Australian Occupational Therapy Journal (2015) 62, 449–451
doi: 10.1111/1440-1630.12195
Viewpoint
Occupational rights and critical occupational therapy: rising to the challenge Karen Whalley Hammell Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
KEY WORDS Convention on the Rights of Persons with Disabilities, human rights, structural competency.
Introduction Critical thinkers within our profession have claimed that occupational therapy is based on the belief that there is a “fundamental relationship between people’s dignified and meaningful participation in daily life and their experience of health, well-being and quality of life” (Pollard, Kronenberg & Sakellariou, 2009, p. 3). They contend that this belief thus “requires occupational therapists to view enabling access to meaningful occupations as a right, not just ‘treatment’ but a political endeavour” (Pollard et al., 2009, p.3). If we accept and agree that equitable access to meaningful occupations is a right, how might we strive towards this? The aim of this article was to suggest three ways in which occupational therapists might begin to address equitable access to meaningful occupations as a right.
Occupational rights The World Federation of Occupational Therapists (WFOT, 2006) has asserted its full endorsement of the United Nations’ Universal Declaration of Human Rights and has issued a Position Statement which articulates the international profession’s position on human rights in relation to human occupation and participation. WFOT’s statement asserts that all people have the right to participate in a range of occupations that enable them to flourish, fulfil their potential and experience satisfaction in ways consistent with their cultures and beliefs. Further, this statement asserts that people have the right to be Karen Whalley Hammell PhD, MSc, OT(C), DipCOT (UK); Honorary Professor. Correspondence: Karen Whalley Hammell, Box 515, Oxbow Saskatchewan, SOC 2BO, Canada. Email: [email protected] Accepted for publication 22 February 2015. © 2015 Occupational Therapy Australia
supported to participate in occupation and that the human right to occupation should be ensured by equitable access to participation, regardless of difference. This statement clearly states that abuses of the right to occupation may include economic, social, or physical exclusion, attitudinal or physical barriers, or may result from control of access to necessary knowledge, skills, resources or venues where occupation takes place (WFOT, 2006). This official WFOT Position Statement accordingly affirms the human right to equitable access to occupational participation, thereby aligning WFOT’s position with the United Nations’ (UN, 2006) Convention on the Rights of Persons with Disabilities. This Convention aspires to promote, protect and ensure: equality of opportunity, full and effective participation and inclusion in society, and access on an equal basis with others, to the physical environment, to transportation, to information and communication technologies, and to other facilities and services provided to the public, both in urban and rural areas. Importantly, both the UN Convention and WFOT’s position accord with the long-held standpoint of disability scholars, who contend that attaining equitable inclusion and participation for disabled people will necessitate a human rights approach (e.g. Armstrong & Barton, 1999). Within the occupational therapy literature, the concept of occupational rights has been outlined to provide occupational therapists with a way to envision and articulate an approach to practise which accords with WFOT’s (2006) position on human rights. Occupational rights are defined as “the right of all people to engage in meaningful occupations that contribute positively to their own well-being and the well-being of their communities” (Hammell, 2008, p.62). Further, occupational therapists who acknowledge and affirm the right of all people to equality of occupational opportunity have been exhorted to commit to critical occupational therapy practices (Whiteford & Townsend, 2011). “Critical” occupational therapy practices reflect an understanding of the impact of historic and social inequities on opportunities and human well-being arising from such factors as colonialism; religious, racial, ethnic, class and economic statuses; gender, age, ability and sexuality, and consequently endeavour to facilitate changes at both
450 individual and environmental levels (Hammell & Iwama, 2012). But how might this sort of critical, rights-based occupational therapy practice be accomplished? How might occupational therapists enlarge their focus, from assessing and modifying people, to assessing and modifying people’s unequal opportunities?
Critical occupational therapy practise: suggested beginnings If occupational therapists believe that equitable access to occupational opportunities is a right – irrespective of age, (dis)ability, class, sexuality, gender identification, race or other dimension of difference – this article suggests three ways in which critical practices might be initiated.
Classifying individuals’ impairments or assessing inequitable environments? First, occupational therapists could expend fewer resources in classifying and cataloguing individuals’ deficits and dysfunctions, and more effort on identifying and building people’s capabilities and strengths and the resources that enable them to do and be what they wish to do and to be (Sen, 1999). “Capabilities”, as described by Sen, are not solely an individual’s abilities, but also the opportunities that derive from their personal strengths and resources, and from the resources of their environments (see Hammell, 2015). Although it is obviously important to assess before intervening, it is puzzling that clients’ abilities, strengths and resources are not assessed as assiduously or enthusiastically as their deficits, differences, dysfunctions and dis-abilities. Occupational therapists habitually compile detailed assessments documenting impairments and the degree of assistance required to accomplish various activities of daily living: factors that have little or no bearing on quality of life (Hammell, 2007). Moreover, former rehabilitation clients have complained that enduring batteries of tests to document and classify every detail of their cognitive and physical deficits are both profoundly dispiriting and unkind. Further, if we take seriously the significant body of evidence indicating that diminished quality of life with a physical impairment might be an outcome of environmental barriers and inequity of opportunity and not solely due to the impairment itself (Hammell, 2007; Miller et al., 2006), then assessments of environmental resources and barriers must become as ubiquitous as those measures of structural and functional abnormalities with which occupational therapists remain preoccupied. Obviously, the parameters of our assessments establish the boundaries of our vision, within which we shall only find what we are looking for.
Aspiring to structural competency This brings us to a second proposition: if quality of life, well-being and participation are dependent upon © 2015 Occupational Therapy Australia
K. WHALLEY HAMMELL
equality of opportunity, as evidence suggests (Hammell & Iwama, 2012), then occupational therapists need to be able to identify socially structured inequalities that constrain equality of occupational opportunity. This ability has been termed “structural competency” (Metzl & Hansen, 2014). We live in an unequal world in which entrenched social structures confer unequal access to opportunities, power and resources for those in different social positions (Pease, 2010). Critics have noted that there has not been much attention among occupational therapists to their powerful social positioning relative to their clients’, or of the unearned privilege and power that therapists possess if and when they are members of the dominant culture (Hammell, 2013; Nelson, 2007). And this is why structural competency is so important. Structural competency (Metzl & Hansen, 2014) is defined as the ability to discern the impact of institutional and social conditions - such as economic and policy decisions, poverty, racism and stigma - on health inequalities, and the commitment to engage in a careerlong endeavour of acting on structural determinants of inequality. Aspirations to structural competency would require occupational therapists to be able to identify and understand their own inequitable access to power, opportunities and resources, and to identify, understand and seek to engage with those structural conditions that unfairly reduce the opportunities available to disabled and other marginalised and disempowered people. Medical anthropologists demonstrate that social structures – economic, political, legal, religious and cultural – prevent, not just individuals, but entire groups and societies (such as migrant workers, Indigenous and First Nations’ peoples) from reaching their potential for health and well-being (Adelson, 2005). Structural vulnerability is produced at the interface of personal factors such as a physical or cognitive impairment, mental illness, sexual and gender identity, race and age - with cultural values and institutional structures, rendering specific individuals and communities vulnerable to socially structured patterns of exclusion and deprivation (Quesada, Hart & Bourgois, 2011). Importantly, the reverse of this equation expands entitlements and accords inequitable advantages and opportunities to those whose positioning - class, race, age, education, ability - places them as dominant and privileged (Pease, 2010). Clearly, this describes the majority of those within the occupational therapy profession in the Western world. It is because “privilege is not recognised as such by many of those who have it” (Pease, 2010, p.ix) that structural competence ought to be an important dimension of client-centred occupational therapy practices. However, despite its espoused allegiance to clientcentred practices the occupational therapy profession has not engaged in sustained critical reflection about the power occupational therapists wield, the powerlessness
VIEWPOINT
of many service users, or the asymmetrical power relations between clients and their occupational therapists (Hammell, 2013).
Asserting occupational rights And this brings us to the third proposition: that we need to dispense with beneficence and assert a rightsbased approach to occupational therapy that is consistent with the UN (2006) Convention on the Rights of Persons with Disabilities and with WFOT (2006) espoused position on human rights. We need, as a profession, to commit to affirming the occupational rights of all people, and to working to translate this rhetoric into reality. In fact, if disabled people have the right to equality of occupational opportunity and for full societal participation on an equal basis with others, then occupational therapists do not have the right to focus solely on trying to change individuals.
Conclusion The WFOT (2006) Position Paper on Human Rights and the UN (2006) Convention on the Rights of Persons with Disabilities clearly situate occupational therapists’ mandate within a rights-based framework. Accordingly, the concept of occupational rights has been proposed to encourage occupational therapists to address “the right of all people to engage in meaningful occupations that contribute positively to their own well-being and the well-being of their communities” (Hammell, 2008, p.62). If the occupational therapy profession aspires to address occupational rights, this paper suggests that assessment of environmental barriers should be as ubiquitous to occupational therapists as assessment of individual dysfunctions. Moreover, it has been proposed that authentic client-centred practise requires occupational therapists to demonstrate structural competency. The paper concludes that if disabled people have rights to equality of opportunity and full participation on an equal basis with others, then occupational therapists are remiss if they focus solely on trying to change individuals.
Acknowledgments This article derives from a keynote lecture: “(Re)Engagement in living: Well-being, participation and critical rehabilitation practice” presented at the Oslo University College of Applied Sciences, Oslo, Norway in September 2014.
References Adelson, N. (2005). The embodiment of inequity. Health disparities in Aboriginal Canada. Canadian Journal of Public Health, 96 (Suppl. 2), S45–S61.
451 Armstrong, F. & Barton, L. (1999). Disability, human rights and education. Buckingham: Open University Press. Hammell, K. W. (2007). Quality of life after spinal cord injury: a meta-synthesis of qualitative findings. Spinal Cord, 45, 124–139. Hammell, K. W. (2008). Reflections on. . . well-being and occupational rights. Canadian Journal of Occupational Therapy, 75, 61–64. Hammell, K. W. (2013). Client-centred occupational therapy in Canada: refocusing on core values. Canadian Journal of Occupational Therapy, 80, 141–149. Hammell, K.W. (2015), Quality of life, participation and occupational rights: a capabilities perspective. Australian Occupational Therapy Journal, in press. doi:10.1111/14401630.12183 Hammell, K. W. & Iwama, M. K. (2012). Well-being and occupational rights: an imperative for critical occupational therapy. Scandinavian Journal of Occupational Therapy, 19, 385–394. Metzl, J. M. & Hansen, H. (2014). Structural competency: theorizing a new medical engagement with stigma and inequality. Social Science and Medicine, 103, 126–133. Miller, W.C., Forwell, S.J., Noreau, L., Jongbloed, L., Proctor, E.S. & Abramson, C. (2006). Community integration following spinal cord injury. In: J.J. Eng, R.W. Teasell, W.C. Miller, D.L. Wolfe, A.F. Townson, J. Aubut, C. Abramson, J.T.C. Hseih & S. Connolly (Eds.), Spinal cord injury rehabilitation evidence, (pp. 4.1–4.37). Vancouver: SCIRE. Nelson, A. (2007). Seeing white: a critical exploration of occupational therapy with Indigenous Australian people. Occupational Therapy International, 14, 237–255. Pease, B. (2010). Undoing privilege. Unearned advantage in a divided world. London: Zed Books. Pollard, N., Kronenberg, F. & Sakellariou, D. (2009). A political practice of occupational therapy. In: N. Pollard, D. Sakellariou & F. Kronenberg (Eds.), A political practice of occupational therapy (pp. 3–19). Edinburgh: Churchill Livingstone Elsevier. Quesada, J., Hart, L. K. & Bourgois, P. (2011). Structural vulnerability and health: latino migrant laborers in the United States. Medical Anthropology, 30, 339–362. Sen, A. (1999). Development as freedom. Oxford: Oxford University Press. United Nations. (2006). Convention on the rights of persons with disabilities. Vienna: United Nations. Whiteford, G. & Townsend, E. (2011). Participatory Occupational Justice Framework (POJF) 2010: enabling occupational participation and inclusion. In: F. Kronenberg, N. Pollard & D. Sakellariou (Eds.), Occupational Therapies without borders. Vol 2. Towards an ecology of occupationbased practices, (pp. 65–84). New York: Cambridge University Press. World Federation of Occupational Therapists (2006). Position Statement on Human Rights. www.wfot.org/office_ files/Human%20Rights%20Position%20Statement%20Final. pdf
© 2015 Occupational Therapy Australia
doi: 10.1111/1440-1630.12195
Viewpoint
Occupational rights and critical occupational therapy: rising to the challenge Karen Whalley Hammell Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
KEY WORDS Convention on the Rights of Persons with Disabilities, human rights, structural competency.
Introduction Critical thinkers within our profession have claimed that occupational therapy is based on the belief that there is a “fundamental relationship between people’s dignified and meaningful participation in daily life and their experience of health, well-being and quality of life” (Pollard, Kronenberg & Sakellariou, 2009, p. 3). They contend that this belief thus “requires occupational therapists to view enabling access to meaningful occupations as a right, not just ‘treatment’ but a political endeavour” (Pollard et al., 2009, p.3). If we accept and agree that equitable access to meaningful occupations is a right, how might we strive towards this? The aim of this article was to suggest three ways in which occupational therapists might begin to address equitable access to meaningful occupations as a right.
Occupational rights The World Federation of Occupational Therapists (WFOT, 2006) has asserted its full endorsement of the United Nations’ Universal Declaration of Human Rights and has issued a Position Statement which articulates the international profession’s position on human rights in relation to human occupation and participation. WFOT’s statement asserts that all people have the right to participate in a range of occupations that enable them to flourish, fulfil their potential and experience satisfaction in ways consistent with their cultures and beliefs. Further, this statement asserts that people have the right to be Karen Whalley Hammell PhD, MSc, OT(C), DipCOT (UK); Honorary Professor. Correspondence: Karen Whalley Hammell, Box 515, Oxbow Saskatchewan, SOC 2BO, Canada. Email: [email protected] Accepted for publication 22 February 2015. © 2015 Occupational Therapy Australia
supported to participate in occupation and that the human right to occupation should be ensured by equitable access to participation, regardless of difference. This statement clearly states that abuses of the right to occupation may include economic, social, or physical exclusion, attitudinal or physical barriers, or may result from control of access to necessary knowledge, skills, resources or venues where occupation takes place (WFOT, 2006). This official WFOT Position Statement accordingly affirms the human right to equitable access to occupational participation, thereby aligning WFOT’s position with the United Nations’ (UN, 2006) Convention on the Rights of Persons with Disabilities. This Convention aspires to promote, protect and ensure: equality of opportunity, full and effective participation and inclusion in society, and access on an equal basis with others, to the physical environment, to transportation, to information and communication technologies, and to other facilities and services provided to the public, both in urban and rural areas. Importantly, both the UN Convention and WFOT’s position accord with the long-held standpoint of disability scholars, who contend that attaining equitable inclusion and participation for disabled people will necessitate a human rights approach (e.g. Armstrong & Barton, 1999). Within the occupational therapy literature, the concept of occupational rights has been outlined to provide occupational therapists with a way to envision and articulate an approach to practise which accords with WFOT’s (2006) position on human rights. Occupational rights are defined as “the right of all people to engage in meaningful occupations that contribute positively to their own well-being and the well-being of their communities” (Hammell, 2008, p.62). Further, occupational therapists who acknowledge and affirm the right of all people to equality of occupational opportunity have been exhorted to commit to critical occupational therapy practices (Whiteford & Townsend, 2011). “Critical” occupational therapy practices reflect an understanding of the impact of historic and social inequities on opportunities and human well-being arising from such factors as colonialism; religious, racial, ethnic, class and economic statuses; gender, age, ability and sexuality, and consequently endeavour to facilitate changes at both
450 individual and environmental levels (Hammell & Iwama, 2012). But how might this sort of critical, rights-based occupational therapy practice be accomplished? How might occupational therapists enlarge their focus, from assessing and modifying people, to assessing and modifying people’s unequal opportunities?
Critical occupational therapy practise: suggested beginnings If occupational therapists believe that equitable access to occupational opportunities is a right – irrespective of age, (dis)ability, class, sexuality, gender identification, race or other dimension of difference – this article suggests three ways in which critical practices might be initiated.
Classifying individuals’ impairments or assessing inequitable environments? First, occupational therapists could expend fewer resources in classifying and cataloguing individuals’ deficits and dysfunctions, and more effort on identifying and building people’s capabilities and strengths and the resources that enable them to do and be what they wish to do and to be (Sen, 1999). “Capabilities”, as described by Sen, are not solely an individual’s abilities, but also the opportunities that derive from their personal strengths and resources, and from the resources of their environments (see Hammell, 2015). Although it is obviously important to assess before intervening, it is puzzling that clients’ abilities, strengths and resources are not assessed as assiduously or enthusiastically as their deficits, differences, dysfunctions and dis-abilities. Occupational therapists habitually compile detailed assessments documenting impairments and the degree of assistance required to accomplish various activities of daily living: factors that have little or no bearing on quality of life (Hammell, 2007). Moreover, former rehabilitation clients have complained that enduring batteries of tests to document and classify every detail of their cognitive and physical deficits are both profoundly dispiriting and unkind. Further, if we take seriously the significant body of evidence indicating that diminished quality of life with a physical impairment might be an outcome of environmental barriers and inequity of opportunity and not solely due to the impairment itself (Hammell, 2007; Miller et al., 2006), then assessments of environmental resources and barriers must become as ubiquitous as those measures of structural and functional abnormalities with which occupational therapists remain preoccupied. Obviously, the parameters of our assessments establish the boundaries of our vision, within which we shall only find what we are looking for.
Aspiring to structural competency This brings us to a second proposition: if quality of life, well-being and participation are dependent upon © 2015 Occupational Therapy Australia
K. WHALLEY HAMMELL
equality of opportunity, as evidence suggests (Hammell & Iwama, 2012), then occupational therapists need to be able to identify socially structured inequalities that constrain equality of occupational opportunity. This ability has been termed “structural competency” (Metzl & Hansen, 2014). We live in an unequal world in which entrenched social structures confer unequal access to opportunities, power and resources for those in different social positions (Pease, 2010). Critics have noted that there has not been much attention among occupational therapists to their powerful social positioning relative to their clients’, or of the unearned privilege and power that therapists possess if and when they are members of the dominant culture (Hammell, 2013; Nelson, 2007). And this is why structural competency is so important. Structural competency (Metzl & Hansen, 2014) is defined as the ability to discern the impact of institutional and social conditions - such as economic and policy decisions, poverty, racism and stigma - on health inequalities, and the commitment to engage in a careerlong endeavour of acting on structural determinants of inequality. Aspirations to structural competency would require occupational therapists to be able to identify and understand their own inequitable access to power, opportunities and resources, and to identify, understand and seek to engage with those structural conditions that unfairly reduce the opportunities available to disabled and other marginalised and disempowered people. Medical anthropologists demonstrate that social structures – economic, political, legal, religious and cultural – prevent, not just individuals, but entire groups and societies (such as migrant workers, Indigenous and First Nations’ peoples) from reaching their potential for health and well-being (Adelson, 2005). Structural vulnerability is produced at the interface of personal factors such as a physical or cognitive impairment, mental illness, sexual and gender identity, race and age - with cultural values and institutional structures, rendering specific individuals and communities vulnerable to socially structured patterns of exclusion and deprivation (Quesada, Hart & Bourgois, 2011). Importantly, the reverse of this equation expands entitlements and accords inequitable advantages and opportunities to those whose positioning - class, race, age, education, ability - places them as dominant and privileged (Pease, 2010). Clearly, this describes the majority of those within the occupational therapy profession in the Western world. It is because “privilege is not recognised as such by many of those who have it” (Pease, 2010, p.ix) that structural competence ought to be an important dimension of client-centred occupational therapy practices. However, despite its espoused allegiance to clientcentred practices the occupational therapy profession has not engaged in sustained critical reflection about the power occupational therapists wield, the powerlessness
VIEWPOINT
of many service users, or the asymmetrical power relations between clients and their occupational therapists (Hammell, 2013).
Asserting occupational rights And this brings us to the third proposition: that we need to dispense with beneficence and assert a rightsbased approach to occupational therapy that is consistent with the UN (2006) Convention on the Rights of Persons with Disabilities and with WFOT (2006) espoused position on human rights. We need, as a profession, to commit to affirming the occupational rights of all people, and to working to translate this rhetoric into reality. In fact, if disabled people have the right to equality of occupational opportunity and for full societal participation on an equal basis with others, then occupational therapists do not have the right to focus solely on trying to change individuals.
Conclusion The WFOT (2006) Position Paper on Human Rights and the UN (2006) Convention on the Rights of Persons with Disabilities clearly situate occupational therapists’ mandate within a rights-based framework. Accordingly, the concept of occupational rights has been proposed to encourage occupational therapists to address “the right of all people to engage in meaningful occupations that contribute positively to their own well-being and the well-being of their communities” (Hammell, 2008, p.62). If the occupational therapy profession aspires to address occupational rights, this paper suggests that assessment of environmental barriers should be as ubiquitous to occupational therapists as assessment of individual dysfunctions. Moreover, it has been proposed that authentic client-centred practise requires occupational therapists to demonstrate structural competency. The paper concludes that if disabled people have rights to equality of opportunity and full participation on an equal basis with others, then occupational therapists are remiss if they focus solely on trying to change individuals.
Acknowledgments This article derives from a keynote lecture: “(Re)Engagement in living: Well-being, participation and critical rehabilitation practice” presented at the Oslo University College of Applied Sciences, Oslo, Norway in September 2014.
References Adelson, N. (2005). The embodiment of inequity. Health disparities in Aboriginal Canada. Canadian Journal of Public Health, 96 (Suppl. 2), S45–S61.
451 Armstrong, F. & Barton, L. (1999). Disability, human rights and education. Buckingham: Open University Press. Hammell, K. W. (2007). Quality of life after spinal cord injury: a meta-synthesis of qualitative findings. Spinal Cord, 45, 124–139. Hammell, K. W. (2008). Reflections on. . . well-being and occupational rights. Canadian Journal of Occupational Therapy, 75, 61–64. Hammell, K. W. (2013). Client-centred occupational therapy in Canada: refocusing on core values. Canadian Journal of Occupational Therapy, 80, 141–149. Hammell, K.W. (2015), Quality of life, participation and occupational rights: a capabilities perspective. Australian Occupational Therapy Journal, in press. doi:10.1111/14401630.12183 Hammell, K. W. & Iwama, M. K. (2012). Well-being and occupational rights: an imperative for critical occupational therapy. Scandinavian Journal of Occupational Therapy, 19, 385–394. Metzl, J. M. & Hansen, H. (2014). Structural competency: theorizing a new medical engagement with stigma and inequality. Social Science and Medicine, 103, 126–133. Miller, W.C., Forwell, S.J., Noreau, L., Jongbloed, L., Proctor, E.S. & Abramson, C. (2006). Community integration following spinal cord injury. In: J.J. Eng, R.W. Teasell, W.C. Miller, D.L. Wolfe, A.F. Townson, J. Aubut, C. Abramson, J.T.C. Hseih & S. Connolly (Eds.), Spinal cord injury rehabilitation evidence, (pp. 4.1–4.37). Vancouver: SCIRE. Nelson, A. (2007). Seeing white: a critical exploration of occupational therapy with Indigenous Australian people. Occupational Therapy International, 14, 237–255. Pease, B. (2010). Undoing privilege. Unearned advantage in a divided world. London: Zed Books. Pollard, N., Kronenberg, F. & Sakellariou, D. (2009). A political practice of occupational therapy. In: N. Pollard, D. Sakellariou & F. Kronenberg (Eds.), A political practice of occupational therapy (pp. 3–19). Edinburgh: Churchill Livingstone Elsevier. Quesada, J., Hart, L. K. & Bourgois, P. (2011). Structural vulnerability and health: latino migrant laborers in the United States. Medical Anthropology, 30, 339–362. Sen, A. (1999). Development as freedom. Oxford: Oxford University Press. United Nations. (2006). Convention on the rights of persons with disabilities. Vienna: United Nations. Whiteford, G. & Townsend, E. (2011). Participatory Occupational Justice Framework (POJF) 2010: enabling occupational participation and inclusion. In: F. Kronenberg, N. Pollard & D. Sakellariou (Eds.), Occupational Therapies without borders. Vol 2. Towards an ecology of occupationbased practices, (pp. 65–84). New York: Cambridge University Press. World Federation of Occupational Therapists (2006). Position Statement on Human Rights. www.wfot.org/office_ files/Human%20Rights%20Position%20Statement%20Final. pdf
© 2015 Occupational Therapy Australia
