the healthcare workforce:
Diversity is critical to increasing cultural competence and thereby improving health care delivery
Increasing diversity in the workforce improves patient satisfaction
Under-represented minority providers tend to practice in underserved areas, thus improving access for the most vulnerable
There are valuable economic benefits
Social justice is served
However, a European occupational therapy academic pointed out that:
Students of different migrant or ethnic minority backgrounds often feel excluded by teachers and fellow students and not attracted to occupational therapy programmes. Furthermore, there is a high dropout rate… It is quite difficult to find good practice about successfully implemented diversity policy in occupational therapy practice and education (van Bruggen 2009, p. xv).
If we are to accommodate a wider range of client needs, the profile of the occupational therapy workforce should better represent the ethnicity and gender of the populations with whom we work, their social, cultural and linguistic backgrounds, their contexts and their interests.
Access to occupational therapy services
Occupational therapists claim to work with anyone who has occupational needs (Creek 2003) but, in reality, we discriminate against certain groups of people, often without being aware that this is what we are doing. Discrimination occurs when services set criteria for who is eligible to receive them without thinking through the consequences for those who are excluded. What might make someone ineligible for occupational therapy?
We may exclude some people from access to our services as a defence against the anxiety of working with those we fear we cannot help, because we judge that they are too ill or otherwise unsuitable. A South African occupational therapist argued that ‘the culture of an institution, which can inform the policy and procedures of that institution and influence its primary task, may be established as a defence against the primitive unconscious anxieties that arise from the workers’ direct contact with clients’ (Nicholls 2007, p. 72). The rhetoric of occupational therapy says that we are concerned with ‘the meaning and purpose that clients place on activities and occupations and with the impact of illness or disability on their ability to carry them out’ (Creek 2003, p. 31). Yet, hearing how our clients feel about the impact of illness or disability on their lives can be anxiety-provoking and we may look for ways to protect ourselves.
A Canadian psychiatrist (Kirmayer 2001) identified that some truths, as defined by the dominant medical discourse, protect the clinician but damage the patient. For example, every psychiatrist has a checklist in his head when he listens to a patient: this checklist contains the information that he needs to make his diagnosis. Every time the patient says something that matches an item on the checklist, the psychiatrist makes a mental tick: ‘I wake up very early in the morning and can’t get back to sleep’ – tick; ‘My clothes are getting loose because I’m not interested in food’ – tick; ‘I think my family would be better off without me’ – tick. Anything the patient says that is not relevant to the checklist is ignored or simply not heard, becoming a lost narrative.
Occupational therapists may have a different checklist in our heads but much of the client’s narrative is still lost because the therapist is looking for specific information rather than trying to hear her or his real concerns. We think that we want to hear what the client has to say but, in reality, we fear that we will not be able understand or cope with a diversity of needs. It is safer to carry out a procedure or fill in a checklist than to confront our own inadequacy in the face of another’s distress; safer to follow prescriptions than to acknowledge that we have choices (Freire 1972).
Those occupational therapists who seek certainty in their work cling to models of practice, tools and procedures that they hope will reveal the facts of their clients’ problems and lead to the right intervention. Graeme Smith identified this need in his Casson Memorial Lecture:
If we allow our professional narratives to be constrained by tests and formal procedures, we will not be able to get close to our clients. Some practitioners feel safer keeping the professional boundaries intact: they may choose to go into areas of work where they are protected by badges, uniforms and technical expertise (Smith 2006, p. 305)… Practitioners fear uncertainty, which feels unsafe and aspire to certainty, which gives the illusion of safety, of knowing where we are going (op cit, p. 306).
The desire for certainty shows not only in the models and procedures followed by many practitioners, but also in how occupational therapy is taught.
Occupational therapy education
The Brazilian educationalist, Paulo Freire, described a ‘“banking” concept of education’ (Freire 1972, p. 46), in which the teacher’s task is ‘to “fill” the students by making deposits of information which he considers constitute true knowledge’ (op cit, p.49). Banking education imposes a passive role on students, discourages critical thinking, minimises creativity and encourages learners to adapt to the world as it is, rather than seeking to transform it. An occupational therapy programme that employs the banking model of education presents theories, models and approaches to practice as though they are both true and universally applicable. Tutors may claim to teach critical appraisal but they discourage any real challenge to their professional authority.
When we teach occupational therapy students, we not only deposit knowledge but also transmit the profession’s beliefs, values, principles and ways of doing things. If students are treated as passive recipients of knowledge, they learn to treat their clients as passive recipients of the occupational therapist’s expertise.
When students are taught to follow models and processes, rather than thinking through the complexity of each client’s situation, they become therapists who conform and who expect their clients to comply.
The professional rhetoric of occupational therapy proclaims that each intervention is ‘a partnership between the client and the therapist, in which both participate actively, thus increasing the client’s responsibility, choice, autonomy and control’ (Creek 2003, p. 30). If this is what we believe, then occupational therapy education should not follow the banking approach, but strive to create a partnership between teacher and student in which both participate actively, thus increasing the student’s responsibility, choice, autonomy and control.
Freire (1972, p. 19) described this approach as ‘a dialogical and problem-posing education’, in which the teacher and students learn in dialogue with each other and are jointly responsible for the process. The teacher ‘does not regard [knowledge] as his private property, but as the object of reflection by himself and the students’ (op cit, p. 54). An occupational therapy educator who espouses the problem-posing model of education presents real problems ‘to the students for their consideration, and re-examines his earlier considerations as the students express their own’ (op cit, p. 54). She or he is driven by curiosity, enjoys exploring and challenging received knowledge and promotes critical exploration in the students.
Problem-posing educators trust in their students’ ability to think independently, to know what they want and to understand the world for themselves (Freire 1972). By inviting their students to bring their own knowledge and expertise into the learning situation, and to share it so that all can learn from each other, these educators are modelling a way of doing occupational therapy that engages the client as an active partner in the process of intervention.
Summary and conclusion
The argument presented here is that diversity among people is not simply a human rights issue but a necessary condition for the survival of the human race. Just as biodiversity provides mutually sustaining habitats for different species, so cultural diversity can be seen as ‘an adaptive process… guaranteeing the survival of humanity’ (UNESCO 2001). Occupational therapists claim to respect people’s differences but this does not go far enough. We need to value human diversity as an essential characteristic of a thriving profession, that is fit for purpose in the modern world.
Occupational therapists need to confront three challenges, as a matter of urgency: increasing the diversity of the occupational therapy workforce; making our services accessible to a wider range of people, and incorporating a greater diversity of ideas into our professional curriculum.
We can choose to cling to the illusion of certainty produced by conforming to the dominant structuralist discourse, or we can choose to embrace a diversity of cultures, ideas, approaches, education and research, that will allow us to envision and create our future.
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