Critical Reflexivity and Occupational Therapy.

Hey friends. I know you’re all probably dying to know more about what I am doing/learning in school, yes?

Part of the reason I have been blogging less is that my writing efforts have had to be directed elsewhere. But I thought, why not kill two birds with one stone, or feed two birds with one scone, as it were. I had to write a final essay for my Occupation and Society: Theory and Practice class that I was proud of and I thought I would share it with you as a way to both put together an easy post and share what I have been up to these last few months.

The essay is about critical reflexivity. If you are unfamiliar with the term, here is a very basic definition.

Critical reflexivity involves aspects of reflection, in addition to the act of interrogating one’s situatedness in society, history, culture, and how this may shape one’s values, morals, and judgments at both individual and social levels.

I took this definition out of a lecture by an OT named Erin Duebel. There is no citation on the particular slide it was on, so I can’t say for sure where she got it or if she wrote it herself. Anyways, that is a vague description. Feel free to give it a goog if you would like more.

The question given to us was this:

Discuss why it is necessary to be critically reflexive about our traditional understandings of occupation, disability, and inclusion. What are the implications for occupation-based research and practice?

I feel that I should point out that this essay had a VERY strict word limit. So I feel like I actually wrote a slightly better essay, but then had to revise the living daylights out of it to get it under the word limit. So if it feels short or like there was much more to say, know that there was, I just wasn’t allowed to say it in this situation. Also it was clearly outlined to us that we needed to thoroughly cover each of the underlined topics – hence the ‘paragraph dedicated to each’ format. Anyways, enjoy:

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Critical reflexivity seeks to question the “conditions under which knowledge claims are accepted and constructed” (Kinsella & Whiteford, 2009, p. 251). Within occupational therapy it aims to challenge current practices and enact change to improve client-centered practice (Phelan, 2011). As occupational therapists, we have assumptions about what occupation, disability, and inclusion mean. Constructed ideals and patterns of thought and action are increasingly viewed as ‘norms’, and as the only correct way of approaching a particular issue (Kantartzis & Molineux, 2011). Critical reflexivity is necessary because it insists that we closely examine our assumptions about occupation, disability, and inclusion in order to determine if the way we approach and define these terms is helping or harming our clients. Challenging these assumptions leads us to challenge the way that we conduct research and the way we practice occupational therapy.

Occupational therapy theory has long-standing and ingrained assumptions about occupation. One of these assumptions is the idea that individuals choose to participate in occupations they find meaningful. Christiansen (1999) states that “individual persons create their unique identities and life meanings through occupations” (p. 556). When we critically examine this idea, a few important things stand out. First, it is reflective of a western culture that values free choice and independent occupational identities (Phelan & Kinsella, 2009). Overall, Phelan and Kinsella (2009) state that the idea of occupational choice shows itself to be rooted in “white, middle class, American and European culture” (p. 87). Second, it is making the assumption that free choice exists and that each person has the ability and self-efficacy to build their own occupational identity. It does not take into consideration occupational injustice or concepts such as occupational deprivation, occupational marginalization, and occupational apartheid (Whiteford, 2000; Hammell & Beagan, 2017; Kronenberg & Pollard, 2005). Considering these two factors, it becomes clear that while some individuals may have the privilege of selecting their occupations and building their occupational identity, that is certainly not the case for everyone. Thus we cannot assume any particular client has the ability, or the desire, to choose their occupations in this way.

The most common disability discourse in healthcare is the individual/medical model. While the social model of disability is not an obscure discourse, the biomedical model dominates most, if not all, areas of healthcare and rehabilitation. As a result, many of the theoretical models of treatment localize disability within the person. Some disability scholars claim that when these dominant perspectives guide rehabilitation professionals, they may introduce interventions that are unhelpful or even harmful to disabled persons (Kielhofner, 2005). It is important to point out that as a profession, occupational therapy has a more client-centered and holistic view of disability than some disciplines; however as Phelan (2011) points out, despite these views, occupational therapists often are “still overshadowed by dominant power structures strongly embedded in the systems we work within” (p. 166). Critically reflecting on disability and the way we approach impairments in occupational therapy may result in the need to reject the typical ways of approaching and treating these impairments. This rejection of the normal medical approach may be the appropriate reaction to the realization that “the health care system may be organized in a manner that denies true client-centered practice” (Phelan, 2011, p. 169). As has been mentioned, one of the reasons critical reflexivity is so important is because of our so strongly held assumptions that our societal ‘norms’ are, in fact, the only right way to do things (Kantartzis & Molineux, 2011). We must be willing to reflect on and challenge our western way of approaching disability and rehabilitation.

Attempts at inclusion that do not involve critical reflexivity run the risk of pushing marginalized people further away. A great example this is the First Nations version of the MoCA (MacLachlan, 2018). In the adapted version, the animals have been changed from a lion, rhino, and camel to a salmon, eagle, and wolf. Clearly, this was an attempt to adapt the test to be more inclusive towards Indigenous people. However, as Janna pointed out in her lecture, the issue with using the MoCA in Indigenous populations was never about the recognizability of the animals, it was about the structure of the test and the way in which western society views assessment (MacLachlan, 2018). By only changing the pictures and doing nothing to the structure of the test, it felt patronizing instead of inclusive. If we reflect on this problem critically, we can see that Canadian health policies and practices have been shaped by the legacy of colonization (Hojjati et al., 2017). In fact, while reviewing the Canadian health care system, the Royal Commission on Aboriginal People (RCAP) found that Canadian healthcare models were oppressive to Indigenous people because they failed to recognize Indigenous culture (Jull & Giles, 2012). This relates to the earlier point by Kantartzis and Molineux (2011) about the way society tends to adopt a single viewpoint as the only correct way to do something. In this case it is the idea that our western form of cognitive assessment is correct and the only way to accurately assess cognition. Taking this into account, it is easy to see why efforts to make colonial assessment more palatable to Indigenous people by using pictures of salmon might elicit a negative response. These same principles apply to other minority and marginalized groups. Mulé et al. (2009) state that those marginalized by gender expression and sexual orientation are “largely excluded from mainstream health promotion research, policy and practice” (p. 2) and as a result often face bias, discrimination, and a lower quality of care.

Critical reflexivity has implications for research in occupational therapy. Reflecting critically on our foundational beliefs results in an understanding that this profession, at its core, reflects Eurocentric values and perspectives (Jull & Giles, 2012). Iwama (2006) points out that these “long held universal assumptions and practices continue to transcend cultural boundaries in places and people outside of the cultural contexts where the ideas originated” (p. 224). Since this is the case, we must recognize that our definitions and ideals do not adequately describe the values and experiences of the society we seek to serve. A solution to this discrepancy is collaboration. A commonly used phrase in the disability community – “nothing about us without us” – applies well here. If we want to apply our research to a certain population, members of that population must be involved in the process. Mulé et al. (2009) point out that in order for the healthcare system to adequately include the LGBT community, their unique and specific needs and issues must be recognized. Jull and Giles (2012) state that to work towards inclusive and culturally safe practice, the profession of occupational therapy must partner with Indigenous people. If we are seeking to produce research that will result in outcomes that are applicable to those outside the white, middle class culture in which occupational therapy was founded, we must include them in our research. We cannot claim to understand cultures and experiences we have not lived, and when we act on the behalf of others without their input, even with good intentions, we can easily do harm. As Bailliard (2016) states, it is “possible to cause injustice through naive and ill-informed attempts to promote justice” (p.8).

An important implication for occupation-based practice concerns the way we address internalized oppression. The pervasiveness of ideas such as colonization, ableism, and the medical model of disability mean that for many, they have become the ‘norm’. In her article about self awareness and social cognition, Heotis (2018) states that “a familiar way of thinking is likely the most accessible and easiest way for the thinker, whereas other ways are relatively difficult” (p. 24). In other words, when these ideas are ever present, it becomes easy to rely on them as the only available options. If there is an underlying message that impairments must be eliminated, clients with impairments are more likely to internalize a negative self-image (Kielhofner, 2005). This means that a therapist may encounter clients with impairments who have very ableist views. What then should a therapist do? Suggesting a client may not overcome their impairments and encouraging the acceptance of them may be discouraging and upsetting, while at the same time, focusing on impairment reduction may reinforce negative views of impairment and contribute towards internalized ableism (Kielhofner, 2005). Is it more client-centered to simply accept their ableist views and adopt rehabilitative goals to strive for independence and able-bodiedness? Or is it more client-centered to educate them and attempt to introduce a new way of thinking and thereby expose the internalized oppression? There may not be an easy answer to this, but it is important to reflect critically on these ideas so that we can see that this issue exists, understand that we will face it in practice, and begin to prepare ourselves to deal with it in the most client-centered way possible.

If we choose not to engage in the important work of critical reflexivity, we become complicit in oppression and injustice. Jull and Giles (2012) state that a lack of critical evaluation of the values on which occupational therapy stands actually promotes injustice and that as a profession we must end our “unquestioning acceptance of its core assumptions” (p. 74). A theme that has been repeated in this paper is Kantartzis and Molineux’s (2011) statement that “within any society, a way of life emerges that members perceive to be the usual and ‘healthy’ way to live, the only possible way of doing things” (p. 62). Critical reflexivity demands we reflect on and challenge these assumptions about the ‘right’ way of doing things. This does not mean that our societal ‘norms’ are universally untrue, but while they may be correct for some, or even most, they do not apply to everyone. And if the goal of occupational therapy is client-centeredness, we cannot be content with “most”.

 

References

Bailliard, A. (2016). Justice, difference, and the capability to function. Journal of Occupational Science, 23(1), 3-16. doi:10.1080/14427591.2014.957886

Christiansen, C. H. (1999). Defining lives: Occupation as identity: An essay on competence, coherence, and the creation of meaning. American Journal of Occupational Therapy, 53(6), 547-558. doi:10.5014/ajot.53.6.547

Hammell, K. R. W., & Beagan, B. (2017). Occupational injustice: A critique. Canadian Journal of Occupational Therapy, 84(1), 58-68. doi:10.1177/0008417416638858

Heotis, E. (2018). Cultivating self-awareness: Dual processes in social cognition. Journal for Spiritual & Consciousness Studies, 41(1), 22-28. Retrieved from http:// search.ebscohost.com.login.ezproxy.library.ualberta.ca/login.aspx?direct=true&db=a9h&AN=131637447&site=eds-live&scope=site

Hojjati, A., Beavis, A. S. W., Kassam, A., Choudhury, D., Fraser, M., Masching, R., & Nixon, S. A. (2017). Educational content related to postcolonialism and indigenous health inequities recommended for all rehabilitation students in canada: A qualitative study. Disability and Rehabilitation, 40(26), 1-3216. doi:10.1080/09638288.2017.1381185

Iwama, M. K. (2006). The Kawa Model: Culturally relevant occupational therapy. New York: Churchill Livingstone.

Jull, J. E. G., & Giles, A. R. (2012). Health equity, aboriginal peoples and occupational therapy. Canadian Journal of Occupational Therapy, 79(2), 70-76. doi:10.2182/cjot.2012.79.2.2

Kantartzis, S., & Molineux, M. (2011). The influence of western society’s construction of a healthy daily life on the conceptualisation of occupation. Journal of Occupational Science, 18(1), 62-80. doi:10.1080/14427591.2011.566917

Kielhofner, G. (2005). Rethinking disability and what to do about it: Disability studies and its implications for occupational therapy.American Journal of Occupational Therapy, 59, 487–496.

Kinsella, E. A., & Whiteford, G. E. (2009). Knowledge generation and utilisation in occupational therapy: Towards epistemic reflexivity. Australian Occupational Therapy Journal, 56(4), 249-258. doi:10.1111/j.1440-1630.2007.00726.x

Kronenberg, F. & Pollard, N. (2005). Overcoming occupational apartheid: A preliminary exploration of the political nature of occupational therapy. In F. Kronenberg, S. Simo´ Algado, & N. Pollard (Eds.), Occupational therapy without borders: Learning from the spirit of survivors(pp.58–86). Edinburgh, UK: Churchill Living-stone Elsevier.

MacLachlan, J. (2018). Occupational Perspectives on Justice and Rights: Implications for Practice [PowerPoint slides]. Retrieved from https:// eclass.srv.ualberta.ca/course/view.php?id=45749#section-9

Mulé, N. J., Ross, L. E., Deeprose, B., Jackson, B. E., Daley, A., Travers, A., & Moore, D. (2009). Promoting LGBT health and wellbeing through inclusive policy development. International Journal for Equity in Health, 8(1), 18. doi:10.1186/1475-9276-8-18

Phelan, S. K. (2011). Constructions of disability: A call for critical reflexivity in occupational therapy. Canadian Journal of Occupational Therapy, 78(3), 164-172. doi:10.2182/cjot.2011.78.3.4

Phelan, S., & Kinsella, E. A. (2009). Occupational identity: Engaging socio-cultural perspectives. Journal of Occupational Science, 16(2), 85-91. doi:10.1080/14427591.2009.9686647

Whiteford, G. (2000). Occupational deprivation: Global challenge in the new millennium. British Journal of Occupational Therapy, 63,200–204. doi :10.11

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