There is an increasing need to diversify the profession of occupational therapy. To do this, we need to examine the pathway to becoming an occupational therapy practitioner in our education programs. Programs must go beyond a focus on diversity and place an equal emphasis on equity and inclusion. Underrepresented minority students report increased racial bias and a high occurrence of microaggressions in higher education programs, including occupational therapy. These microaggressions are often not addressed and can lead to increased stress, insecurity, and marginalization, as well as decreased retention rates. It is imperative that faculty examine the equity and inclusivity of their programs, and they should be supported in addressing their own implicit bias. Faculty, students, and staff should be equipped to address microaggressions as they occur. This article identifies examples of microaggressions and suggests strategies to address implicit bias and microaggressions in occupational therapy programs.
Demands for diversity and inclusion in the field of occupational therapy are abundant (Brown et al., 2021; Grullon et al., 2018; Taff & Blash, 2017) and are present in the American Occupational Therapy Association’s (AOTA’s; 2020a) Code of Ethics. Equity, inclusion, and diversity comprise one of the pillars of AOTA’s Vision 2025. Accessibility to services, and a desire to provide culturally relevant services, are another (AOTA, 2019). These pillars represent the impact that the profession hopes to have on the populations we serve as well as the impact that diversity has on the profession itself.
The benefits of a diverse workforce in occupational therapy include improved outcomes, satisfaction, and engagement in care among diverse client populations (Taff & Blash, 2017). To diversify our workforce, we need to examine our educational programs. Despite increased awareness and acknowledgment of racial inequities in occupational therapy education, student diversity rates remain lower than those of the general population (Brown et al., 2021). We define underrepresented minorities as all those who do not identify as non-Hispanic White (Brown et al., 2021).
The push to increase diversity in our educational programs is not enough because without equity and inclusion, diversity is meaningless (Puritty et al., 2017). A growing body of literature points to higher incidences of racial microaggressions, defined as “subtle and racialized offenses” (Morales, 2021, p. 72), and systemic bias against underrepresented minorities across higher education as barriers to student retention and well-being (Lewis et al., 2019; Puritty et al., 2017; Wong et al., 2020). Compared with their peers, students who frequently experienced microaggressions (on at least a weekly basis) are more likely to screen positive for depression (14.2%), consider transferring (14.5% vs. 4.7%, p < .001), and drop out altogether (18.2% vs. 5.7%, p < .001; Anderson et al., 2021). Furthermore, students who frequently experience microaggressions in health care programs are less likely to recommend their programs to others of similar backgrounds (Anderson et al., 2021).
We argue that addressing racial microaggressions in occupational therapy education is a crucial step toward true diversity and inclusion in the profession. We cannot provide equitable, inclusive, diverse, or accessible services if our workforce does not reflect our values, and that starts with the learning environment in which we educate future practitioners.
History of Race in the Profession
The history of race and diversity in our profession is long and complex. Underrepresented minorities were not considered for admission into occupational therapy programs until 1943 (Black, 2002). Minutes from the Subcommittee on Schools and Curriculum of the Educational Committee at the time indicated that just 3 of the 16 accredited programs expressed a willingness to admit “colored” and disabled students who were “highly qualified” (Black, 2002, p. 141; Colman, 1990).
Although the profession’s values and beliefs have evolved, the current standards of occupational therapy do not require schools to document their efforts to recruit and retain underrepresented minorities (Brown et al., 2021). If these standards are not created by the Accreditation Council for Occupational Therapy Education (ACOTE®, 2018), the organization responsible for establishing the standards and curriculum of occupational therapy education, then there is no accountability on the part of academic institutions to enact practices that reflect those endorsed by the profession’s governing body, AOTA.
There continue to be significant racial disparities within the profession. According to AOTA’s 2019 Workforce Survey (AOTA, 2020c), 83.7% of occupational therapy practitioners identify as non-Hispanic White. Diversity in faculty demographics is even more limited, with 89% of faculty members identifying as White (AOTA, 2010). Although student demographics are slightly more diverse, around 76% of occupational therapy students (master’s and doctoral) identify as White (AOTA, 2020b). In 2019, 60.1% of Americans identified as non-White (Frey, 2020). As the number of people of color in the United States continues to grow, it is critical to have a workforce that reflects such diversity to better meet the needs of our clients. Given the history of our country and our profession, it is also equally critical that we change the way we educate future practitioners to create a more inclusive workforce that welcomes such diversity.
Experiences of racial microaggressions are common for underrepresented minorities. More than 75% of Black Americans report daily microaggressions, with other underrepresented groups reporting high instances of microaggressions compared with White Americans (Sue et al., 2019). For underrepresented students in the field of health care, the statistics are equally troubling. A study of 759 medical students of White and non-White backgrounds enrolled across 120 universities found that 99% of students had experienced at least one microaggression throughout their professional education, 61% of students had experienced microaggressions weekly, and 34% reported daily experiences (Anderson et al., 2021). Although microaggressions tend to be unintentional, the impact can be powerful, leaving an individual feeling mentally and physically unsettled, stressed, insecure, self-doubting, and marginalized through the creation of an exclusionary educational environment (Brown et al., 2021; Wong et al., 2020).
A study conducted by the Equality and Human Rights Commission (2019) found that although 43% of institutions said they felt that antiracism policies are effective, more than half of all microaggressions go unreported. Underrepresented students also experience higher levels of obvious and covert microaggressions at a rate higher than their White counterparts (Locke & Trolian, 2018), with Black, Asian, and multiracial students reporting the highest frequency of microaggressions and feeling a lack of belonging (Anderson et al., 2021; Lewis et al., 2019). This often results in underrepresented students not speaking up in class for fear of being judged by their classmates or professors (Grier-Reed, 2010). Such experiences can contribute to the challenges in retention among this population. Because most occupational therapy educators are White, they may not recognize this reality for underrepresented students. In addition, the likelihood of non-White students reporting such instances is low. In acknowledging the power dynamic between marginalized students and those in power, educators must do their part to examine how they perpetrate microaggressions, whether intentionally, subconsciously, or unconsciously.
Microaggressions can occur within the classroom, in clinical settings, and during extracurricular activities. The following are some examples of microaggressions in occupational therapy:
▪ Singling students out because of their ethnic or racial background: A professor asks one of three Black students to share how often Black people wash their hair in front of their White classmates during an activities of daily living laboratory exercise.
▪ Confusing students of similar racial backgrounds for one another: A fieldwork educator repeatedly confuses a student, Mia, with another student, Joy, both of whom are Asian American.
▪ Ignoring microaggressions between students, including in nonacademic contexts: A student says, “That neighborhood is so ghetto, and people in that part of town are so dangerous. I would never want to do fieldwork there.”
▪ Minimizing a student’s experience of microaggressions: During an advising meeting, Julia, a Latina student, expressed feeling frustrated that other professors keep mispronouncing her name. Her advisor responded by saying, “They don’t mean anything by it. It’s hard to remember.”
Making Actionable Change
The next step is to go beyond acknowledgment and begin to make actionable change. One approach is replacing microaggressions with microinterventions, defined as efforts, big or small, that combat microaggressions (Sue et al., 2019). Although microinterventions will not immediately eliminate microaggressions, they can promote an environment of safety and inclusion (Sue et al., 2019).
There are various ways to address microaggressions (Harrison & Tanner, 2018), education being one of the most fundamental (Sue et al., 2019). Because microaggressions are often unintentional, people may be unaware that they have committed one or the impact on the individual. When microaggressions occur, they need to be addressed immediately. The perpetuation and impact of microaggressions are similar to that of bullying. Defined as “unwanted, recurring aggressiveness that causes psychological or physical harm, and creates a psychological power imbalance between the bully and targets” (Nitkin, 2020, p. 1), bullying is something that all academic programs affirm as reprehensible and worthy of acknowledgment and actionable change. Microaggressions should be treated similarly. This may occur in the moment or privately, for example, after class (Harrison & Tanner, 2018). When addressing the microaggression, the perpetrator should listen objectively and avoid becoming defensive. That person should also acknowledge the negative impact the microaggression has on the individual and others (Sue et al., 2019) and learn from the interaction to avoid or reduce the chances of perpetrating further hurt.
The burden of addressing microaggressions should never fall on the person experiencing said aggression. However, because microaggressions can be inconspicuous, those on the receiving end should look for ways to bring awareness of the incident. Although direct communication is ideal, many people, especially students, may be hesitant to confront a professor, clinical supervisor, or classmate for fear of retaliation or damaging their relationship with that person. In such situations creating avenues for anonymous feedback may be beneficial.
There is currently no evidence supporting the impact of anonymous feedback on addressing microaggressions; however, we support this as a way of increasing awareness that a microaggression has occurred and suggest that anonymous feedback may be a way to begin a dialogue in the classroom regarding this topic. Because it is important to acknowledge that a microaggression has occurred, the faculty member (or other individuals who have perpetrated a microaggression) must be creative in addressing the feedback. One suggestion is for the faculty member to discuss this incident with the class as a whole and invite anyone who was affected to join them in further discussion outside the class. Both people in a position of leadership and students should be held accountable to ensure an inclusive and welcoming environment in which all students feel safe reporting their experiences and are confident that action will be taken to prevent similar issues in the future.
Finally, if you witness a microaggression, step in to address it. “I don’t agree with what you said” or “Although I appreciate you have a right to your opinion, what you said was not respectful, and I am asking that you think about what you are saying and share in a more respectful manner” are possible examples (Sue et al., 2019). Asking for further clarification is another powerful tool. Asking questions such as “Could you tell me what you meant when you said that?” defuses the situation while allowing for self-reflection and education on the perpetrator’s behalf.
A microintervention approach taken by the Department of Occupational Therapy at Rush University is the establishment of an advisory committee (Rush Occupational Therapists for Action), which is composed of students and faculty who address social injustice and antiracism initiatives within the program. Increasing awareness of and reducing microaggressions in the program is a key goal of the committee.
The following are examples of actionable changes the Rush program has taken to address microaggressions in occupational therapy education. These can be used as a guideline for other programs to implement similar changes:
▪ Mandatory unconscious bias workshop training for all faculty, staff, and students
▪ Assessments of intervention plans, case studies, and curricula for cultural relevance and considerations
▪ Use of cultural toolkits and antiracism resources, such as those provided by the Coalition of Occupational Therapy Advocates for Diversity (2020) and AOTA (n.d.).
▪ Events to increase awareness of microaggressions:
TED Talks or movie viewings and discussions
Podcast listening and discussions
▪ In-services for students on how to address microaggressions while on fieldwork assignments
▪ Encouraging all students, fieldwork supervisors, and faculty to attend bystander intervention training
▪ Incorporation of anonymous student feedback mechanisms to report microaggressions in the classroom:
Provision of immediate follow-up (within 48 hr) on an individual basis, or general and sincere apology/acknowledgment in front of the entire class
We cannot achieve diversity without inclusion. Microaggressions in occupational therapy education are a major contributor to the recruitment and retention of underrepresented students because they cause feelings of otherness and create an exclusionary environment. Although microaggressions are often unintended, they have lasting effects on the person experiencing them. Going beyond acknowledgment to implementing simple but actionable change is the way forward toward a more diverse profession.