Experiences of epistemic racism among occupational therapists

Experiências de racismo epistêmico entre terapeutas ocupacionais

Abstract

Objective

Epistemic racism establishes the knowledges and ways of knowing of a dominant group as legitimate, invalidating those of groups marked by racialization. Professions are demarcated by their knowledge claims, making epistemic racism a powerful mechanism of exclusion within professions. This paper examines experiences of epistemic racism in occupational therapy across Canada.

Method

Using a critical interpretive qualitative approach, ten therapists from racialized groups were interviewed (in-person or telephone), with transcripts coded and analyzed iteratively.

Results

Participants routinely experienced epistemic ‘mis/fit’ with the profession, rarely seeing themselves reflected in the profession’s knowledge base, leadership, values or assumptions. Racialized therapists were routinely denied expertise and authority, by students, clients and colleagues. They walked a tightrope between professional assimilation and marginalization.

Conclusion

The presence of racialized therapists is insufficient, when their authority is consistently delegitimized and they are required to assimilate. Leadership roles for racialized therapists must be accompanied with epistemological multiplicity, destroying the domination of whiteness.

Keywords:
Power; Knowledge; Racism; Social Justice; Qualitative Research

Resumo

Objetivo

O racismo epistêmico estabelece os saberes e formas de saber de um grupo dominante como legítimos, invalidando os de grupos marcados pela racialização. As profissões são demarcadas por suas reivindicações de conhecimento, tornando o racismo epistêmico um poderoso mecanismo de exclusão dentro das profissões. Este artigo examina experiências de racismo epistêmico em terapia ocupacional no Canadá.

Método

Usando uma abordagem qualitativa interpretativa crítica, dez terapeutas de grupos racializados foram entrevistados (pessoalmente ou por telefone) e as transcrições foram codificadas e analisadas indutivamente.

Resultados

Os participantes vivenciam rotineiramente o “desajuste” epistêmico com a profissão, raramente se vendo refletidos na base de conhecimento, liderança, valores ou suposições da profissão. Os terapeutas ocupacionais racializados eram rotineiramente negados a perícia e autoridade, por alunos, clientes e colegas. Eles caminharam na corda bamba entre a assimilação profissional e a marginalização.

Conclusão

A presença de terapeutas ocupacionais racializados é insuficiente, sendo sua autoridade consistentemente deslegitimada e eles são obrigados a assimilar a ordem vigente. Os papéis de liderança para terapeutas ocupacionais racializados devem ser acompanhados de multiplicidade epistemológica, destruindo a dominação da branquitude.

Palavras-chave:
Poder; Conhecimento; Racismo; Justiça Social; Pesquisa Qualitativa

Introduction

Despite the fact that white supremacy permeates the sociopolitical economy of Canada (DiAngelo, 2017), many institutions have developed policies, procedures and position statements to hinder/redress/reduce racism (e.g. Canadian Association of Occupational Therapists, 2020). Too often, these address individual, overt comments or acts of racism, leaving untouched the broader, more complex systemic and institutional racism. Epistemic racism is a particular form of systemic racism, in which the ways of knowing and forms of knowledge considered legitimate are those of a dominant group, rendering all others inferior. It is particularly difficult to tackle, as dominant ways of knowing become rendered ‘natural’, inevitable, the only possible valid way to know. Yet it is a profoundly important aspect of racism, undermining the authority of racialized and Indigenous knowers and knowledges, through the guise of ‘objective neutrality’, thus distorting their lives and experiences. Canada does not collect race-based data, but existing national census data suggest ‘visible minority’ individuals make up 13.7% of occupational therapists compared with 22.3% of the overall population (Statistics Canada, 2016). In this paper we explore the experiences of ten non-Indigenous racialized occupational therapists across Canada, with a focus on epistemic racism. We ask how racism operates through processes of knowing, through what knowledges and knowers are valued and devalued, what expertise is respected or dismissed, what competence and credibility are presumed or undermined.

Background

Epistemic racism

Racialization is the social process of categorizing groups hierarchically by constructing some perceived racial differences as significant and others as insignificant (Miles & Brown, 2003). ‘Races’ are social constructs given meaning through racism, a system of oppressive social power relations rooted in history and operating at many levels, through multiple social structures and institutions, as well as through interpersonal interactions (Miles & Brown, 2003). Here, then, we use the term ‘racialized groups’ to disrupt the representation of ‘races’ as natural and inevitable, while highlighting that the construction of not only racial hierarchies, but even racial groups themselves is a thoroughly social process. Structural racism refers to broad social patterns of inequitable access to and advantage through social resources; it means the way a society structures relations and activities is shaped by, and in turn reproduces, race-based inequities. In part structural racism operates through ideologies that cast racialized people – people of colour – as lesser, marginal, inferior, and portray social inequities as the normal, inevitable outcome of this inferiority (Miles & Brown, 2003). Epistemic racism is one distinct component of structural racism (Kubota, 2020), and the focus of this paper.

Epistemology refers to a theory of knowledge, defining what can be known, what counts as legitimate knowledge, what ways of knowing are considered valid, and who can be considered an authoritative knower (Collins, 2000). We employ epistemic racism, then, referring to dominance of the knowledge systems of one group over others, groups differentiated by racialization. In the global North, this differentiation is marked by white supremacy, the presumed superiority of white people and their/our ways as normative standards for humanness (DiAngelo, 2017). White supremacy is a legacy of colonialism, slavery, and racialized capitalism, embodied in contemporary forms of sociopolitical governance. It is expressed in such commonplace ideas as ‘meritocracy,’ ‘natural’ racial differences, cultural explanations for inequities, ‘colour-blindness’, and liberal notions that equality already exists (Bonilla-Silva, 2006).

Epistemic racism establishes white ways of knowing, white knowledges, as the only legitimate knowledges or ways of knowing, requiring all other groups to assimilate or face exclusion and marginalization (Almeida, 2015; Kubota, 2020; LaChaud, 2020). This kind of epistemic hegemony, in which alternative ways of knowing are invalidated or erased, proceeds in part through “[...] the disqualification of the social agents that operate according to such knowledges” (Santos, 2014, p. 243). In short, dismissing alternative knowers, as well as knowledges. A form of epistemic violence (Spivak, 1988), or epistemic oppression (Dotson, 2014), epistemic racism is grounded in unequal, hierarchical social relations, and includes not just the content of knowledges deemed valid, but also ways of communicating, expressing and formulating ideas (Santos, 2014). We deliberately employ the plural form ‘knowledges’ throughout this paper to signal that there exists always a multiplicity of knowledge forms, content, and ways of knowing, with some dominant and some subordinated or even erased. If it is jarring grammatically, that is an intended disruption to the epistemological hegemony of dominant authoritative knowledges.

Epistemic racism in occupational therapy

All knowledge claims “bear the fingerprints of the communities that produce them” (Harding, 1993, p. 57).

Over the past two decades, scholars in occupational therapy around the world have begun to name the epistemological biases which taint the knowledge claims of occupational therapy, challenging the pretense of neutral objectivity (a ‘view from nowhere’). Iwama (2003) was among the first to publicly identify how the dominance of Western epistemologies marginalizes Eastern cosmologies. He questioned notions of the separability of self from surrounding world; the primacy of individualism, rationality, self-determination and linearity; and the perceptions of human agency embedded in linking doing with being and becoming. This Western/Northern conceptual dominance (or theoretical imperialism [Hammell, 2011]) has resulted in “significant deficiencies” in occupational therapy models and theories, such as disregarding occupations centered on belonging or communal well-being (Hammell, 2015, p. 719). The ‘fingerprints’ (Harding, 1993) on the knowledge claims of occupational therapy are white and Western/Northern.

Internationally, scholars from the Global South have clearly demonstrated the “cognitive colonization” (Córdoba, 2020, p. 1373), or “colonization of knowledge” (Silvestrini et al., 2019, p. 936) through which Eurocentric occupational therapy knowledge claims from the Global North/West move from situated knowing to pretenses of universality. In so doing, the epistemologies of other peoples and places are rendered non-existent (Córdoba, 2020). The cultural imposition of a logic of neoliberal capitalism, with its emphases on productivity, independence and technical-rational governance, depoliticizes ‘social problems’ casting them as matters of individual enablement rather than the need for social transformation (Farias & Lopes, 2020; Córdoba, 2020; Silvestrini et al., 2019). This monocultural imperialism casts Northern/Western ways of knowing in occupational therapy as universal ways of knowing, even when speaking and writing about cultural and political differences (Santos & Spesny, 2016). Algado (2016) warns that exporting theories and models of practice that are situated knowledges, emerging from excessively wealthy nations (“[...] as a consequence of savage capitalism and neoliberalism” [Córdoba, 2020, p. 1370]), risks having them become at best irrelevant, at worst agents of oppression.

In Indigenous contexts in Canada, scholars have identified how core occupational therapy concepts such as the meaning of play, developmental milestones, and independence are infused with Western colonial bias (Gerlach et al., 2014). Even the deficit model often employed in occupational may completely contradict the strengths-based approaches of many Indigenous Peoples (Gerlach, 2018). The very tools and assessments available to therapists embody white, Western cultural norms and ways of thinking (Hunter & Pride, 2021; White & Beagan, 2020). Gibson (2020) has documented countless small and large ways ‘mainstream’ occupational therapy misaligns with Indigenous epistemologies, from perceptions of wellbeing to evaluation processes.

In Canada, Grenier (2020) has documented how white supremacy is implicated in the epistemological foundations of occupational therapy. The nation was created through building a political economy based on colonial genocide and displacement of Indigenous Peoples. Capitalist colonial expansion was accomplished in part through racialized labour, including African-heritage slaves and indentured servants, as well as Chinese labourers. Occupational therapy was founded and developed by white Western women in the early 1900s, embodying that racialized hierarchy:

Occupational therapy helped to reinforce who was seen as the epitome of the moral, rational and socially useful human, as well as whom healthcare was inherently intended for. Entwined in a healthcare system steeped in anti-Blackness, anti-Indigenous colonial relations and Orientalism, occupational therapy ‘grew up’ contributing to, and being shaped by, White supremist and racialising ideologies within an already deeply racialised Canadian healthcare system – a key site for the maintenance and reproduction of these racial relationships (Grenier, 2020, p. 637).

Theories, models, frameworks, assessments and interventions remain mired in the epistemologies of settler colonial whiteness. Not surprisingly, the few studies of racialized occupational therapists suggest they find the core values of the profession a poor fit with their own (Beagan & Chacala, 2012; Beagan et al., 2022).

Drawing in part on the work of Critical Race Theorist Charles Mills (2007), Medina argues that when a hermeneutical injustice (an injustice involving meaning-making and conceptual understanding) such as epistemic racism is identified, it is important not to stop there, but rather to interrogate who, how, in what contexts, to purposes, and through what dynamics? He stresses that while such injustices definitely operate at an impersonal structural level – how whiteness infuses pedagogy, curricula, research and so on – it is also important to attend to their “agential components”, the ways they operate through everyday interpersonal interactions (Medina, 2017, p. 42). This can help identify individual and collective responsibility for perpetuating racism. In his theorizing about racism and epistemologies, Mills himself focuses on failures to recognize and respect the personhood of another, as part of the relations of dominance and subordination (2007). Epistemic racism not only establishes legitimate and illegitimate knowledges, but also two distinct classes of epistemic agents: knowers and sub-knowers (Pohlhaus Junior, 2017, p. 17). This distinction is maintained in part through devaluing the credibility of some knowers (Dotson, 2014). As Pohlhaus Junior (2017, p. 20) argues, “In such cases, an epistemic agent is unfairly prevented from participating fully within epistemic systems owing to an unfair distribution of epistemic power due to unwarranted credibility deficits and assessments of competency”.

In this paper we examine the experiences of non-Indigenous, racialized occupational therapists in Canada, exploring how they experienced epistemological inclusion and exclusion within the profession as routinely taught and practiced. We focus on their experience as racialized knowers, and their observations of the authority granted to racialized knowers. The fact that these are experiences therapists have had within the profession, in their professional roles, does not mean all actors involved are members of the occupational therapy profession; in their professional roles therapists interact with clients and other health professionals too, moments where their epistemic legitimacy may be bolstered or undermined.

Methods

We draw here on a subset of data from a larger qualitative study examining the experiences of health professionals (physicians, nurses, occupational therapists) who self-identify as disabled, working-class origin, racialized, ethnic minority, and/or minority sexual/gender identity. The experiences of Indigenous professionals will be a later phase of the research, led by an Indigenous therapist, employing Indigenous methodologies. The study was approved by three university research ethics boards. Participants were recruited from across Canada, using the professional networks of team members for snowball sampling, as well as posting recruitment information in provincial professional newsletters, and through social media. Those who responded were emailed the study information and consent forms, and their eligibility was confirmed. Participants had to self-identify with one or more of the groups listed above, plus have five years’ practice experience, in any field, anywhere in Canada. Anyone who volunteered was accepted.

This paper includes the 10 occupational therapists who self-identified as racialized, some of whom also self-identified with other marginalized groups. Recruitment information explained the study as exploring professionals’ experiences of inclusion and exclusion, belonging and marginalization. We drew on the tradition of critical phenomenology, exploring taken-for-granted aspects of everyday life as experienced and interpreted (Moustakas, 1994). We employed a critical interpretive approach, interrogating the conditions, institutions, assumptions and power relations that structure taken-for-granted aspects of everyday life (Ahmed, 2006). While an in-depth phenomenological study might include multiple interviews delving into layers of meaning and experience, this was not a time commitment feasible for busy health professionals. We say ‘drawing from’ critical phenomenology in the sense of staying relatively open-ended in our interviews, following the lead of participants while striving to elicit their experiences and interpretations.

Individual, in-depth interviews were conducted by phone or in person with participants, exploring belonging and marginality, experiences of oppression, as well as coping and resistance. For example, interview questions asked about experiences such as how the person decided to enter the profession, how they learned what was expected of them as ‘a professional,’ and when they most and least felt they belonged in professional contexts. All interviewers (n=4) were members of the marginalized social groups we recruited into the study, and most were situated in occupational therapy. Some interviewers were racialized and Indigenous, while some were white. Interviews were typically 60-90 minutes long and often interviewers drew on their own experiences to foster reciprocity with participants. We discussed the interviews weekly, to reflect on immediate impressions and develop ways to deepen reflection.

Interviews were recorded and transcribed verbatim, then coded inductively using ATLAS.ti qualitative data analysis software for ease of team coding and transcript management. Some codes drew from theory and literature, while others were identified through repeatedly reading the data. Iterative analysis moved between compiling coded data and re-reading full transcripts, shifting between theory and data, focusing on codes such as microaggressions, overt hostility, belonging, and coping strategies. While we began the study attuned to matters of racism, the conceptual framework of epistemic racism gradually emerged through ongoing team analysis and discussions about the data, providing an overarching thematic structure for this paper. Weekly team meetings over about 30 months that initially focused on interview strategies, later turned to discussion of data interpretation. Typically, discussions were framed around questions like, “What do you think this participant means when they say…?” Later we shifted more to how we were conceptualizing the codes we were using, whether we needed new codes to capture some aspects of the data, and how codes might need to evolve – being divided as we recognized greater nuance, or collapsed as we recognized a common core (Braun & Clarke, 2021). Once we moved into writing, weekly discussions engaged more with theory and various ways to interpret the data.

As we engaged in collective interpretation, drawing in diverse theoretical frameworks and experiential knowledge, we made no attempt to ‘bracket’ previous knowledge; we take the epistemological stance that all qualitative research is interpretive, rather than bias-free or objective. Lived experience informed every aspect of the research as we strived to mobilize our ‘biases’ and perspectives to enrich analyses. For individual reflexivity, we interviewed one another at the outset. Collectively, we engaged in ‘transpersonal reflexivity’ (Dörfler & Stierand, 2020, p. 788), team members “thinking together” so that perceptions, experiences and beliefs became sources of interpretive insight. The bias least likely to have been challenged in our analyses remains the connection all authors have to the profession of occupational therapy.

Quotations were organized and reorganized as sub-themes emerged, then ‘cleaned’ by removing false starts and filler words like ‘um’ and ‘ah’ for readability. While we report demographics (Table 1), we deliberately keep details vague to reduce identifiability.

Table 1
Demographics.

Characteristic	Category	N=10
Age	30s	6
	40s	3
	50s	1
Years in practice	5-9	5
	10-14	2
	15-19	1
	20+	2
Location	Rural/town	1
	Small/mid-sized city	3
	Large city	6
Practice setting *	Hospital	4
	Private practice	2
	Community	6
	Academia	2
Racialized identity	Black/African Canadian	3
	East Asian	3
	Southeast Asian	1
	West Asian	2
	Latina	1

• ^*
  Totals more than 10 because some practice in multiple settings.

Limitations and Rigour

The study is limited by our having conducted only single interviews with participants on a complex topic. This minimized participant burden, as past experience suggested professionals would be unlikely to commit to more than 60-90 minutes, which was evident when some therapists cut interviews short to return to clinical duties. The study is also limited by the heterogeneity of a relatively small sample, including members of several racialized groups. This may gloss over important differences in racism experiences. Though sample heterogeneity did enable exploration of racism across racialized groups, it is often considered an impediment to thematic saturation of data – seen as a gold-standard for rigour in qualitative research (Guest et al., 2006). While the notion of ‘information redundancy’ is plausible to anyone who has conducted qualitative data collection – we certainly had those moments when we began to hear common narratives in subsequent interviews – we agree with those who argue that data saturation is not really possible in interpretive research, it is a post-positivist holdover (Braun & Clarke, 2021). Data analysis spirals ever deeper, uncovering layers of meaning and interpretation.

Lastly, we did not employ member-checking, as many years of previous experience has shown professionals rarely respond to preliminary analyses, and circulating transcripts alone serves a kind of pseudo-validation (Birt et al., 2016). We did present our preliminary analyses at a national occupational therapy conference, receiving a great deal of affirmation from racialized therapists, which increased our confidence in the resonance of our analyses.

Results

All participants identified as women, from five broad ethno-racial categories (see Table 1). Participants primarily worked in small and large cities, and in community settings. Some were first or second generation Canadians, some had roots in Canada for many generations. Though they all had found ways to survive, even thrive, in the profession, they all also raised experiences and observations regarding epistemic racism: 1. Most concretely, there was lack of representation, particularly in positions of power and authority – expert knowers. 2. The professional expertise and authority of racialized therapists were challenged by students, clients and colleagues. 3. The epistemological dominance of white Western/Northern knowledges in the profession cast racialized professionals as epistemological misfits, the “sub-knowers” (Pohlhaus Junior, 2017) referred to above. 4. Consequently, therapists faced a constrained choice between professional assimilation and resistance.

Absence in the profession, particularly in positions of authority

Almost all participants spoke about being the only, one of the only, or the first student of their racialized group in occupational therapy school. Many were the first and/or only racialized employee at their workplace. The one participant who said there were other Asian students in her program and worked with racialized managers in her workplace, nonetheless noted the absence of racialized faculty when she was in school: “A lot of our professors were white. I don’t really remember there being professors of a minority. No, there really wasn’t much”. Another therapist commented on not seeing herself reflected among faculty, “I just assumed that they were different from me, and that they wouldn’t understand me, and my circle and my journey”. None of the Black therapists had ever worked with another Black therapist, though among them they had over 50 years of experience. In their workplaces, participants perceived pervasive whiteness within management circles: “There is no person in leadership or management or a VP role, of a visible minority. None… Not one manager”. The sheer absence of racialized people conveys a powerful message about the whiteness of the profession. It builds on, but also reflexively reproduces the tacit understanding of who can be a legitimate professional, a legitimate knower.

Some suggested that as credentials steadily rise for entry to the profession, racialized, Indigenous and low-income applicants are systematically hindered from entry. One participant noted that programs are all full-time and intense, disadvantaging students from all marginalized groups: “Our programs presume an upper-middle-class, full-time, doesn’t-need-a-part-time-job, student”. A tendency toward problem-based and tutorial learning further disadvantages those who are learning in a second language, or whose cultures discourage speaking out: “I used to be so conscious about my accent… I wasn’t able to really concentrate on what I wanted to say, so I was always so anxious … I was a very, very quiet person in the tutorials”. Another participant noted that she lost confidence in school, as she saw white, higher-class students navigate the social field with familiar ease, speaking up and appearing to belong. Her knowledge, her ways of knowing were not considered valid, legitimate.

Expertise & authority of racialized therapists challenged by others

If racialized people are disproportionately less-visible in the professions, particularly in positions of power and authority, a predictable consequence may be that those who do occupy professional positions face ongoing challenges to their expertise and authority. In our data such challenges arose from students, clients and colleagues (within and beyond the profession). Such challenges convey a tacit message about who can plausibly be a legitimate knower, a legitimate occupant of this professional role. We term this kind of challenge to their legitimacy epistemic racism because knowledge/knowers are deemed superior/inferior on the basis of racialization.

For example, one therapist in an academic position found some students challenged her in ways white faculty members found surprising. In addition to derogatory comments in class, she received aggressive emails:

The types of emails that I’ll get from students… [for] example an email where someone flat out was… [being] aggressive and asking me to justify learning objectives of a course. … I don’t want to say question[ing] my authority, … but, it was a really weird kind of questioning of my intellect, maybe? … And other faculty saying they’ve never gotten an email like that.

She faced “backlash” from students in her course evaluations regarding her religion, which is closely intertwined with her ethno-racial identity. She described a student sitting with his feet up on his desk while consulting with her in class: “You tell me if I’m wrong, but you never put your feet up on a desk, while someone’s sitting right across from you. Right? Like, that’s just a little on the degrading side”. She saw incidents like this this as deliberate disrespect contesting her role as legitimate knower.

Similarly, the professional authority and expertise of racialized occupational therapists were sometimes denied by clients. For Asian participants, authority was routinely undermined by the perception that they looked ‘too young’ to be health professionals, a distinct intersection of race and gender for Asian women.

I’m a small Asian woman and I look really young, maybe they don’t take me as seriously… One guy I can think of basically told me to go away, like I don’t know what I’m doing or what I’m saying. He was like, ‘Well what do you know? You’re not a professional. You’re just a girl’ or whatever. And other people just thought I was like, their granddaughter’s daughter, coming in to visit them. They thought I was selling Girl Guide cookies.

Perceptions of youth may sound like a compliment, but participants were clear that such racialized/gendered comments complicated their work, raising questions about their years of practice experience and suspicions about their credibility.

I do get a lot of clients telling me that I look too young to do this job, [and] some clients did ask me about my college registration to prove that I’m an actual occupational therapist. So I have gotten that a lot too… One client had [condition] and I was there to do a home assessment, and while I was doing the assessment, he started asking me, like, challenging my knowledge. He was asking me, ‘Do you know what [condition] is? Do you even know what you’re doing?’ or ask, ‘When did you finish school? How long have you been practicing?’

For this therapist, youthful appearance coupled with accented English undermined her authority: “It was the impression I had, that because of my accent they didn’t then see me as a professional”. In turn she made sure that her name badge was always showing, to prove her status: “People did ask me to see my College registration, that I was actually registered with the College. … So, I just make sure that my main badge ID is showing”.

Some clients refused to be seen by a racialized therapist (Beagan et al., 2022) or those with ‘accents’. Others challenged therapists more directly. One participant described a client’s son screaming at her because his mother did not meet equipment funding criteria: “I remember her son just being completely irate, yelling at me in the hallway, ‘If I was [Asian], you would be getting a scooter for my mom’ and saying things like that, which was completely racist”. Others had clients challenge their authority and expertise by employing ethno-racial stereotypes positioning racialized women as personal care workers, cleaners or other staff: “They think I’m there to help them or give them a massage”.

The same kinds of assumptions may be employed by colleagues and other health professionals, again denying the expertise of racialized therapists. For example, one participant described an incident where a client had fallen and she called paramedics, who upon arrival asked her to clean the incontinent patient: “I think when they saw me, they thought that I was her caregiver, like, I was hired help, even though when they walked in, I introduced myself. I told them I was an occupational therapist”. The experience of therapists is loss of epistemic credibility, the undermining of professional authority despite earned credentials.

This denial of racialized therapists as legitimate knowers was markedly evident when their ideas were refused, ignored or challenged by colleagues. One therapist worked hard to always present her ideas through the lens of evidence-based practice, yet was still dismissed.

One of the consequences of being racialized, and also a woman, is that I feel like my opinion isn’t taken into consideration. … [So] I’ll talk about the evidence, instead of talking about my personal opinions. … say things in a way that will be perceived by others as valid.

She noted that even when she researched initiatives, and brought solid evidence to the team, changes were rarely implemented. Another therapist observed that her ideas only got taken up when expressed by someone else:

Sometimes I feel that my ideas, depending on the audience, are not taken seriously. … [I may offer] an idea about something then even in that meeting, it would be dismissed and another person would take up that same idea that had been dismissed and they would say Wow! [laughs] I used to keep quiet and then [started saying], ‘Isn’t that what I’ve just said?’

She also noted that colleagues would consult her, then present her ideas as their own.

Finally, one participant who had been delivering educational events in her area of practice, naming the impact of systemic racism, was directly challenged by a colleague.

One of the psychologists didn’t like what I had to say, which was just a manifestation of the systemic racism, so much so that she actually wrote a letter to my College. Now I’m under investigation because she couldn’t agree to disagree… She didn’t see someone with twenty years experience and a graduate student, and all this knowledge personally and professionally, even though that’s what I presented myself as. Instead, she saw an ignorant Black woman, and wanted to shut me down.

These narratives paint a picture in which seeing a racialized person – perhaps especially a woman of colour – in a position of authority may be cognitively dissonant, their expertise subject to invalidation.

Epistemological misfits

This dissonance, this construction of racialized therapists as less than authoritative, may be grounded in the professional dominance of white Western epistemologies (Grenier, 2020), which subjugates and invalidates other ways of knowing. At the level of epistemologies (what counts as valid knowledge), participants described a profession steeped in whiteness and Western ways of knowing, which leaves other worldviews, other lived experiences, not fitting easily. It may result in struggle for those who are constructed as ‘misfits’, leaving them feeling at their core that their worldviews and epistemologies do not belong.

Participants suggested that assessments and interventions too often rely on normative cultural expectations, pathologizing other cultural patterns and understandings. For example, one Asian therapist spoke about the importance of hanging onto possessions for Asian immigrants who had lived through war and displacement; She frequently had to explain this to white Western therapists who misunderstand this as hoarding. Participants argued that white Western epistemologies also infused approaches to charting, documenting, and codes of ethics.

The ethical stance against gift-giving between clients and therapists was raised several times, as completely violating the norms of many cultures. A Latina therapist, for example, had watched her father – a physician – being given gifts in exchange for his services. She personally endorsed this practice, but it contradicted professional ethics, leaving her conflicted when clients offered her gifts in gratitude.

Sometimes I say the College doesn’t allow me to do that. But I don’t think it’s a moral dilemma. I think it’s just the nature of the culture where they don’t really see boundaries with professionals and clients … they want to offer me gifts and they think that it’s okay to do that. It’s normal. And like to meet with my husband and come over to their house for dinner for another time, just to chitchat. I don’t see that as a weird thing [laugh].

The very notion of professional boundaries reinforces Western ideas of hierarchy and authority, ideas incomprehensible in many cultures. As one participant pointed out, professional codes of ethics employ “a very reductive version of power dynamics” ignoring oppression, and thus the possibility that “the clinician could be the vulnerable one, in a therapist/client dynamic”.

Some participants commented that the entire approach to practice they had learned in school failed to take racism into account: “It’s like, depression is a thing, but let’s not talk about how racism might be contributing to that in any way. Let’s not factor that into the equation… It’s just not a part of the conversation”. This therapist went on to say, “Any kind of discrimination at all, including the ones that can come from being a visible minority, is simply not taken into consideration, with any of the evaluations, any of the interventions that we learn in school”. She continually researched alternative assessments, and had developed her own approach to doing “a cultural map” with every client. She advised students to keep searching for tools appropriate for racialized communities, saying, “Don’t forget when you graduate, you will need to take that into consideration and no one will tell you how. It’ll be all on you. Just like it’s all on me”. Individual therapists and students are left trying to circumvent systemic problems.

Several participants said they never really fit in occupational therapy as a profession: “Do I feel I fit in? Probably, to be honest with you, most of the time I don’t”. When asked how her own values and worldviews fit with those of the profession, one participant said this is “actually a question I’m trying to answer!” She felt increasingly disenchanted with the theories and frameworks of the profession, and through social media connections with other racialized therapists was “really trying to think more critically about decolonizing our understanding of occupational therapy”. Another therapist argued her ways of being in the world were seen as simply ‘wrong’ for the professional context: “My epistemologies were not at all valorized, my way of doing things, my emotionality when I express myself – like all of that was not valorized. In fact, it was put down”. She identified this as epistemic injustice, wherein people are routinely judged from within a paradigm that clashes with their own.

Finally, one therapist suggested that her expertise may be considered a fit for some jobs and not others, curtailing her professional options.

I think in the community, [Asian identity] helps… there’s people who are of similar background as me… But when applying to bigger companies, I think there are certain barriers in that maybe the culture of their current work environment, they’re not sure if I would fit in… Maybe is it because I’m Asian? Or because they have certain assumptions about me? Is this why they’re not willing to hire me?... I don’t look like their other OTs.

While some therapists felt a greater sense of belonging when working with their own communities, one also pointed out working in community means clients may feel “more entitled to treat you with disrespect” in their own home, and therapists have few, if any, colleagues for support. Thus epistemic racism may position some therapists as only suited to a narrow range of job possibilities, their social identities valued while their status as knowers, their expertise, is invalidated.

Professional assimilation/resistance: a constrained choice

In the face of epistemic racism, one of the few options available to racialized therapists is to assimilate to professional expectations grounded in white, Northern/Western notions of ‘professionalism’ and respectability. As Kubota (2020, p. 713) has noted, “[...] epistemological racism excludes us [racialized peoples] from and simultaneously assimilates us into the dominant white knowledge”. For example, at a more superficial level, participants spoke of taking up yoga, or going to Starbucks, or lunching at a “burger joint” instead of a place they preferred, in order to fit in with colleagues. Some always ensured they were dressed in business attire, lest their professional credibility be questioned. If ‘looking professional’ is defined through whiteness, racialized therapists may work to fit that image: “I always felt like I look unprofessional if my hair was not straight… I’ve spent quite a bit of time straightening my hair”.

More fundamentally, some participants altered their ways of being in order to fit in with (white, Western/Northern) professional expectations. One therapist termed this “a politics of respectability,” wherein people from non-dominant groups get defined as “too” much: “You are a little too emotional, hysterical, rude, whoever decided what rude was, assertive, whatever.” For one participant, this meant carefully constraining any mention of spirituality, despite the fact that it is ostensibly central to occupational therapy, and a key part of her ethno-racial identity. To fit in to the profession she needed to silence part of herself: “Spirituality is an occupation that a lot of people don’t like to talk about. And I found it really hard to completely cut that part of me off.” She even found she altered her tone of voice and intonation in work contexts: “That was another thing that I had to shift and change. When I’m passionate about something, … this is what I actually sound like when I’m talking at home. But… if I talk like this, [people] get intimidated.” She went on to say:

They just decide that I’m either angry, intimidating or closed off. And it’s something that I’ve noticed colleagues like myself face time and time again… The piece around being intimidating and having to speak softer in a certain way… I think that I’ve had to do that quite a bit more in all aspects of my speech and nonverbals which is, I think, when it becomes a little problematic. Like, when your family says they don’t recognize you when you’re speaking to someone at work, that’s a telltale sign that that’s probably a problem.

This was echoed by another therapist who said it is not okay for her to express emotions with white colleagues. She described venting annoyance about something personal in the staff room one day, and having colleagues try to calm her down:

I was tense and angry and letting them know how frustrated I was with that experience. And their first response was ‘Calm down’… in the white community, I’m not allowed to get angry. I’m not allowed to express my feelings in a way that feels comfortable for me, because they’re getting uncomfortable… So I don’t get to be myself when I’m in a room of white people.

She stated that she is always more reserved with white people, and only in Black community can she be fully herself: “That’s what it is all the time… I’ve got to bend myself in a pretzel, to make sure that they don’t feel uncomfortable.” All three Black participants raised the angry Black woman stereotype as something employed to contain, curtail, silence them.

When expectations of professionalism are rooted in whiteness, part of assimilating entails constantly proving yourself as good as or better than others. Virtually all participants stated that they thought they had to work twice as hard to earn the same respect and status as their colleagues:

I’ve had to work much harder than other colleagues, to be awarded the same kind of respect. In all fairness, I think now I’m at the point where I do have even more respect than my colleagues. So I think I have managed to exceed the ‘proving myself’ expectation. But I’ve had to sacrifice time with my family for it. You know, I’ve done many years of studying and working, instead of just clocking out at the end of the day and relaxing with my family and friends… I would say it hasn’t promoted a lot of balance and self care [laugh].

All participants agreed remaining connected to community is critical, providing a counterpoint to the pressures of professional assimilation: “You need your people. You need to find spaces where … you’re not modulating your performance; where you’re just you and who you are is not just good enough, it’s awesome”.

Even when choosing to challenge racism directly, participants had to make their resistance ‘palatable’ or they would not be heard. Professional respectability may demand a very careful approach to expressing resistance. One therapist said, “I’m still in a place where I feel like I have to compromise myself”, yet was increasingly speaking out against racism, despite possible risks: “I’m going to look like the trouble maker, right? And that’s how I’ll be scapegoated”. Another therapist noted that ‘the angry Black woman’ stereotype was always available as a way to dismiss or delegitimize her analysis of racism:

I’ve had a friend tell me, ‘Well, if you’re going to talk about racism, it depends how you bring it up. If you bring it up all angry and things, then it’s normal that no one would want to listen.’ … There’s a lot of rules. Like, I can’t talk about it all the time. I have to be careful how I talk about it. Everybody needs to still be comfortable around the topic and if they’re not comfortable, then I have to drop it [laugh].

White Western/Northern notions of how ‘professional’ is embodied, of what it means to enact professional respectability, shape even the ways racialized therapists are expected to talk about racism.

Discussion

Experiencing epistemic racism and credibility deficits

When the assessments, theories, models and frameworks taught, learned and practiced in occupational therapy encompass only white, Western/Northern worldviews, this embodies and enacts epistemic racism, or white supremacy (Santos & Spesny, 2016; Grenier, 2020; Córdoba, 2020; Silvestrini et al., 2019; Algado, 2016). Epistemic racism is evident at all levels in the participants’ accounts – what counts as knowledge, the rules for assessing knowledge claims, who can be a knower, what can legitimately be known, and how knowledge can be spoken or conveyed. Professions are by definition bounded by epistemological claims. Each profession bases its practice on a body of knowledge which can be demarcated as fairly exclusive, using accredited formal educational programs to convey its knowledge and skills (Gorman & Sandefur, 2011). Professions claim jurisdiction over particular aspects of human experience through exclusive knowledge and action claims, establishing the grounds for granting power and authority to professional expertise.

Client refusals to work with racialized therapists, demands that therapists prove professional status by showing their College registration, direct challenges by students – these are messages of a “credibility deficit” (Dotson, 2012, p. 27), a (coded) insistence that the knowledge claims upon which professional authority is granted do not extend to certain kinds (colours) of knowers, or epistemic agents. When the ideas of a racialized therapist remain unheard until spoken by a white colleague; when ideas are presented by others as their own; when suggestions must be backed by independent research or be ignored – this is epistemic racism. The reported absence of racialized people in management positions and faculty roles, even in large multicultural cities, suggests people of colour may not be constituted as legitimate knowers, legitimate authorities.

The professional authority of virtually every participant was undermined, repeatedly. In this way, the power relations of racism (and arguably sexism) operate through epistemic injustice to position these racialized therapists as “less than competent knowers (Pohlhaus Junior, 2017, p. 17). In many instances racism intersected with other forms of oppression, including sexism, ageism, and ethnocentrism; youth, gender and religion were also employed to dismiss credibility. Participants were ‘too young,’ ‘too angry,’ ‘too accented,’ ‘too emotional’; they were exceeding their scope of practice; they were required to defend their teaching to students; they had to prove themselves good enough, relentlessly. Ideas were both ignored and appropriated. Even the dismissals of authority employed available racist stereotypes: Asian women as demure and subordinate, Black women as angry or over-emotional. Pohlhaus Junior (2017, p. 21) argues that the omni-presence of “pernicious stereotypes… adds to the cognitive labor of those stereotyped in ways that can impede their epistemic activity in comparison to those who are not perniciously stereotyped and so do not need to engage in such additional epistemic labor”. In other words, racialized therapists must constantly work against stereotypes that deny them credibility as knowers, as legitimate professionals.

Assimilation and resistance

In that context a dominant way of coping with epistemic racism is assimilation to (white, Northern/Western) professional expectations. Tame your hair, change your style of dress, alter your hobbies, tone down your anger, modify your tone of voice – these are survival strategies when racialized therapists are excluded from legitimate embodiment of professional authority. As Santos (2014, p. 244) has argued, in situations of epistemological dominance, “many alternatives are left out: alternative types of agents other than docile bodies and strangers, alternative knowledges”. So participants take on the extra work, practicing as dictated by their (white) profession, while finding other ways to connect with clients, researching other ways to do their jobs. They do the work, sometimes working twice as hard to earn equal respect, struggling to see how the values and beliefs of the profession fit with their own. They may feel marginalized in their profession, never having a sense of belonging, or fitting, despite bending themselves “into pretzels” to accommodate normative expectations. When racialized therapists instead (or additionally) choose to confront racism, they must do so in very particular ways, ways that carry epistemic privilege and professional approval, or they will be dismissed as loud, angry, emotional, incompetent – ultimately, unprofessional. Again, to cite Santos (2014, p. 326) “Knowledge diversity is not limited to the content and kind of its privileged intervention in social reality. It includes as well the ways in which it is formulated, expressed, and communicated. Our participants strived to communicate in the ‘right’ ways, the legitimated ways, to minimize epistemic racism, garnering themselves the status of legitimate knowers.

It is difficult to imagine increasing numbers of racialized occupational therapists as an appropriate solution: should more people endure such struggles? Yet keeping in mind that participants often found themselves ‘the only one’ in a sea of whiteness, and keeping in mind the importance of community spaces where your very self and your ways of knowing are considered credible, building a critical mass of racialized therapists has more radical potential. Minimally, it begins to undermine the physical whiteness of the profession, holding potential for creating an epistemic shift.

Philosophers Fricker (2007) and Dotson (2012) identify three forms of epistemic injustice. In the most basic (testimonial injustice), a person’s credibility as knower is undermined by prejudice, such as racism. This may take indirect forms, such as accusing the knower of not understanding, not being objective, or being unprofessional. It was clearly evident in our study, with racialized therapists being undermined as valid authorities. More complexly, ‘hermeneutical injustice’ occurs when as a culture, we lack the epistemological resources to make sense of a marginalized person’s experiences in their own terms. Available discourses, ideas, concepts, language are lacking, unable to encompass experiences outside the dominant mainstream. Neither speaker nor hearer has the concepts to capture a subordinated reality. Yet Dotson (2012) adds the notion of ‘contributory injustice,’ which insists that alternative epistemologies always exist, circulated among members of oppressed communities. Thus, not seeing any way to make sense of a divergent reality (in dominant discourses) is willful ignorance, relegating alternatives to invisibility. The frameworks employed within non-dominant groups get no uptake.

This framework has lessons for occupational therapy. It certainly echoes the critiques raised by therapy communities from the Global South, who have sustained a discourse of the need for occupational therapy to engage in socially transformative praxis (e.g. Farias & Lopes, 2020). It is possible that peer support, mentoring, communities of practice, and increased recruitment of racialized therapists and faculty, plus movement of racialized therapists into management positions, could begin to establish greater epistemological multiplicity, the surfacing and legitimizing of non-white, non-Western epistemologies. But the power of assimilating forces was also strongly apparent in our study. As a profession, occupational therapy in the North may be poised at a juncture: 1. strenuously pursue the knowledge claims of ‘objective’ Western/Northern science, emphasizing professional neutrality while striving to align ever more fully with biomedical and clinical epistemologies, or 2. uphold professed commitments to social justice, making space for epistemological multiplicity, inviting alternative ways of knowing and being that surface subordinated knowledges and value marginalized therapists. We recognize this poses significant challenges, but the latter may help the profession move further toward decolonizing and disrupting white supremacy. It also requires a complete rethinking of the profession and its institutions (see also Melo et al., 2020; Córdoba, 2020; Silvestrini et al., 2019).

“The consequence [of Eurocentric epistemological dominance] is that everything that is not this way of understanding the world is left out, denied, as a zone of not being” (Córdoba, 2020, p. 1370). Critical reflexivity demands that members of the occupational therapy profession in Canada become more critically aware of our epistemological practices (see Kubota, 2020), something distinctly challenging in institutional contexts mired in neoliberal individualism (Santos & Spesny, 2016; Córdoba, 2020; Algado, 2016). This includes attention to gaps, or “produced absences” (Santos, 2014, p 249). Whose ideas, whose knowledges do we employ, promote? Whose do we dismiss, ignore, fail to take up or teach? What counts as legitimate knowledge? On what bases? Who is positioned as a legitimate knower, and on what bases? These are not new questions, they have been advanced by racialized, Indigenous and other scholars for some time now (e.g. Santos & Spesny, 2016; Gerlach, 2018; Gibson, 2020; Córdoba, 2020; Hunter & Pride, 2021; Iwama, 2003; Silvestrini et al., 2019; White & Beagan, 2020). But they take on ever-increasing urgency as occupational therapy increasingly attends to ‘diversifying’ the profession, bringing in more and more people who will be expected to assimilate and conform to epistemic whiteness, and who may seldom be granted full professional authority.

Conclusion

Epistemic racism establishes some knowers and knowledge systems as legitimate, invalidating all others. It is a mechanism through which the knowledge claims, expertise, authority and professional identity of racialized occupational therapists are undermined. The consequence – that racialized therapists are rendered ‘misfits’ in the profession – demands of them assimilation to normative expectations and epistemologies, or resistance. Both carry unacceptable costs for those therapists. Occupational therapy has the possibility of embracing epistemological multiplicity, strongly supporting subordinated knowledges and ways of knowing, plus the authority of racialized knowers. This, along with ensuring racialized therapists move into leadership positions, is a step toward disrupting systemic racism and the culture of whiteness within the profession.

Acknowledgements

Our gratitude to the participants, and the rest of the research team: Josephine Etowa, Debbie Martin, Anna MacLeod, Michelle Owen, Doris Kukuru, Shayla McMillan.

• How to cite: Beagan, B. L., Sibbald, K. R., Pride, T. M., & Bizzeth, S. R. (2022). Experiences of epistemic racism among occupational therapists. Cadernos Brasileiros de Terapia Ocupacional, 30, e3211. https://doi.org/10.1590/2526-8910.ctoAO24533211

• Funding Source

  Canadian Institute for Health Research (CIHR) PJT-159664.

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Edited by

Section editor

Profa. Dra. Ana Paula Serrata Malfitano

Publication Dates

• Publication in this collection
  22 Apr 2022
• Date of issue
  2022

History

• Received
  19 Nov 2021
• Reviewed
  21 Dec 2021
• Reviewed
  10 Feb 2022
• Accepted
  03 Mar 2022