Breaking the silence: Racism and anti-racism in occupational therapy

In everyday occupational therapy practices, where passion and expertise intersect, a silent adversary lurks, compromising the foundations of our professional practice: racism

Occupational therapy originated in Western Europe and North America and as a result, has long held Westernised views such as independence and capitalism at its core (Mahoney & Kiraly-Alvarez, 2019). As occupational therapy practices and education programs have expanded into non-Western locations, the dominant Western cultural narrative has prevailed.

When we persist in valuing Westernised ideals in occupational therapy without questioning them, we risk exacerbating power imbalances within occupational therapy practice that diminish non-western values and occupations. We also risk alienating occupational therapists who themselves do not align with Westernised values and occupations. The result may be occupational therapy services that are not able to meet the needs of all communities in an equitable way.

In 21st century Australia, we have struggled to come to terms with our colonial past. Racism has been embedded in policies and practices for 200 years and has sought to exclude non-white settlers and First Nations Peoples. Australia has historically imposed an expectation of ‘assimilation’ into white Anglo culture, combined with a denial of the racism that non-white communities have endured (Elias et al., 2021). It is no surprise that the occupational therapy profession in Australia has also been impacted by this colonial past and the issues of racism acknowledgement and denial of privilege.

But this is not what we set out to achieve as a collective profession. Occupational therapy is a profession that has inclusion and participation at its core. We have long advocated for the inclusion of people and communities who have traditionally been excluded. As a profession, there have been many initiatives that have worked towards anti-racism, for example, cultural responsiveness is written into the Occupational Therapy Competency Standards (AHPRA, 2018).

Despite this, occupational therapists work within health and community institutions where racism is pervasive and at times, invisible. Institutional racism occurs when organisations fail to reflect, question and challenge historical ways of delivering health services to culturally and linguistically diverse (CALD) communities (Elias & Paradies, 2021). The result is health institutions that preference the needs and rights of one group of service users over others, exacerbating health inequities for example between CALD and non-CALD people in Australia (Khatri & Assefa, 2022).

Racism has been estimated to cost the Australian economy $37.9 billion per year, just over 3% of Australia’s overall GDP (Elias & Paradies, 2016). These costs were determined by measuring the negative health outcomes associated with experiences of racial discrimination, which impact individuals, families, communities and government institutions.

Occupational therapists are at the forefront of providing critical health services to diverse communities. Recent systematic reviews have evidenced occupational therapy as an effective therapy, resulting in lower health costs and improved outcomes for people in hospitals (Lockwood & Porter, 2022) and in the community (Rahja et al., 2018).

However, the profession in Australia is made up of predominantly middle-class white women, who in the course of delivering high quality health care may be blinded to the institutional racism pervading the policies and practices of the health systems they work within. The first author of this article also identifies as a middle-class white woman and has experienced lifelong unearned privileges as a result of this.

A structural perception of racism has been found to be associated with “increased support for policy initiatives designed to combat the effects of societal racial inequity” (Rucker and Richeson, 2021, 19, 22). In other words, if people understand the foundational and structural nature of racism, they are more likely to support anti-racism remedy. This is why confronting the denial of racism and privilege is so important. Confronting and acknowledging this privilege can be uncomfortable. Lerner and Kim (2022) have suggested that confronting the reality of one’s own privilege and the associated discomfort, is the first important step on the road to anti-racism. Some scholars argue that if people are too uncomfortable by confronting their own privilege, they disengage from antiracism initiatives (Smith et al., 2022), which is counterproductive. In keeping with a tried and tested mantra in occupational therapy, perhaps we need to seek the ‘just right challenge’ in facilitating our predominantly white profession to acknowledge their own racial privilege and raise awareness in their workplaces in a way that challenges enough to inspire change, without inciting defensiveness. So, what can we do to move towards anti-racism in our everyday lives?

1. Practice reflexivity. This is a process of reflecting on your own power and privilege and how this impacts your practice. Nixon (2019) presents privilege and oppression as two sides of the same coin. With privilege on the top and oppression on the bottom. Whether you are at the ‘top’ of the coin (privilege) or the ‘bottom’ of the coin (oppression), you did nothing to earn your place there. For those at the top, take the time to reflect on how this impacts your interactions with occupational therapy clients. Anti-racism is not just about learning, it is also about unlearning some of the things we have come to know and accept or things we were blind to that have exacerbated inequities. Sterman and Njelesani (2021) have urged occupational therapists to ask themselves, what is the dominant cultural narrative that is reflected in your occupational therapy practice and in the policies and systems which govern your practice? Do racist narratives infiltrate your workplace, for example a culture of blaming or shaming particular groups, or expectations of compliance? Is there a denial of the existence of racism in your workplace?

2. Challenge biases. Challenge the biases present in theoretical models of occupational therapy that are prominent in occupational therapy practice and education. Categories of self-care, productivity and leisure reflect predominantly white and middleclass values (Mahoney & Kiraly, 2019). Whose perspectives are represented when deciding which occupations and activities are most meaningful?

3. Engage in cultural humility. This is a process of recognising that cultural differences may manifest through interactions between therapists and their culturally diverse clients. When we meet someone in a therapeutic relationship, we do not always know everything, but we can be open to listening and learning what their meaningful occupations are (Lerner & Kim, 2022). There may be a discomfort in not having the answers to give your client. Beagan (2015) described that cultural humility is not about having the right answer, but rather, asking the right questions (Beagan, 2015).

4. Recognise intersectionality. Recognise the multifaceted and intersecting identities of the people we support (Buchanan & Wicklund, 2020). Do not reduce a person to only their cultural diversity in practice. Recognise the impact of intersectional disadvantage where a person may be a member of multiple groups that experience disadvantage, exacerbating the inequities in accessing health care for example, people with disabilities or members of LGBTIQ+ communities.

5. Engage in bystander anti-racism. Occupational therapists may witness racism in their daily practice. This could be from colleagues, clients or carers and they may not know how to respond appropriately and safely. Bystander anti-racism involves calling out racism when you witness it in the moment.