A confluence of factors during 2020 placed needed attention on the social and structural determinants of health, systemic racism, and social injustice. Institutions across the country are taking a hard look at themselves to evaluate how they are complicit in perpetuating these problems and what role they have in dismantling them. In this article, we discuss the influence of systemic racism on the profession of occupational therapy, noting that the profession lacks a clear plan, informed by stakeholders, on how to address it. The American Occupational Therapy Association hosted a series of listening sessions titled “Be Heard—We’re Listening” in June and July 2020 to learn about the experiences of occupational therapy students, practitioners, and educators who are Black, Indigenous, and People of Color (BIPOC). The listening session participants provided ideas for change and recommendations that establish a call to action for persons, groups, and populations.
You have been paid for. Each of you, Black, White, Brown, Yellow, Red—whatever pigment you use to describe yourselves—has been paid for. But for the sacrifices made by some of your ancestors, you would not be here; they have paid for you. So, when you enter a challenging situation, bring them on the stage with you; let their distant voices add timbre and strength to your words. For it is your job to pay for those who are yet to come.—Maya Angelou (2014)
The events of 2020 included a worldwide pandemic that exposed racial and ethnic health disparities and the murder of George Floyd, which energized an international social justice movement. As a result, increased attention has been placed on the issue of systemic racism in the United States, and the occupational therapy profession has been engaging in self-reflection and self-evaluation. In June and July 2020, the American Occupational Therapy Association (AOTA) hosted a series of listening sessions titled “Be Heard—We’re Listening” to provide a platform for Black, Indigenous, and Persons of Color (BIPOC) to come together to talk about their lived experiences as BIPOC occupational therapy students and professionals. The listening session participants provided ideas for change and recommendations that, taken together, establish a call to action that all occupational therapy education programs, practice settings, state and local organizations, and AOTA can undertake to effect change. In this article, we discuss how systemic racism affects the profession of occupational therapy and the profession’s lack of a clear plan, informed by stakeholders, to address it. We then present the findings from the listening sessions and recommendations for action.
The coronavirus disease 2019 (COVID-19) pandemic uncovered the depth of racial health inequities and spurred an increased demand to dismantle systemic racism in the United States. As of September 9, 2021, COVID-19 had claimed 747,970 lives and infected a total of 46,180,190 Americans (Centers for Disease Control and Prevention [CDC], 2021a). The pandemic has disrupted the U.S. economy and ways of life, and these effects have disproportionately affected BIPOC. According to the CDC (2021b, 2021c), racial and ethnic minority groups are at increased risk of becoming seriously ill and dying from COVID-19 because of factors such as systemic discrimination in health care, education, and the criminal justice system; reduced access to and utilization of health care; low socioeconomic status; residence in multigenerational homes; and greater exposure to risk related to employment as “essential workers.” For example, compared with the White, non-Hispanic population, Black Americans are 1.1 times more likely to become infected but 2.8 times more likely to be hospitalized and 2.0 times more likely to die (CDC, 2021c). Similarly, Latinx and Native Americans have disproportionately greater rates of infection, hospitalization, and death (CDC, 2021c).
Attention to health disparities in the United States is not new. For years, U.S. health policy researchers and public health practitioners have written about and investigated health disparities, fought for policy changes, and developed and implemented programs to address inequities that have an adverse impact on self-efficacy, self-agency, and health outcomes for BIPOC populations. These advocates have elucidated the relationship between health status and outcomes and identified social determinants of health, defined as conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks (CDC, 2021b). Although these efforts have been ongoing for many years, the COVID-19 pandemic created a heightened mainstream awareness of issues that influence the health and well-being of BIPOC.
In addition to COVID-19, protests and racial unrest in 2020 forced U.S. society to face the stark reality of the longstanding history of White privilege, systemic racism, and predatory practices of law enforcement in interactions with Black people. The unrest was spurred by multiple events, including the death of Breonna Taylor, who was shot by police in her own home; the killing of Ahmaud Arbery, a Black man shot by a White father and son while jogging in their neighborhood; and the death of George Floyd, who was killed when police officer Derek Chauvin suffocated him by putting his knee on his neck for 8 minutes and 46 seconds (Ortiz, 2020). Riots and protests erupted across the country after Floyd’s death as BIPOC and their allies refused to tolerate the continual assaults on their dignity, humanity, and survival. In greater numbers than ever before, White people and those with privilege acknowledged that in addition to inequities in access and resources, Black people experience disproportionate violence and oppression that have been supported and enabled by federal, state, and local regulations and institutional policies.
As worldwide media outlets reported on Floyd’s death and the ensuing multicity protests and riots, AOTA members and nonmembers started to look to the Association to articulate the profession’s position and provide guidance and representation; however, the profession lacked a clear plan for addressing issues related to systemic racism. AOTA President Wendy Hildenbrand decided to host a series of listening sessions, inviting BIPOC occupational therapy students, practitioners, and educators to participate in a forum where their collective voices and stories of racialized trauma and systemic racism could be heard.
Occupational Therapy Then and Now
To understand the lived experience participants shared in the listening sessions, it is important to consider the history and current context of the profession. Occupational therapy was founded in 1917 by three White men and three White women in Clifton Springs, New York, during the segregation (1900–1939) and Jim Crow eras (1877–1964; AOTA, 2017). Although the social climate at the time did not support the inclusion of racial and ethnic diversity in the profession, AOTA has, over time, sought to address issues related to diversity, equity, and inclusion (DEI) by engaging with external groups such as the Multicultural, Diversity, and Inclusion (MDI) Network (AOTA, n.d.-b), established in 1984, and the Coalition of Occupational Therapy Advocates for Diversity (n.d.), established in 2014. AOTA has also developed resources, including a Diversity, Equity, and Inclusion toolkit (AOTA, n.d.-a) and “AOTA’s Guide to Acknowledging the Impact of Discrimination, Stigma, and Implicit Bias on Provision of Services” (AOTA, 2020a). Myriad position papers related to nondiscrimination and inclusion have been published, and these values are reflected in AOTA policies and procedures (e.g., Policy D.4: Diversity and Inclusive Membership; AOTA, 2019). In February 2020, AOTA leadership established a Diversity, Equity, and Inclusion Task Force to target governance refinement, develop a strategic plan, and identify action steps to address DEI issues.
Despite these efforts, racial and ethnic representation in the field of occupational therapy has changed only minimally since the profession’s inception; it remains a White female–dominated profession (Data USA, n.d.,). Eighty percent of occupational therapists in 2019 were White, with very little variance from 2014 to 2019 (84%). Black representation remains stagnant, at a little over 6% ; and regarding gender, approximately 90% of occupational therapists are women (Data USA, n.d.). This lack of diversity is reflected in AOTA governance and leadership, among occupational therapy organizations and groups (e.g., state associations, academic programs, research programs), and among practitioners across practice settings (Harvison, 2020).
Be Heard—We’re Listening Sessions
AOTA hosted four 1.5-hr virtual Be Heard—We’re Listening sessions between June 18 and July 23, 2020 (AOTA, 2020b). The first session provided an open forum for BIPOC occupational therapy and occupational therapy assistant students, practitioners, and educators to share their stories, and the three subsequent sessions targeted each group individually. The listening sessions were marketed to BIPOC individuals by AOTA staff in collaboration with the AOTA Board of Directors. To ensure sessions were open to the occupational therapy community beyond members, communication was a multipronged approach that used the AOTA website, social media outlets, email blasts, and direct communication to colleagues by Board members and staff. All student occupational therapists and occupational therapy assistants were welcome to attend. However, the discussion points were focused on the unique issues of each BIPOC group. Participants heard one another’s lived experiences, which spanned decades and painted a comprehensive picture of the current landscape, creating a rich background for discussion. The sessions were well attended, with an average of approximately 200 participants per session.
Each session featured a panel representing the targeted group, facilitated by AOTA staff in concert with AOTA President Hildenbrand and representatives from the AOTA Board of Directors. Each panelist shared their experiences navigating workplace or academic environments as a BIPOC. The participants were then given the opportunity to share, comment, and reflect on their own experiences and ask questions. Many participants added their own experiences to the conversation and engaged in a robust discussion in the Zoom chat box. The panelists and other participants offered suggestions for how AOTA could better address the needs of BIPOC occupational therapy students, practitioners, and educators at the individual, group, organizational, and population levels.
The second author (Elizabeth A. Kleine), a postprofessional OTD student volunteer, attended all sessions, and she reviewed the transcripts and Zoom chat files immediately afterward. She drafted a summary of topics, experiences, and recommendations for action provided by the participants in each session. Kleine identified common topics, experiences, and recommendations for action across sessions, transferred them to an Excel spreadsheet, and categorized and summarized them according to emerging themes. Sabrina Salvant and Varleisha D. Gibbs reviewed the emerging themes independently and then discussed the findings to reach consensus.
The experiences and suggestions shared by the participants revealed three broad themes related to areas of need: (1) the lack of diversity and representation of BIPOC at all levels of the profession; (2) the experience of racialized trauma, stress, and fatigue; and (3) antiracism. Participants’ experiences and suggestions can provide a starting point for individuals, groups, and populations to engage in active discussion and problem solving.
Lack of Diversity and Representation of BIPOC
Participants consistently reported the experience of being “the only” occupational therapy practitioner or student of color in their educational program or among work colleagues. They described a lack of representation of diverse races and ethnicities among faculty, supervisors, and workshop presenters and in their educational materials. They also reported feeling as though they were the “only one” experiencing pressure to “represent my race” and having no one to share experiences with. Participants who attended historically Black colleges and universities and those who at some point met another BIPOC student, faculty member, or mentor expressed the significant value of seeing a person who exemplified “what is possible” or of having access to someone who could relate to their experience.
Experience of Racialized Trauma, Stress, and Fatigue
Participants in all groups shared experiences of present-day discrimination, bias, and racism ranging from unintentional microaggressions to overt racism. These acts were perpetrated by faculty, fieldwork educators, colleagues and peers, and clients. Students reported being told they would have to work “50 times harder than everybody else” to succeed and felt pressure to assimilate to the dominant group, for example, by changing their hair and nail styles to appear “less ethnic” for an occupational therapy school interview. Because of the lack of representation and their feelings of being “the only,” participants described the challenge of being surrounded by colleagues and peers who were unaware of or unable to relate to the impact of current events, including police brutality and racial unrest, on their emotional well-being and feeling of safety. Participants implied that such experiences create stress, trauma, and fatigue beyond what non-BIPOC practitioners and students experience and that supports are not in place to address these needs.
The term antiracism has become better known since the racial unrest of 2020, and the concept was infused throughout participants’ sharing of experiences, discussion, and recommendations. Educator and activist Ibram X. Kendi (2019) defined an antiracist as “one who is supporting an antiracist policy through their actions or expressing an antiracist idea” (p. 13) and “one who is expressing the idea that racial groups are equals and none needs developing, and is supporting policy that reduces racial inequity” (p. 24). A core element of this concept is that to be antiracist, one must act to dismantle systemic racism. Antiracism has been part of the shift that has been occurring as a result of the social justice movement sparked by George Floyd’s death. To be antiracist, persons, groups, and populations must take an active role in dismantling systemic racism. During the AOTA listening sessions, attendees suggested that “AOTA and professional organizations need to establish mechanisms for safe reporting of incidences of racism, engage in lobbying efforts to support antiracist legislation, and adopt an action-oriented and anti-racist approach with measurable goals, objectives, and timelines.”
Call to Action
The listening session participants provided recommendations to address the needs of BIPOC in the occupational therapy profession that together form a call to action. They highlighted the need to act and to provide specific resources to address the unique needs of BIPOC and suggested the following specific actions:
Improve recruitment and retention of BIPOC to the profession by promoting pipeline programs starting in elementary, middle, and high school to expose BIPOC youth to occupational therapy; by adopting holistic admissions practices in educational institutions; and by providing financial support for BIPOC.
Promote programs to encourage BIPOC occupational therapy practitioners to act as mentors at all educational and professional stages.
Diversify occupational therapy educational materials and presentations.
Establish bias reporting systems and antidiscrimination policies (in professional organizations, educational institutions, and health care institutions) that are infused with follow-up and accountability procedures.
Create ways for BIPOC occupational therapy practitioners and students to share their experiences of racism or trauma, strategize ways of coping, and connect with groups like the MDI Network, which includes the National Black Occupational Therapy Caucus.
Assess biases and identify antiracist action steps that include measurable goals, objectives, and timelines at the individual and organizational levels of the profession.
Adopt practices in AOTA, other professional organizations, and educational institutions that support DEI (e.g., review of statements, policies, and strategic visions) and engage in lobbying efforts to promote legislation that supports DEI.
Encourage educational institutions and programs to adopt practices that support DEI in recruitment, admissions, curriculum, instruction, and student support.
Summary of Discussion and Recommendations
Addressing systemic racism and inequality is complex; however, opportunities exist for the occupational therapy profession to collaboratively identify and implement strategies to do so. The findings and suggested actions from the listening sessions can provide the basis for reflection and discussion at all levels and across education settings, clinical practice settings, and professional organizations. We suggest the following four questions to facilitate discussion as a starting point for future action:
What model or framework can be developed to support BIPOC occupational therapy students, practitioners, and educators?
What are the facilitators of and barriers to implementing the suggested action steps in clinical practice and academic settings?
What is AOTA’s role in supporting BIPOC students and practitioners, and how much influence can AOTA really have across practice and academic settings?
What information can be deduced from the key findings of the listening sessions that supports advocacy for BIPOC occupational therapy practitioners and students?
Discussion of Findings and Recommendations
The shared experiences of the listening session panelists and participants reveal the influence of systemic racism on the occupational therapy profession. The lack of diversity at all levels of the profession is one significant indicator of systems that perpetuate inequality and harm among BIPOC occupational therapy practitioners and students. Although most of the participants’ recommendations were directed at AOTA, individual occupational therapy practitioners, academic institutions, health care organizations, and state and national organizations also have a responsibility to address issues related to systemic racism in occupational therapy.
In this article, our intent has been to disseminate the results of the Be Heard—We’re Listening sessions; share the experiences of BIPOC occupational therapy students, practitioners, and educators; and mobilize readers to take part in supporting diversity, equity, and inclusion initiatives within occupational therapy in whatever manner is appropriate for their professional role. We believe the listening sessions can serve as a launchpad for further reflection, discussion, and research on DEI initiatives and for the development of a framework to support BIPOC occupational therapy practitioners and students at multiple levels. Ideally, through discussion, planning, and eventually action, we will begin to see changes in education and workplace practices. Informed practice and leadership by AOTA and state occupational therapy associations can be key to this transformation. Readers are encouraged to review and consider the following:
Suggested actions offered by the listening session participants (AOTA, 2020b)
New resources and articles available through the AOTA Store—for example, a continuing education article on systemic racism (Lucas & Washington, 2020)
Recommendations offered by Justice-Based Occupational Therapy, which advocates for people involved with the justice system (Jaegers et al., 2020)
The newly created AOTA (n.d.-a) DEI Toolkit
The need for continued action by AOTA, state associations, legislators, employers and colleagues, and educational institutions to address systemic racism.
The Be Heard—We’re Listening sessions opened a conversation for the occupational therapy profession about the continued work needed to address systemic inequities in occupational therapy. BIPOC occupational therapy professionals and students experience bias and trauma and have unique needs that are not being adequately addressed in academic and workplace environments. Session participants recommended individual and collective actions for persons, groups, and populations, some of which AOTA has already developed and implemented. We urge members of the profession to engage in continued discussions to determine the way forward toward a more diverse, equitable, and inclusive future.
We thank the participants in the listening sessions, who provided their time and commitment to addressing the issues experienced by BIPOC in the occupational therapy profession. Much appreciation to Duana Russell-Thomas; Jewell Dickson; Candice Freeman; Theresa Rhette-Davis; Gregory Sutton; Tyra Banks; Alondra Ammon; Hazel Breland; Ronald Drummond, AOTA Assembly of Student Delegates (ASD) chair; Brendan Cook, ASD OT vice-chair; Naomia Rivera, ASD OTA vice-chair; and Marquie Price. We also thank Wendy Hildenbrand, AOTA president, and all AOTA board of directors members who participated.