Float to grow: nurturing the roots of socially inclusive and just practice in occupational therapy students

Flutuar para crescer: nutrir as raízes da prática socialmente inclusiva e justa com estudantes de terapia ocupacional.

Abstract

Models of practice and theoretical frameworks that seek to deemphasize impairment and focus on the implications of societal attitudes, norms, and culture are significant and relevant to the practice of occupational therapy. As an underpinning of client-centered practice, there is a need to highlight and embrace the intersection of impairment-deemphasizing theories and move from conceptual understanding to true application of those theoretical models in practice. This article describes the inclusion of the Salamander Workshop; an experiential learning activity designed to facilitate the development of students’ therapeutic self-awareness and initiate a starting point for incorporating social frameworks into authentic practice. Student reflections conceptualize the discussion about professional growth and development against the backdrop of disability experiences, social change, and empowerment. The article begins with an introduction to how the profession of occupational therapy and disability studies interconnect. This is followed by a description of both the occupational therapy education program where the experiential learning activity took place, and details of the workshop itself. The final two sections of the article articulate and discuss student reflections of the experiential learning exercise and conclude by framing the discussion within the larger context of occupational therapy pedagogy. The Salamander Workshop facilitated an opportunity for students to immerse themselves in the lived experience of others, while enhancing their own self-awareness, which in turn may translate to their growth and development as inclusive practitioners.

Keywords:
Higher Education; Curriculum; Interdisciplinary Studies; Disability Studies; Social Justice

Resumo

Modelos de prática e referenciais teóricos que buscam diminuir a ênfase e focar nas implicações de atitudes sociais, normas e cultura são significativos e relevantes para a prática da terapia ocupacional. Para aprofundamento na prática centrada no cliente, há uma necessidade de destacar e abordar a interseção de teorias que reduzem a ênfase na deficiência e passar da compreensão conceitual para a verdadeira aplicação desses modelos teóricos na prática. Este artigo descreve a inclusão da Workshop de Salamandra; uma atividade de aprendizagem experiencial projetada para facilitar o desenvolvimento da autoconsciência terapêutica dos estudantes e iniciar um ponto de partida para incorporar estruturas sociais no interior de práticas autênticas. As reflexões dos estudantes conceituam a discussão sobre crescimento e desenvolvimento profissional no contexto de experiências de deficiência, mudança social e empoderamento. O artigo inicia com uma introdução sobre como a profissão de terapia ocupacional e os estudos sobre deficiência se interligam. Isto é seguido por uma descrição do programa de educação em terapia ocupacional no qual a atividade de aprendizagem experiencial ocorreu e detalhes do próprio workshop. As duas seções finais do artigo articulam e discutem as reflexões dos estudantes sobre o exercício de aprendizagem experiencial e concluem analisando a discussão dentro do contexto mais amplo da pedagogia da terapia ocupacional. O Workshop Salamandra facilitou uma oportunidade para os estudantes mergulharem na experiência vivida pelos outros, ao mesmo tempo em que aprimoraram sua própria autoconsciência, o que, por sua vez, pode se traduzir em seu crescimento e desenvolvimento como profissionais inclusivos.

Palavras-chave:
Educação Superior; Currículo; Estudos Interdisciplinares; Estudos sobre Deficiências; Justiça Social

Introduction

The profession of occupational therapy has undergone numerous paradigm shifts since its inception over one hundred years ago. There has been a conceptual ebb and flow of philosophical interpretations to describe where and how occupational therapy is situated within society’s worldview of health and wellness, disease, and disability. The early 1950’s saw an increase in scientific literature focused on medical diagnostics, leading the profession of occupational therapy in western culture to turn to more reductionist biomechanical/medical models of practice (Dirette, 2013). Such models highlight the focus of practitioner interaction on individual impairments. In more recent years, there has been a slow shift towards reframing occupational therapy practice within broader, less individualistic perspectives. Current literature has embraced theories such as the social model of disability (Goering, 2015; Heffron et al., 2019; Phelan, 2011) and other approaches focused on concepts aligned with social justice, occupational justice, and human rights (Durocher et al., 2014; Hocking, 2017; Hocking & Townsend, 2015). This shift has begun to alter our collective critical thinking to include a deeper understanding of the lived experience of disabled people, informed by explorations of political, societal, cultural, and environmental barriers that foster continued marginalization.

While the current professional paradigmatic view appears to embrace a less traditionalist/reductionist approach in theory, the actual practice of occupational therapy continues to support a medical model of disability (Holler at al., 2021; Sakellariou & Pollard, 2013). This distinct lack of inclusion of more current socially mediated and justice based-theoretical approaches into the occupational therapy process illustrates a continuing theory-practice gap. One potential area of concern is occupational therapy education, where curricula have remained focused on medically modeled and individualistic approaches to therapeutic interventions (Block et al., 2005; Gitlow & Flecky, 2005; Hocking, 2017; Hocking & Townsend, 2015; VanPuymbrouck & Friedman, 2020) that do not reflect an understanding of discrimination or social inequality (Bailliard & Aldrich, 2017). However, occupational therapy programs are steadily attempting to counter this deeply entrenched educational model. The infusion of coursework that introduces students to disability studies and disability-based frameworks and theories is helping to facilitate what Block et al. (2005, p. 559) have referred to as, “dual vision” whereby students develop the ability utilize their therapeutic lens while at the same time be able to “fundamentally recognize persons with disabilities as citizens, neighbors, friends, and family members”.

Occupational justice is described in the literature as the conceptualization of social and political factors that can be a facilitator or barrier to occupational performance. Occupational justice is rooted in the complementary notion of inclusive and diverse opportunities for life participation (Jakobsen, 2004). While the term ‘occupational justice’ may be limited to the profession in lexiconic use, (Whalley-Hammell, 2017), its definition frames a larger, socially mediated perspective regarding the human right to full opportunities for engagement in society, for all individuals (Hocking, 2017; Riegel & Eglseder, 2009).

Nilsson & Townsend (2010) have argued the importance of health professionals’ practice from an occupational justice- oriented framework and their continual advocacy for a barrier-free society where the fundamental occupational rights of all are equally supported. Within the context of occupational therapy, occupational rights refer to what Whalley-Hammell & Iwama (2012) described as an individual’s innate right to take advantage of participatory opportunities. The development of an occupational justice mindset, and the ability to infuse occupational justice tenets into practice, should begin early on in professional growth. This then becomes the moral imperative of our occupational therapy education programs.

How do we structure occupational therapy education curricula to nurture the development of students’ worldview and skillset that encompass the ideas of occupational justice, equality of occupational participation, and innate human right with realistic, client interactions? How do we craft authentic educational experiences that will serve to support this crucial development? This article serves to illustrate student engagement in a learning activity, designed to create a collective experience that facilitates exploration and growth of perspective. The article describes, through the lens of student reflections, how future practitioners gain a conscious foothold on their internal awareness that may contribute to their growth and development as healthcare professionals who embrace the tenets occupational justice and the human right to participation as a beginning framework for socially equitable practice.

The Occupational Therapy Program at Stony Brook University

The Occupational Therapy Program at Stony Brook is a combined Bachelor’s/Master program in which fieldwork is completed in the fall of the final year, followed by a return to campus to complete didactic coursework. Students return to campus energized and inquisitive about the very nature of the human spirit. Their experiences in the field have contributed to their growth, not only as fledgling occupational therapists, but also as human beings. In the spring of that final year, students enroll in the course, “Disability and OT,” which was designed by (Author) and taught annually beginning in 2004. In the course, students are introduced to various theoretical models that can be used to frame the exploration of ethical and psychosocial issues that contribute to social participation barriers faced by disabled people throughout their life span and develop a rich appreciation and understanding for the complex issues faced by people with disabilities. Students engage in discourse about cultural and societal influences on experiences and explore services and opportunities available to people with disabilities (Block et al., 2005; Block, 2014). The intention is to foster the development of both therapeutic use of self and an occupational justice lens using a variety of traditional and nontraditional pedagogical experiences involving disability.

The Salamander workshop project

The Salamander workshop was developed by Petra Kuppers, a professor, artist, and dancer, and Neil Marcus, a playwright, poet, and performer, both of whom are disabled. It began as a self-care project to incorporate exercise into Neil's life to help him keep his stiff limbs moving and was transformed into the initial artistic interpretation of what is now known as the Salamander Project. (Calit2 Theatre, 2014). The Salamander workshop, now part of the Olimpias Performance Research Projects (Olimpias, 2015), is a collaborative experience encompassing a wide community of artists and activists whose water-based performances are intended to highlight the disability experience, social change, and empowerment.

Kuppers describes the Salamander workshops as “ecopoetic work” (Hume, 2013; Kuppers, 2016; Kuppers & Leto, 2012), meaning the art is released from traditional boundaries and set free in the environment. All who are present participate in the process of creation. This community-driven artistic creative process is initiated through exposing groups of people to cultural expressions of disability, with the philosophy that embodiments of all sorts evoke beauty and deserve embracing (Salamander Project, 2015).

The Salamander workshop represents the spirit of community because of its social inclusion approach to artistic and creative endeavors. How can disabled people participate in fun creative activities as artists and creators, not just as “clients” and “patients”? What happens when therapeutic engagements are initiated outside of clinical contexts by non-clinicians, indeed initiated and controlled by the disabled people themselves for their own goals and purposes? Salamander workshops bring this artistic initiative to communities all over the world. They include swimmers and non-swimmers, wet and dry participants, writers and readers and people of all ages with all types of bodies. Following the water play, the groups gather and enjoy each other's company as they reflect on the emotions they have evoked and the art they have created together (Kuppers, 2016).

Salamander comes to stony brook

In May 2014, Dr. Pamela Block invited Petra Kuppers to the Stony Brook campus to facilitate a Salamander workshop with students from occupational therapy, disability studies, and theater, as well as faculty. For the third-year occupational therapy students in the “Disability and OT” class, workshop engagement was a required learning experience in the course. As emerging health practitioners, occupational therapy students must develop a deep appreciation for disability, viewed through a socio-critical lens, so that as practitioners they will actively embrace the opportunity to support empowerment of the people they will serve throughout their careers. Exposing them to Kuppers' workshop was a step forward in that direction.

Students and faculty came together with Kuppers at an indoor hotel swimming pool to experience each other through the free motion of their bodies in the water. Faculty facilitators met Kuppers in the lobby prior to the workshop. It was obvious that she is an artist and more specifically a dancer. As she entered the lobby to greet the faculty and students, the group was struck by the gracefulness and beauty of her movements. Later an analogy would be drawn comparing her voice to the water as it flowed just as elegantly in its warmth and invitation. Kuppers introduced herself and requested that each of the workshop participants do the same. She talked about the Salamander workshop and what she has termed, the “everyday diversity of the pool” (Kuppers, 2016, p. 38). Kuppers evoked the images of what was to come – bodies coming together in medium of equality, to congregate, play, and explore not only each other, but also ourselves.

The “wet” participants entered the water. First, they physically supported each other, allowing one another to float atop the hands of their partners. The dry participants recited poetry readings from selected works that embody the spirit of the project. Then the swimmers were photographed from an underwater perspective to capture the aesthetic beauty of their bodies as they interacted with one another and with the water. Following the community performance in the pool, the group then met together to enjoy a meal while they shared their interpretations of the experience and described the emotional responses that were evoked. Student participants had the opportunity at that point to view photographs that were taken of them from below the surface of the water. They were asked to describe and interpret any personal meaning or imagery drawn from the photographs and to do some “free writes” creative writing inspired by the experience.

Reflections on the experience: occupational relevance to participants

Medical schools across the country have begun to embed the arts and humanities into their curricula as a means of fostering the growth and development of skills such as self-reflectiveness, empathy, and critical observation (Howley et al., 2020; Prince et al., 2022). Surprisingly, there is little written about the incorporation of arts and humanities specific to occupational therapy education, although the benefits to students may be just as valuable. Coppola et al. (2017, p. 12) found that an arts-based module in an occupational therapy curriculum facilitated students’ ability to engage in self-reflection, more creative ways of thinking, “perspective-shifting”, which the authors noted as an important skill to client-centered practice and clinical reasoning.

As occupational therapy educators, we questioned the value of having students participate in a project about spirituality, poetry, and body imagery. Would such an activity have relevant meaning for them as budding practitioners? How might this contribute to a transforming worldview that supports a more socially focused lens that recognizes and embraces the value of framing practice around justice-based concepts that, when examined through the lens of occupational therapy, highlight and seek to address systemic participation restriction and insidious marginalization of people with disabilities?

Self-reflections shared with us by the students allowed us to intimately enter their consciousness and understand how the Salamander workshop affected them not only as occupational therapy students, but also as human beings. Following two years of organized and structured learning in traditional settings, this free form, artistic endeavor seemed to unsettle the students. Although previously exposed to Kuppers’ written work, they had difficulty making sense of what the workshop was supposed to be for them. Individual journal entries conveyed this sense of insecurity.

What is Petra Kuppers talking about? What is she going to have us do? To be honest, these were the only questions that came to mind when it came to this week’s topic. Reading Petra Kuppers’ material before meeting her was confusing for me to fully grasp. I went into the workshop with unsure expectations.

At first, I found the experience a bit confusing, as I was overly concerned with what I was supposed to doing, what I was supposed to be thinking, what I was supposed to be feeling. Looking around the pool, I think many of my other classmates felt that way as well.

Some of the writings reflected a desire to frame the workshop in occupational therapy terms that they had already become accustomed to and grown comfortable with:

I reflected on how social activity can play a big role in developing a good quality of life.

Maybe as therapists, we need to design our therapeutic interventions to be more client-centered, so our clients enjoy going to therapy. He [Neil Marcus] may have benefited from aqua therapy.

Permeating multiple student reflections was a blossoming of self-awareness and insight that might ultimately be actualized in therapeutic practice.

By leaning on each other we can develop a mutual relationship.

I felt that I was more aware of my surroundings and how important each individual is, whether or not they have a disability... I have to give new people and experiences a chance, in order to grow as an individual.

How occupational therapy practitioners come to a greater understanding of their clients' narratives relies on their ability to self-evaluate and reflect on their own experiences (Taylor et al., 2009). How those practitioners become consciously aware of the social juxtaposition between themselves, and their clients requires an approach through a more critically interpretive

lens. Embedded within the students’ writings was the foundational development of a shifting perspective and increased awareness of the societal stigmatization faced by those with disabilities. In the personal reflections following the Salamander workshop one can begin to see sensitivity, empathy, and self-awareness emerge. These characteristics form the foundation of therapeutic use of self, which in turn offer a starting point for understanding the role of social systems as barriers to participation and the need to align occupational therapy practice with justice-based concepts and approaches.

Lessons and implications for occupational therapy pedagogy

Magalhães (2012, p. 12) fears that an occupational therapy ever in pursuit of science leads us to “embrace a soul-less discipline”, and that “somehow we have been able to sanitize our work so that it is free of such contentious topics as hope and love”. As health practitioners, Pillay (2011, p. 124) contends that as health practitioners, we engage in methods that “build biologic images of patients through a medical gaze”. Occupational therapy educators need to take conscious action to counter-act this sanitized and medically oriented view of life and practice. To facilitate students' full potential as occupational therapy practitioners, faculty must look beyond the borders of traditional experiences to expand our students’ self-reflective abilities and nurture what will ultimately become their occupational consciousness.

Kronenberg et al. (2011) have described occupational consciousness as an awareness and appreciation of the role of personal and collective occupations which perpetuate practices that foster cultural power of dominant groups over others, therefore contributing to an increased understanding of the need for occupational justice perspectives. Nurturing occupational consciousness feeds what Magalhães might define as the professional soul. This being the “OT soul” from which students’ moral values and integrity will become more clearly defined and understood within the context of professional life. The challenge for faculty is to educate future practitioners in the science of occupational therapy and to nurture their personal development, therapeutic sense of self, and impart an understanding of the central role of justice in occupation. This then becomes the foundation for socially inclusive practice in which the potential for power disparities in traditional therapeutic relationships is consciously recognized.

Through unique pedagogical experiences such as the Salamander workshop, occupational therapy educators might begin to understand that they must create and offer learning experiences that draw on the arts/humanities and relational experiences to foster self-awareness as a key component of therapeutic use of self, and an understanding of occupational justice concepts that illustrate individuals’ basic right to equal, barrier-free participation in desired and meaningful and necessary life activities. Occupational therapy educators are uniquely positioned to increase awareness of the need for change in ideologies that clearly separate and unequally position rehabilitation professionals and people with disabilities. The evidence of students burgeoning occupational consciousness and increasing awareness of the social contexts in which they will practice, is revealed in their individual self -reflections following the workshop:

After attending the workshop, I felt that I was more aware of my surroundings and how important each individual is, whether or not they have a disability.

The Salamander Project allowed participants to socialize, let their guards down and create relationships with peers they may not have had prior contact with.

We need to form a partnership with our clients to attain the greatest results rather than exerting authority over our clients.

Recent literature examining disability studies and occupational therapy education has argued that a distinct need to address “students’ ableist thinking” (Friedman & VanPuymbrouck, 2021, p. 8) still exists. Ableist thinking remains a significant contributor to implicit bias which, in turn, contributes to the perpetual nature of health and social disparities for people with disabilities (Friedman & VanPuymbrouck, 2021; Heffron et al., 2019; VanPuymbrouck et al., 2021). However, translating this identified need into relevant and meaningful curricular change in occupational therapy programs remains elusive.

The Salamander workshop was an opportunity to test the waters of an experiential learning activity intended to help students more fully immerse themselves in the lived experience of others, while enhancing their own self-awareness. Such experiences are the ingredients needed to nurture therapeutic self and a deep appreciation for the concepts of social justice through a developing occupational therapy lens. Occupational therapy programs should begin to critically examine how their curriculums address justice-based concepts and focus effort on creating intentional learning experiences that guide students to intentionally incorporate those concepts into their practice experiences.

Acknowledgements

The authors would like to thank Petra Kuppers for bringing Salamander to Stony Brook University and for all her supportive comments and suggestions for various drafts of this article. We also thank the Stonybrook University Occupational Therapy Class of 2014 for their bravery, openness, and creativity. Thanks to the Humanities Institute at Stonybrook University for sponsoring Petra’s visit to the campus in May 2014.

• How to cite: Karp, P., & Block, P. (2022). Float to grow: nurturing the roots of socially inclusive and just practice in occupational therapy students. Cadernos Brasileiros de Terapia Ocupacional, 30, e3312. https://doi.org/10.1590/2526-8910.ctoRE253533122

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Edited by

Section editor Profa. Dra. Ana Paula Serrata Malfitano

Publication Dates

• Publication in this collection
  12 Sept 2022
• Date of issue
  2022

History

• Received
  26 Apr 2022
• Reviewed
  29 Apr 2022
• Reviewed
  06 June 2022
• Accepted
  02 Aug 2022