Occupational Therapy in an Ecological Context: Ethics and Practice

Researchers agree that changes in the earth’s climate since the middle of the 20th century are anthropogenic in origin, meaning they are primarily related to increased greenhouse gas emissions resulting from human activity (Cook et al., 2016). Researchers suggested that people living in the United States use a disproportionate amount of the earth’s resources (Jackson et al., 2019). For example, in 2018, average per capita emissions in the United States were 16.6 tons of carbon dioxide, compared with an average of 4.8 tons of carbon dioxide per person globally (Jackson et al., 2019). Unsustainable lifestyles, or patterns of occupations that limit the ability of future generations to meet their basic needs, have been cited by the World Federation of Occupational Therapists (WFOT; Shann et al., 2018) as posing a threat to health and well-being. WFOT has issued multiple position statements calling for environmentally sustainable action from occupational therapy practitioners, researchers, and national occupational therapy organizations (Shann et al., 2018; WFOT, 2012). These documents aim not only to broaden occupational therapy’s scope of practice to include sustainability principles (WFOT, 2012) but also to embed such principles into occupational therapy research and practice (Shann et al., 2018). These position statements specifically target Western occupational therapy practitioners, who have the resources to enact climate-responsible changes in their professional practice (Jenkin et al., 2016).

To my knowledge, no formal climate action policy has yet been enacted by occupational therapy practitioners in the United States. Although the Occupational Therapy Practice Framework: Domain and Process (4th ed.; American Occupational Therapy Association [AOTA], 2020) provides a general endorsement of consideration of the natural environment as part of clinical reasoning and intervention at the population level, additional guidance on how to address sustainability at the individual level is needed. Research, policy, and practice guidelines specific to the United States are necessary so that a proactive approach to sustainable lifestyles can be developed. In this column, I examine some underlying contextual factors that influence occupational therapy philosophy and practice that may act as barriers to the adoption of a sustainability agenda. I then briefly discuss why it is imperative for occupational therapy practitioners in state occupational therapy organizations and AOTA to develop and implement climate-responsible practices and policies. I conclude by introducing strategies that may facilitate a transition toward sustainability within occupational therapy practice, policy, and research.

The issue of sustainability in occupational therapy challenges us to question some of our profession’s most basic assumptions. Because professional norms can be born out of the culture in which a profession emerges, contextualization of these beliefs is essential to gain a comprehensive understanding of an issue (Kantartzis & Molineux, 2011). Occupational therapy has its origins in the United States, Canada, and the United Kingdom (Dunlop, 1933). The founders of occupational therapy were shaped by the Western society in which they resided, one that was dominated by an individualist philosophy; a Judeo–Christian belief system; and a capitalist, industrial economy (Kantartzis & Molineux, 2011).

Iwama (2003) noted that individualism is a Western construct that is highly integrated into occupational therapy theory and treatment. Authors have argued, however, that a fixation on individualistic occupations may overlook the potential of occupation to foster community and interdependence (Kantartzis & Molineux, 2011; Rushford & Thomas, 2016). This, in turn, may hinder the development of sustainable global initiatives within occupational therapy (Whittaker, 2012). Moreover, an overemphasis on the individual (Persson & Erlandsson, 2014) can conflict with sustainability efforts in which a person must adapt their occupations to benefit the global community (Whittaker, 2012).

In addition, the assumptions inherent in individualism, such as self-responsibility and self-reliance, imply that personal misfortunes reflect poor choices on behalf of the individual, despite contextual influences (Gerlach et al., 2018; Kantartzis & Molineux, 2011). These beliefs have implications for undue placement of blame. For example, many oppressed populations, especially those affected by poverty, those who live in regions of political instability, and those affected by natural disasters, lack the agency (Hammell, 2009) to correct environmental and occupational injustices that are caused by wealthier populations in geographically distant locations.

Mastery of the environment is a concept derived from Judeo–Christian belief systems (Hammell, 2009; Kantartzis & Molineux, 2011; Rushford & Thomas, 2016). Within these systems, humans are placed at the center of the natural world (Rushford & Thomas, 2016) and regarded as a totally discrete part of the environment (Iwama, 2003). Humans, elevated above other living things, are permitted to dominate the environment (Hammell, 2009). These concepts are ingrained in occupational therapy philosophy as an innate human need to master the environment (Hammell, 2009). In occupational therapy practice, contextual and environmental factors are taken into account during treatment to determine how they may best serve the client (do Rozario, 1997; Rushford & Thomas, 2016), but little regard is given to how an occupation may negatively affect the natural environment (do Rozario, 1997).

Industrialization promotes specialization and fragmentation of occupations (Aoyama, 2014) for the sake of efficiency and profit (Persson & Erlandsson, 2002). Although large-scale production, consumption, and disposal of resources increases productivity, it also generates distance between an individual and the environment, thus creating a large occupational cycle (Aoyama, 2014), that is, a linking of occupations through which natural resources are harvested, processed, used, and disposed of within a society (Aoyama, 2012). Large, complex occupational cycles obscure the environmental impact of one’s occupations, which limits the opportunity to learn how occupations affect one’s community or the environment. Neo-liberal capitalism, an economic ideology consisting of deregulation of large businesses, privatization, free trade, and tax reductions for large businesses and wealthy individuals (Kotz, 2009), obfuscates this feedback by promoting occupations associated with conspicuous consumption and materialism (Persson & Erlandsson, 2002). By manipulating the economic context in which occupational cycles occur, the social and environmental impact of one’s occupations becomes concealed. Materialism further promotes unsustainable consumption, depleting the earth’s resources (Persson & Erlandsson, 2002; Rushford & Thomas, 2016). For example, occupations such as online shopping sprees are often resource intensive because of the extensive packaging of products required for mailing and the dependence on fossil fuels for delivery of items, causing materialistic occupations to be performed without regard for the greater ecological and social contexts.

It is possible that some aspects of Western culture, embedded in occupational therapy philosophy, unintentionally justify and perpetuate environmental degradation. At present, individualism, mastery of the environment, and industrial capitalist values appear to benefit a few people at the expense of others and the natural environment, thereby contributing to occupational injustices (Rushford & Thomas, 2016). We must ask ourselves this: Can we fulfill our comprehensive goal of “achieving health, well-being, and participation in life through engagement in occupation” (AOTA, 2020, p. 5) if our daily occupations are destroying the natural environment on which we depend for survival? This question warrants the exploration of non-Western cultural beliefs. Examinations of African, East Asian, and Indigenous perspectives may provide insights into reformation of contemporary occupational therapy theory.

According to Guajardo et al. (2015), African tradition places emphasis on social, spiritual, and environmental interconnectedness while also celebrating diversity and multiplicity. This is exemplified in the term ubuntu, which means that an individual person’s identity is constantly reshaped and redefined through interaction with others. This ethic implies a collective responsibility to care for other humans and the environment. Similarly, East Asian belief systems view humans as part of a larger whole and therefore inseparably related to their environment (Iwama, 2003). Social relationships take precedence over individual desires. Humans, instead of being in competition with nature, are viewed as part of nature and thus must strive to achieve harmony with the environment (Iwama, 2003). Indigenous peoples of Canada were found to prioritize balance in daily life, in particular among the physical, mental, emotional, and spiritual realms (Fijal & Beagan, 2019). They believe that health can be achieved only through balance among these dimensions and at the individual, community, and environmental levels.

The aforementioned description of African, East Asian, and Indigenous perspectives is brief and incomplete; however, there are common motifs among them; namely, that these cultures appear to value interdependence over independence, environmental stewardship over environmental mastery, and balance among all forms of life. Although these principles represent a way of life for many people around the world, they may arouse ethical tensions when implemented in a Western context. One discord specific to occupational therapy centers on reconciling the occupational therapy values of individualism, independence, and client centeredness with large-scale, interdependent, ecological approaches (Chan et al., 2020; Jenkin et al., 2016; Whittaker, 2012). In particular, the appropriateness of using sustainability-focused treatments with clients who do not value sustainability has come into question. Moreover, the prevailing health care climate in which Western occupational therapy practitioners predominantly work does not prioritize sustainability practices (Chan et al., 2020); neither does it provide reimbursement for sustainability interventions. These issues are worsened by a lack of related practice guidelines and health care sustainability research (Jenkin et al., 2016).

Although ecological theories specific to occupational therapy (Dennis et al., 2015; Persson & Erlandsson, 2002, 2014; Ung et al., 2020) exist in the English language literature, implementation of these theories into practice in the United States has yet to occur, possibly because of the aforementioned ethical and cultural challenges. A second reason why it may be difficult for occupational therapy practitioners in the United States to integrate ecological theories into practice could be related to our method of generating knowledge. Western science has been described as reductionist, rationalist, and positivist (Fijal & Beagan, 2019; Guajardo et al., 2015). It recognizes as valid only information generated by means of the scientific method. Its truths are absolute, and it does not invite the use of alternate epistemologies. Western epistemology may make it difficult to contemplate other forms of knowing or to incorporate non-Western perspectives into practice.

In an examination of global Southern perspectives, Guajardo et al. (2015) highlighted the advantages of drawing from multiple epistemologies. They stated that, unlike dominant North American and European epistemology, the global South embraces multiple ways of understanding. This idea is exemplified by two-eye seeing, a method embraced by Indigenous researchers that is used to reconcile different epistemologies (Fijal & Beagan, 2019). It calls on the viewer to consider the strengths and weaknesses of differing viewpoints with an open mind so as to obtain an unbiased, comprehensive understanding of a topic. This method of thought may help occupational therapy practitioners to simultaneously consider non-Western and Western viewpoints when analyzing ethical dilemmas related to occupation and sustainability. Two-eyed seeing could be used to facilitate a balance between the short-term health of individual clients and the long-term health of the population as well as between human occupations and environmental health. Similarly, it may be used by state and national organizations as policy and practice guidelines are developed. Finally, using two-eyed seeing in research may help expand and clarify varying perspectives of occupation, health, and sustainability.

Fostering awareness of and competence in this area of practice is essential to the successful translation of skills to various cultures (Thibeault, 2006). Education and guidance from national and state organizations are critical in supporting the sustainability efforts of occupational therapy practitioners (Chan et al., 2020). The use of guidelines from global organizations, such as the United Nations, may be particularly useful to occupational therapy educators when aligning program content with sustainability initiatives (Thibeault, 2006; Wagman et al., 2020). Finally, advocating for policy changes at the institutional level, such as in health care, is needed to further support practitioner involvement (Chan et al., 2020).

The profession of occupational therapy must help mitigate climate change, one of the most pressing issues of our time. Given that some Western cultural values and modes of thinking appear to present an impediment to climate-related action, it may be appropriate for occupational therapy practitioners to expand their way of knowing to encompass multiple epistemologies, including non- Western ways of thinking. By intentionally inviting new forms of thought and differing perspectives, occupational therapy practitioners in the United States may help facilitate the adoption of sustainable lifestyles, promote balance between occupation and environmental health, and become active global participants in addressing climate.

I have no conflicts of interest to disclose. I thank the anonymous reviewers whose comments helped improve the content of this article.