Professionalism and the disciplinary control of occupational therapists at the margins

Profissionalismo e controle disciplinar de terapeutas à margem

Abstract

Occupational therapy’s goal of professional status comes with costs. Sociologists argue that ‘professionalism’ exhorts workers to conform with normative expectations for behaviour and performance, becoming a mechanism of social control. Those performative expectations are established by socially dominant groups, constructing occupational therapists from marginalized groups as not-professional, unless they can contort themselves to conform. Here we explore the specific behaviours and forms of embodiedness that become encoded as ‘professional’ in occupational therapy, leaving particular groups of occupational therapists subject to discipline through the concept of ‘unprofessional’. We conducted a critical interpretive synthesis of literature indexed in CINAHL and EBSCOhost defining professional behaviour in occupational therapy (n=26). We also draw from in-depth qualitative interviews with 20 Canadian occupational therapists who self-identified as racialized, ethnic minority, disabled, 2SLGBTQ+, and/or from working-class/impoverished family origins, exploring how ‘professionalism’ serves to discipline and control them. For both approaches, we employed reflexive thematic analysis. Texts encode professionalism as specific behaviours and forms of embodiedness grounded in white, western politics of respectability. Some also exhort occupational therapists to never make the profession ‘look bad’. In our interview data, occupational therapists from marginalized groups risked being construed as ‘unprofessional’ by having the ‘wrong’ bodies, appearances, presentation of self, speech language use, emotions, behaviours, and boundaries. When ‘professionalism’ demands assimilation to normative standards that exclude particular kinds of people, we narrow the potential of occupational therapy to encompass diverse valuable ways of doing, being, becoming and belonging. There is an important role for ‘professional resistance.’

Keywords:
Professional Practice; Social Conformity; Social Justice; Social Oppression; Occupational Therapy

Resumo

O objetivo de status profissional da terapia ocupacional acarreta custos. Os sociólogos argumentam que o “profissionalismo” convencem os trabalhadores a conformarem-se com as expectativas normativas de comportamento e desempenho, tornando-se um mecanismo de controle social. Essas expectativas performativas são estabelecidas por grupos socialmente dominantes, construindo terapeutas ocupacionais de grupos marginalizados como não-profissionais, a menos que possam lutar para outra conformação. Aqui exploramos os comportamentos específicos e as formas de corporificação que são codificadas como “profissionais” na terapia ocupacional, deixando grupos específicos de terapeutas ocupacionais sujeitos à disciplina através do conceito de “não profissional”. Conduzimos uma síntese interpretativa crítica da literatura indexada na CINAHL e EBSCOhost definindo comportamento profissional em terapia ocupacional (n=26). Também nos baseamos em entrevistas qualitativas aprofundadas com 20 terapeutas ocupacionais canadenses que se identificaram como racializados, de minoria étnica, deficientes, 2SLGBTQ+ e/ou de origem familiar da classe trabalhadora/empobrecida, explorando como o “profissionalismo” atua para disciplinar e controlá-los. Para ambas as abordagens, empregamos análise temática reflexiva. Os textos codificam o profissionalismo como incorporando comportamentos específicos e formas de corporificação baseadas nas políticas brancas e ocidentais de respeitabilidade. Alguns também conformam os terapeutas ocupacionais a nunca fazer com que a profissão 'pareça ruim’. Em nossos dados de entrevistas, os terapeutas ocupacionais de grupos marginalizados corriam o risco de serem interpretados como 'não profissionais' por terem corpos, aparências, apresentação de si mesmos, uso da linguagem da fala, emoções e emoções 'errados'. comportamentos e limites. Quando o “profissionalismo” exige a assimilação de padrões normativos que excluem determinados tipos de pessoas, restringimos o potencial da terapia ocupacional para abranger diversas formas valiosas de fazer, ser, tornar-se e pertencer. Existe um papel importante para a ‘resistência profissional’.

Palavras-chave:
Prática Profissional; Conformidade Social; Justiça Social; Opressão Social; Terapia Ocupacional

Introduction

Professionalism has long been a valued guiding concept within occupational therapy. As concept, it starts from a set of ethical virtues such as honesty and altruism, intended to help and not harm those who seek occupational therapy services, through ensuring good moral conduct. At the same time, because the professions have historically been the terrain of elite groups, notions of professionalism have also served as a mechanism for policing the boundaries of in-group/out-group. This entails, in part, movement away from ethical virtues toward more observable behaviours and more tangible aspects of performance, comportment, decorum, and embodiedness. This more symbolic professionalism employs the contingent concept of ‘unprofessional’ to discipline the bodies and behaviours of therapists from non-dominant social groups toward conformity with narrow conceptualizations of respectability. Here we critically synthesize existing literature on professionalism in occupational therapy, then introduce examples from qualitative interviews with 20 therapists from non-dominant groups, to explore application of the construct. We argue for more thoughtful conceptualizations of ‘professional’ and ‘unprofessional’ that account for a plurality of ways of doing and being, encompass resistance to conformity, and return to clearer focus on ethical virtues. But first, ‘professionalism.’

Understanding professionalism as construct

The professions are fields of work that typically enjoy relatively high social prestige and salaries, considerable work autonomy, and exclusive domain over a specified field of knowledge and scope of practice, considered their area of expertise. In exchange they ensure restricted entrance through intense education and training, a lengthy period of cultural immersion, controlled licensure, regulation, and discipline of their own members according to a code of ethics and standards of practice. Professionals are granted certain rights and powers because they are oriented toward altruistic service to the public good, putting the needs of individual clients/patients, and the needs of the social collective, ahead of their own interests (Abbott, 1988; Freidson, 2001; Gorman & Sandefur, 2011; Martimianakis et al., 2009; Sibbald & Beagan, 2022).

Professionalism as construct originally pertained exclusively to these relatively rarified domains of employment, such as law, medicine, engineering, dentistry, and architecture. Such classic professions have been seen to lose some power and status over time, eroded by the market forces of neo-liberalism and managerialism, with their emphases on efficiency and accountability, as well as the rise of widespread access to information and knowledge (Abbott, 1988; Adams, 2016; Freidson, 2001). Yet the construct of professionalism has not necessarily diminished. In fact, it can be argued that it has expanded its terrain. As Valérie Fournier has argued, notions of professionalism have become ubiquitous: “The most unlikely occupations are becoming candidates for professionalisation. Secretaries, restaurant staff, security personnel, furniture retailers (among others) are all allegedly offering ‘professional services’” (Fournier, 1999, p. 107). This, she argues, is not merely a marketing trick, but rather a claim upon the expertise, trust and credibility traditionally reserved for the professions.

At the same time, however, Fournier argues that casting workers as professionals extends to them the logic of autonomous self-regulation, inviting them to govern or control themselves on behalf of employers: “Constituting employees as ‘professionals’ … also involves the delineation of ‘appropriate work identities’ and potentially allows for control at a distance by inscribing the disciplinary logic of professionalism within the person of the employees so labelled” (Fournier, 1999, p. 290). Using ‘competencies frameworks’ and promoting ‘appropriate conduct,’ the discourse of professionalism is used “to convince, cajole, and persuade employees, practitioners, and other workers to perform and behave in ways that the organization or the institution deem to be appropriate, effective, and efficient” (Evetts et al., 2006, p. 114). Professionalism as construct becomes a mechanism of control: “Once the discourse of professionalism pervades organisational life, it becomes difficult for employees not to align themselves with it, or not to constitute themselves as ‘professional’ for not doing so would mean being marked as ‘unprofessional’” (Fournier, 1999, p. 302). That mark, or label, may be grounds for dismissal.

Further, Fournier argues that professional “competencies delineate an appropriate mode of conduct rather than simply a way of performing one’s job” (Fournier, 1999, p. 296). Even in customer service jobs, when suffused with language of professionalism it is not enough to do a good job, one must be the kind of person articulated by notions of professionalism, to have any hope of attaining the prestige associated with the professions:

The ‘competent person’ … is not the person who is merely competent at his/her job or expert in a field but who, for example, ‘seeks responsibility and welcomes accountability’, ‘demonstrates customer care principles’, interacts with colleagues in an appropriate way (e.g. ‘treats colleagues as customers’, ‘generates enthusiasm’), ‘is self-critical’, or ‘listens.’ (Fournier, 1999, p. 296-297).

Organizational or employer control is no longer necessary, as workers are invited to self-manage and engage in personal development aligned with corporate goals. The discourse of professionalism functions as a mechanism of governance (Foucault, 1979, 1980), disciplining workers into appropriate conduct through inculcating self-control over behaviour (Mieg & Evetts, 2018). While this may be viewed by some (especially employers) as a positive move, it may also incorporate policing a myriad of non-work attributes and ways of being.

Professionalism disciplining at the margins

Professionalism begins from a fundamental concern with ethical virtues, meeting moral obligations to individuals and society (see Dige, 2009). The trust placed in professionals (including the power to self-regulate) is premised on understandings that they will exemplify altruism, integrity, respect for others, and principled fairness, employing their distinct knowledge and skills in service to others (Gorman & Sandefur, 2011; Martimianakis et al., 2009; Mieg & Evetts, 2018; Sibbald & Beagan, 2022). Yet these well-established virtues are challenging to observe and measure. In an age of managerialism that demands measurement, efficiency and accountability, professionalism has been steadily “hollowed out” to a “discourse of performativity” (Hoff & Kuiper, 2021). In this context, professionals gain authority, expertise and influence through the embodiment of respectability.

Philosopher Iris Marion Young argues that normalizing standards for professional behavior enter everyday life through the ideal of respectability:

Conforming to norms that repress sexuality, bodily functions, and emotional expression. It is linked to an idea of order: the respectable person is chaste, modest, does not express lustful desires, passion, spontaneity, or exuberance, is frugal, clean, gently spoken, and well mannered. The orderliness of respectability means things are under control, everything in its place… All signs of bodily function… should be hidden behind closed doors (Young, 1990, p. 136-137).

Young goes on to argue that, “Despite the claim that professional comportment is neutral, it is in fact the product of socialization into a particular culture. White Anglo heterosexual middle-class men are most socialized into this culture” (Young, 1990, p. 140).

Others agree, pointing to the ways particular bodies and peoples are then constructed as not-fitting, not-professional, unless they can manage, suppress and repress themselves to fit normative expectations. This departs substantially from ethical virtues to performing professionalism. For example, while both men and women are expected to constrain their bodies and emotions in professional contexts, women are expected to avoid “excessive sexuality but to maintain a proper level of femininity so as not to become ‘mannish’ and to remain visually appealing” (e.g., Sullivan, 2012). Because queer bodies are often understood as inherently ‘excessively sexual,’ they face the demands of ‘heteroprofessionalism’ (Mizzi, 2013) to conform to dominant norms for professionalized self-presentation (Bizzeth & Beagan, 2023; Davies & Neustifter, 2021; Rumens & Kerfoot, 2009). Professionals from working class or impoverished family backgrounds work to grasp the social and cultural norms of the upper-middle classes, to successfully ‘pass’ within the professions (e.g., Beagan et al., 2022a; Brosnan et al., 2016). With professionalism firmly rooted in colonialism and white supremacy, racialized and Indigenous professionals suppress expressions of their racial and cultural identities, striving to conform for acceptance (e.g., Gooding & Mehrotra, 2021; Pride, 2023). As Adams argues, “professionalism can marginalize collectives of people – sometimes quietly, sometimes overtly, sometimes unknowingly – in ways that enforce and reinforce neoliberal discourses of obedient, entrepreneurial workers” (2012, p. 336).

When professionalism is increasingly defined by performance of specific (classed, gendered, racialized, colonial, ableist, heterosexist) notions of comportment and decorum, the contingent concept of ‘unprofessional’ may function as an effective mechanism for disciplining the behaviours and persons of professionals from marginalized groups, and/or excluding them entirely. In the name of self-regulation, control over the being and doing of professionals extends even to “beyond-work behaviours and identities, rather than work performance… [including] judgements about conduct that extend[s] beyond what might typically be considered the realm of ‘work’, focussing on ‘personal’ behaviours too” (Eppolite & Burford, 2020, p. 537). A medical text from 1890 described the professional decorum expected in work and non-work contexts:

It is your duty, as well as to your interest, to display no political or religious emblems, portraits, etc. about your office, because these relate to your personal sentiments… A physician is judged by the company he keeps. Avoid associating with aimless idlers and those who bear stigma… a physician’s dress, manners and bearing should all agree with his dignified calling. (Cathell, 1890, cited in Martimianakis et al., 2009, p. 829).

The extension of normative expectations into personal lives is justified by the notion of public trust in the profession: “Unprofessional behaviour by any one individual reflects badly on the profession as a whole and ultimately results in a loss of public faith and, possibly, in the revoking or limiting of a profession’s self-regulating status by government” (Martimianakis et al., 2009, p. 831).

In this article we ask how professionalism has been conceptualized within occupational therapy, particularly in Canada, and how that construct may function to govern the conduct of therapists from non-dominant/marginalized groups. We conduct this analysis through both critical synthesis of existing literature, and analysis of interviews with therapists.

Methods

Critical interpretive synthesis

This is an approach to reviewing existing literature with a focus on conceptual or theoretical complexity, teasing out interpretations and clarifications, and engaging with ideas critically and reflexively (Dixon-Woods et al., 2006). It is not ‘unsystematic,’ but compared with ‘systematic reviews’ has less focus on technical processes (search strategy, inclusion and exclusion criteria, critical appraisal etc.) and more focus on in-depth, critical thinking (Greenhalgh et al., 2018). Like all forms of interpretive review, it is inherently perspectival.

For this analysis one author (MBB) searched CINAHL and EBSCOhost using subject terms for occupational therapy/ists, professionalism, and professional behavior/iour. A second author (BLB) repeated the same searches six months later to confirm and update the results, and to add commonly referenced books. We also hand-searched reference lists. Sources were included if they were written in English, were peer-reviewed, focused on occupational therapy, and focused on defining, measuring or teaching/learning professionalism. We excluded sources that focused on occupational therapy’s status as a profession, and on the importance of professional identity for practice. In total 120 sources were identified, with 26 retained for the critical synthesis. Interpretive thematic analysis (Braun & Clarke, 2019) involved reading and re-reading the source materials, identifying patterns, looking for connections and contradictions, and extracting quotes and text summaries to be sorted thematically. One author (MBB) did the initial analysis, with the results assessed and confirmed by a second author (BLB). This paper’s first author then drew more heavily on three of the themes in the initial thematic analysis, which directly address the questions for this paper. While it would be informative to analyze the literature in light of the subjectivities embodied by the authors (author race, ethnicity, gender identity, dis/ability, class, sexual identity and so on) that information is typically not provided.

Qualitative interviews

The methods for this part of the research have been detailed elsewhere (Beagan et al., 2022b). In short, after university ethical approval, 20 occupational therapists from across Canada were recruited through professional networks and snowball sampling, all with at least five years Canadian experience and self-identifying with one or more non-dominant groups (working class/impoverished family origins, racialized, ethnic minority, disabled, 2SLGBTQ+). Sixty- to ninety-minute interviews by phone or in person explored experiences within the profession. Verbatim transcripts were analyzed thematically, supported by AtlasTi software. Ongoing, regular team discussions about coding and interpretations enriched the analysis. For this paper, the lead author drew on data coded professional/unprofessional, ‘passing’ as professional, personal/professional tensions, and professional credibility. We have written elsewhere about experiences within the profession (Beagan et al., 2022b); here we focus on some examples from the data that illustrate the ways professionalism as construct is used to discipline and govern therapists from non-dominant groups.

Results

First, we will detail what we found in reviewing the literature, focusing briefly on professional values, then more extensively on behaviours deemed professional. Then we will turn to evidence of those conceptualizations in practice, within our interview data.

Conceptualizing professional behaviour in occupational therapy

The 26 sources included were published from 1996 to 2023, as journal articles plus one book. They were published in Canada, the United States, Australia, Britain, and Scandinavia. A few were literature reviews, most were empirical studies (surveys, qualitative studies), and two used Delphi methods to reach consensus among experts. One was a text guiding professionalism in occupational therapy. Most commented on ethical virtues, or professional values, through the focus was primarily teaching and assessing behaviours. The literature endorses core values like altruism, client-centeredness, integrity, honesty, compassion, empathy, respect, and fairness (e.g., Aguilar et al., 2012, 2013; Campbell et al., 2015; Gurley et al., 2022; Hordichuk et al., 2015; Kasar & Muscari, 1999; Lecours et al., 2021; Mason & Mathieson, 2018).

Normative standards for professional behaviour and comportment

When sources focus on the professional attitudes and behaviours required in occupational therapy, the move into performative or symbolic professionalism becomes even more apparent. Some behaviours are clearly ways of enacting ethical values, such as maintaining confidentiality as a way of respecting client/patient autonomy and privacy. Many others are clearly issues of comportment, decorum – looking and acting ‘like a professional.’ In addition to practice skills such as sound clinical reasoning and effective time management, we identified many common markers of professionalism (Table 1).

Table 1
Performing professionalism.

Professional presentation	Appropriate lines of communication
Suitable appearance	Communicating properly, verbally and non-verbally
Appropriate dress, grooming	Appropriate body language
Effective team player	Appropriate eye contact
Open to feedback, not easily offended	Personable
Appropriate in conflicts	Dispassionate, distant
Appropriate boundaries	Confident
Adherent to policies, code of conduct	Self-aware, insight, self-regulating
	Diplomatic

For example, Fidler (1996) depicts professional behaviour as including proper eye contact, confident body language, appropriate tone of voice and facial expressions. Koenig et al. (2003) refer to grammar, spelling and legibility, as well as interacting “appropriately” with others, including eye contact, body language and non-verbal communication. Campbell et al. (2015) not only expect professionalism to include adherence to policies (such as dress codes), but also suggest as professionals occupational therapists should never feel inferior, should not be easily offended, should be excited about work, should be appropriate in conflicts, and should be “personable,” defined as, “Versatile, good sense of humor, playful, congenial, easy going, pleasant, outgoing, friendly, social, people person” (Campbell et al., 2015, p. 6). There is heavy reliance on ambiguous, subjective qualifiers to measure professional attributes such as “proper,” “appropriate,” and “adequate,” which is one of the ways normative standards drawn from dominant groups can infiltrate ostensibly objective, neutral measures of professional behaviour, producing instead a disciplinary tool for compelling conformity. While communicating is a necessary part of doing the job (e.g., communicating assessment results), it is harder to see how a specific type of eye contact is anything more than demanding conformity.

An American text by DeIuliis (2017) provides an excellent example. She defines professionalism as, “Conformation to the standards and norms of a given profession” (DeIuliis, 2017, p. 1) and “behaving in a manner defined and expected by the chosen profession” (DeIuliis, 2017, p. 10). She states explicitly that “appearances matter” (DeIuliis, 2017, p. 23), specifically mentioning clothing, hairstyles, tattoos, piercings, body language, and eye contact. She decrees that, “Professionals in health care shall conceal all tattoos,” that earrings must be “limited to no more than two ear piercings in each ear,” that hair styles must be professional and make-up neutral (DeIuliis, 2017, p. 25). She devotes a page to proper eye contact, two pages to professional and unprofessional handshakes (plus numerous photos), and four pages to professional body posture and arm positioning. Though she mentions openness to cultural differences repeatedly, and devotes sections of two chapters to professional dress (including a sample student dress code policy), she never mentions (for example) wearing hijab, or the ‘appropriate’ way to respond when a patient pulls your hijab off or a colleague mocks it.

Lastly, in defining professionalism, this body of literature also contains elements of making the profession look good, and avoiding critique. For example, from their study with occupational therapist employers, Mason & Mathieson (2018) define professionalism in part as, “Committed to representing the profession, department and employer well with clients, in organization meetings, on social media, and out in the community,” plus “Adhering to company policies” (Mason & Mathieson, 2018, p. 8). One source defined students as unprofessional if they verbalized complaints or critiques of their peers, instructors or their academic institution (Gutman et al., 1998), while another emphasized the importance of following “appropriate lines of communication” (MacKenzie et al., 2020, p. 442). One source quoted an occupational therapy faculty member in their study saying, “You have a contract with your profession… to never let your profession look bad… it’s like getting married only you can never get divorced” (Robinson et al., 2012, p. 280).

If notions of professionalism are grounded in white, western politics of respectability, how then are these used to demand conformity, to discipline therapists toward conformity?

Professional/unprofessional: disciplining conformity

Our interviews with occupational therapists who self-identified as racialized, ethnic minority, disabled, 2SLGBTQ+, and/or from working-class/impoverished family origins provide numerous examples about ways they were (are) policed to produce the ‘right kind of person’ to conform with normative standards of professionalism. Concerns were raised about bodies, language, speech, emotions, self-presentation, and boundary-maintenance. Therapists who identified as racialized, working class and disabled were particularly likely to be seen as embodying ‘unprofessionalism’:

I always felt like I look unprofessional if my hair was not straight. So I know for OSCEs and such, I spent quite a bit of time straightening my hair. I felt like I needed to dress up quite a bit. (racialized OT).

Working class… it’s like, written on my body, it’s written in my mannerisms… those little social, like, ‘Don’t put your elbows on the table,’ all these little cues that people have grown up with, when you’re of a certain class. (working class OT).

It’s one thing [for a client] to know it, but it’s another to see the symptoms. I would be afraid they would shut down or think, ‘This person’s not professional enough.’ (disabled OT).

Sometimes people’s presentation of self was deemed ‘unprofessional’ and they altered self-presentation accordingly. This particularly came up among 2SLGBTQ therapists and those from working class backgrounds: “I think I would dress more flamboyant… I don’t think I’ve pushed the limit… I would wear bright clothing in my personal life, but I don’t think I’d do it very much in my work… I definitely dress conservatively at work” (2SLGBTQ+ OT). Others hid tattoos or removed jewelry.

Some people’s language, accents and speech patterns were seen as ‘unprofessional.’ Grammar and language use were easier to change than accents.

Using words like, I never say ‘yes’. I say, ‘yeah’ all the time, and just little things like that, they sort of give you away, right? So you sort of learn to… adjust your language, the way you speak, the way you dress, the way you move, just mannerisms. (working class OT).

People did ask if I have the right credentials, or if I, like, they wouldn’t directly say about my accent, but… it was the impression that I had, that because of my accent, they didn’t then see me as a professional. (Hispanic OT).

My tone of voice and my intonation etc changes when I’m talking to someone at work, versus someone that I’m just comfortable with, in my day to day. So that was another thing that I had to shift and change… all aspects of my speech and non-verbals. 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. (racialized OT).

The third quote above suggests a kind or ‘tone policing,’ to use a term popularized in social media. In effect, people are required to adhere to unwritten speech rules if they wish to be taken seriously. While everyone tends to adjust in a new work context, when the ‘rules’ of professional decorum are based on dominant groups, those from marginalized groups face a lot more contortions.

Sometimes people’s emotions were deemed ‘unprofessional.’ This came up particularly among Black therapists, though a queer ethnic minority therapist also said, “[There’s] a politics of respectability… if you are a little too emotional, hysterical, rude – whoever decided what rude was – assertive, whatever, all that stuff, you fall into testimonial injustice [lose credibility].”

I was venting to the staff [about something] … and their first response was, ‘Calm down!’… 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… I’ve got to bend myself in a pretzel, to make sure that they don’t feel uncomfortable. (Black OT).

[I was told,] ‘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.’ … So, like, I do feel 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. You know? Everybody needs to still be comfortable around the topic and if they’re not comfortable, then I have to drop it. (Black OT).

There’s a pattern here of repressing emotions to make dominant-group members feel comfortable.

Behaviours were also an arena for potentially being read as ‘unprofessional.’ For example, some Asian therapists noted the professional expectation of embodying expertise clashed with the cultural expectation to defer to their elders. A South American therapist resisted gifts and offers of dinner from her South American clients, though she did not believe accepting is actually unethical. Some disabled therapists took care to behave as non-disabled, to ensure colleagues would not use disability in “negative” ways:

If I need to express my symptoms I would maybe go for a walk or excuse myself to go on an errand and kind of do it in my car… take an extra long bathroom break or just leave a meeting without discussing it and come back when I felt I was able to suppress my symptoms. (disabled OT).

People described being policed or policing themselves regarding ‘professional boundaries.’ For example, one Jewish therapist steered clear of any discussion of religion or ethnicity:

I didn’t want it to be a potential barrier between me and a client, right? I didn’t want a client, I felt that the professionalism altruistic piece of being an OT that it was my responsibility to make sure that the clients felt comfortable with me, and so I needed to keep that out, so that it couldn’t be a potential barrier. (Jewish OT).

This was echoed by another Jewish therapist who stated, “You shouldn’t be talking about your personal life in any capacity… you’re working in a professional capacity.” Another therapist who identified as lesbian had been taught to keep her personal life private in professional contexts:

Clinicians kind of discouraged anyone from sharing anything about their personal identity. That that would somehow impact their clients, and that that should be kept very separate. But they didn’t have that same opinion of their straight coworkers. I had a preceptor tell me that. I had another professional tell me that. I think it’s bullshit… that [being openly lesbian] was going to have some sort of negative impact on clients. (LGBTQ+ OT).

In identifying that openness about queer identity is considered crossing boundaries, but openness about heterosexuality is not, this therapist identified the use of professionalism to discipline those at the margins.

Discussion

Writing in the context of postgraduate medical training, Mantoa Mokhachane and colleagues write that, “Professionalism as a construct is weaponized to police and punish those who do not fit the norm” (Mokhachane et al., 2023, p. 1). In our interview data, therapists from marginalized groups risked being construed as ‘unprofessional’ by having the ‘wrong’ bodies, appearances, presentation of self, speech language use, emotions, behaviours, and boundaries. Though it extends beyond our study methods and data, from our collective years learning, teaching and practicing in occupational therapy in Canada, we have witnessed therapists – and particularly students – from marginalized groups being policed for being ‘too much’ or ‘too little’ in so many ways: too loud, too quiet, too reserved, too radical, too angry, too sensitive, too emotional, too flamboyant, too queer, too accented, too direct, too indirect, too fidgety, too intense, too little eye contact, too much eye contact, just too… Our experiences and observations reflect the text cited earlier by DeIuliis (2017), in which professionalism is reduced to conformity in dress, hairstyles, jewelry, eye contact, body language, tone of voice and type of handshake. Similar patterns were seen throughout the occupational therapy literature analyzed. As Mokhachane et al. (2023) argue, “The western notion of professionalism looks down on those who dare to be different or are different. They experience discrimination and frequent reminders that they must be obedient to western notions of what it means to be a [professional]” (Mokhachane et al., 2023, p. 1).

When professionalism is reduced from complex ethical virtues to more observable, concrete attributes, as evident in the occupational therapy literature, it becomes “hollowed out” to a “discourse of performativity” (Hoff & Kuiper, 2021). At the same time, when it encodes particular notions of respectability as constituting ‘professionalism,’ notions grounded in the cultural ways of dominant groups, it ensures white, western, upper-middle-class, cis-heterosexual, able-body-minded people fit more readily into preconceptions of ‘professional.’ In their study with 49 medical trainees, Daniela Maristany et al. (2023) found “some participants, mostly White trainees, had not considered professionalism oppressive and had difficulty recalling when professionalism had negative consequences or interfered with their training” (Maristany et al., 2023, p. S34). In contrast, trainees from marginalized groups had professionalism concerns raised regarding their speech, accents, clothing, appearances, body types, hair, personalities, and openness about or self-presentation congruent with queerness. As one Black student in their study asked, “Is something that I’m doing going to be seen as unprofessional because I’m just being who I am?” (Maristany et al., 2023, p. S37). In our data, racialized, ethnic minority, disabled, working class and 2SLGBTQ+ occupational therapists similarly risked accusations of ‘unprofessionalism’ for being who they were.

Lilach Marom (2019) has coined the term ‘professional microaggressions’ to talk about subtle forms of racism and colonialism hidden beneath professionalism. In her research with Indigenous teachers, she found ‘professionalism’ hides the policing of people from non-dominant groups toward compulsory assimilation, conformity with normative expectations. The teachers in her study reported being taught to look like a teacher (dress code), talk like a teacher (speech patterns), and teach like a teacher (Western knowledge, pedagogy). One participant who had deliberately worn Indigenous dress to connect with Indigenous students, gradually found that commitment eroded: “It was so unconscious… I guess it was because of the gaze, the body language, the comments, the looks that I would get … It was stripped away from me so subtly and I have acculturated or assimilated so silently” (Marom, 2019, p. 327).

In occupational therapy in Canada, Indigenous therapists have also reported being compelled to assimilate, their own knowledges, cultures and ways of doing and being marking them as less-than-professional. They find little space in the profession for their worldviews, which are demeaned and devalued. They suggest they are welcome in occupational therapy only when they are “the ‘right’ kind of minority” who will “come in, sit down, and shut up” (Pride, 2023, p. 222).

Professionalism as construct demands assimilation to a set of normative standards that exclude particular kinds of people (Flanigan Adams, 2012; Sullivan, 2012). As Fournier writes, “being a professional is not merely about absorbing a body of scientific knowledge but is also about conducting and constituting oneself in an appropriate manner” (Fournier, 1999, p. 287). Though that (ill-defined) ‘appropriate manner’ may be intended to evoke trust from patients/clients, it may backfire. An American study with 50 patients about trust in mental health clinicians found ‘professional’ perceived negatively, with connotations of rigidity and bureaucracy:

Patients used the word professional as a pejorative. The term described behaviors that patients found untrustworthy: emotionless, buttoned- up conduct, fealty to organizational constraints, and reliance on pat scripts … [plus] affective neutrality… Instead, patients developed trust when they believed they witnessed rules being broken. The rules interviewees were glad to see broken were institutional impositions, like the length of time allotted to an appointment. (Vale & DelVecchio-Good, 2020, p. 216).

Trust in clinicians was evoked when clinicians bent bureaucratic, institutional rules, showing flexibility and engaging with patients as fellow humans, rather than ‘professionals’ (Vale & DelVecchio-Good, 2020, p. 217). Is it possible that occupational therapy’s emphasis on professionalism actually undermines intentions to center practice on clients/patients?

Deconstructing professionalism within occupational therapy

The reliance on symbolic markers of (performative) professionalism was amply evident in our critical interpretive synthesis of three decades of occupational therapy literature, where it means “behaving in a manner defined and expected by the chosen profession” (DeIuliis, 2017, p. 10). Yet there have also been clarion calls for deconstructing the assimilationist concept of professionalism. Almost two decades ago, Hazel Mackey wrote about professionalism in occupational therapy as involving “face work,” superficial performances intended more for colleagues and managers than for clients (Mackey, 2007, p. 100). She argued powerfully that the “normalising professional discourse” produces, “Docile bodies able to be moulded, but also self-censoring and disciplining” (p. 98). This works through professional training, monitoring progress, passing judgements and shaping attitudes and behaviours.

More recently, Turcotte & Holmes (2021) have argued that the occupational therapy profession governs, regulates and disciplines its members, repressing and silencing disobedience and dissent. Debate and contestation, which are healthy for any vibrant field, are suppressed in favor of overall consensus:

Dominant discourses represent a form of disciplinary propaganda (Holmes et al., 2006a) with which occupational therapists must conform, whether they are aware of it or not. From this pattern of conformity emerges a new sort of morality, where virtue means to be like the rest and vice is to be different. (Turcotte & Holmes, 2021, p. 11).

Inclusion within the field requires obedience and submission to the (often implicit) rules and norms. They note that national associations specifically state in their codes of ethics that members are expected to support their associations even when they disagree. This was evident in the literature reviewed here as well, a disciplined avoidance of critical self-reflexivity within the profession, which serves to maintain the status quo while hindering growth and change.

In contrast, Turcotte & Holmes encourage occupational therapists to welcome disagreement and debate, incite oppositional voices, enact disobedience, question authority and (false) consensus, and disrupt the status quo by becoming “common sense rebels” (Turcotte & Holmes, 2021, p. 15) who question dehumanizing social conditions, instead of adapting to them. They warn that this takes courage. Such dissent appears to be more common in the global South, giving professionals in the North much to learn. For example, from South Africa, Sonday et al. (2019) describe therapists engaging in professional role transgressions as a form of resistance to hegemonic structures. From Brazil, García Ruiz & Malfitano (2024) argue that we need to deliberately cultivate resistance to challenge hegemony, the patterns of domination that we otherwise reproduce through everyday actions, such as “the implementation of policies, plans, programs, projects, and budgets” (p. 4). Resistance creates alternatives.

What does ‘professional resistance’ look like?

Tasha Wyatt and her colleagues detail the complex calculations that go into every act of resistance in medical education (Wyatt et al., 2024). They remind us that the hierarchical organization of the profession is upheld through repeated acts of “deference and obedience” (Wyatt et al., 2024, p. 10) which means that structure can also be undermined by defiance and disobedience. In their research, learners and professionals from non-dominant groups were skilled at resistance, “identifying the line between pushing too hard and not enough” (Wyatt et al., 2024, p. 10). Resistance was not thoughtless, careless or unreasoned, it was intentionally crafted, taking into account which kinds of actions respond effectively to different kinds of power. They argue that resistance is ‘professional’ when it thoughtfully considers context (what are the risks here?), subjectivities (who am I in this?), and interactions (who, where, how?). These considerations may prove valuable in occupational therapy.

For example, skilled resistance may require a contextual cost/benefit calculation (Wyatt et al., 2024). How serious are the costs? Costs to whom, and benefits to whom? The costs to an individual may be worthwhile if the benefits accrue to many. What is the potential for retaliation? What is the best time and place for resistance? In terms of ‘subjectivities,’ we might consider Who am I in existing power relations? Can I afford possible negative consequences? For example, a student earning A grades may be able to afford resistance that a student at risk of failing cannot. We need to ask what can we live with saying/doing? And also, what can we live with not saying/doing? Black lesbian feminist poet Lorde wrote in Transforming Silence into Language and Action,

You’re never really a whole person if you remain silent, because there’s always that one little piece inside you that wants to be spoken out, and if you keep ignoring it, it gets madder and madder and hotter and hotter, and if you don’t speak it out one day it will just up and punch you in the mouth from the inside. (Lorde, 1984, p. 42).

What toll will it take if we do not say/do something when we encounter oppression? What toll does it take carrying that mad, hot silence around? (And how does that toll differ depending on who we are? For some of us silence maintains the comforts of privilege, for some of us silence inflicts yet another wound to the spirit.)

In pondering subjectivities, we need also consider connections with others that may increase safety (Wyatt et al., 2024). Do we occupy official positions, carry official titles, that we can mobilize to resist? Can we work with a union, a student group or society? Can a group be formed? Can resistance be anonymous? (Yes, we know, that doesn’t follow ‘appropriate channels of communication’ as promoted in the occupational therapy literature!)

Considering interactions, what impacts might resistance have for relationships, within and without (Wyatt et al., 2024)? For example, if resistance has limited benefit and sacrifices all credibility with colleagues, is this the right time/place/action/message? If resistance creates ill-relations with another department, such that my clients/patients can no longer access services they need, is this the right form of resistance right now? It also means assessing interactions with others. Who in this context might support resistance? Who appears to be open to challenges? Who does not appear open to challenge, perhaps wasting our efforts? What should we say, who should we say it to, and how can we say it best?

These are precisely the types of questions that comprise critical reflexivity and ethical decision-making within occupational therapy and other health professions. Skilled resistance may then be an embodiment of ethical professional practice.

Professional activism and refusal

Professionalism has been defined (at least in the global North) as prohibiting political action or activism. This, of course, obscures the fact that inaction is always also political action to maintain the status quo. Resisting the construct of professionalism will require political action and will not always be comfortable or easy:

As health professionals… We may push against the boundaries, raising questions they may not want to hear, encouraging people to take action that is not part of our job description. It may bring us into conflict with our bosses and endanger our jobs. (Levins & Dunn, 2008, p. 126).

Nonetheless, given anti-oppressive practice is now part of the professional competencies for occupational therapists in Canada, we are obliged to begin developing skills for ‘disobedience and dissent’ (Turcotte & Holmes, 2021). We are obliged to teach “professional activism” (Costa et al., 2021) to occupational therapy students.

What would it mean for occupational therapy if we could no longer use the non-transparent term ‘unprofessional’ as a way of policing ourselves and each other into conformity? How instead might we govern ourselves and each other? What might happen if we named the perceptions that underpin assessments of professionalism, such as saying ‘I feel disrespected’ rather than ‘You are being unprofessional’? What alternatives might arise if we refused reliance on constructs of professional/unprofessional? As Kylie Flanigan Adams asks, “What are alternative ways of organizing currently marginalized by the professionalism episteme? Is it possible to rearticulate professionalism with what might be considered radical ideals: love, compassion, dignity, respect, diversity and conflict?” (Flanigan Adams, 2012, p. 340). Quechua scholar Sandy Grande reminds us that refusal differs from resistance “in that it does not take authority as a given,” becoming dangerous because it casts the entire system into doubt (Grande, 2018, p. 59). Can we in occupational therapy refuse the allure of ‘professionalism,’ with its enticement of status and prestige?

Conclusion

Drawing on our own interviews with occupational therapists from non-dominant groups, and on critical synthesis of occupational therapy literature on professionalism, we identify ways professionalism has been reduced from important ethical values to a set of symbolic performances grounded in normative standards that best fit for members of dominant groups. We have shown how the construct of professionalism and its corollary ‘unprofessional’ serve to police and discipline occupational therapists at the margins. We join those calling for professional dissent, disobedience, common sense rebellion, resistance and refusal, making room for a plurality of ways of knowing, doing and being ethical, virtuous practitioners.

• 1
  Sources included in the critical interpretive synthesis: Aguilar et al. (2012), Aguilar et al. (2013), Bossers et al. (1999), Burford et al. (2014), Campbell et al. (2015), Davys et al. (2021), DeIuliis (2017), Fidler (1996), Gurley et al. (2022), Gutman et al. (1998), Hordichuk et al. (2015), Hung et al. (2022), Kasar & Muscari (1999), Koenig et al. (2003), Lecours et al. (2021), MacKenzie et al. (2020), Mackey (2007, 2014), Mason & Mathieson (2018), Parsa et al. (2021), Randoph (2002), Robinson et al. (2012), Sullivan & Thiessen (2015), Taylor et al. (2023), Walder et al. (2022), Wood (2004).
• How to cite:
  Beagan, B., Bizzeth, S., Brison-Brown, M., Pride, T., Sibbald, K., & Valavaara, K. (2024). Professionalism and the disciplinary control of occupational therapists at the margins. Cadernos Brasileiros de Terapia Ocupacional, 32, e3859. https://doi.org/10.1590/2526-8910.ctoAO397538592
• We dedicate this paper to Meredith Brison-Brown, Nov 14, 1983–Jul 15, 2024.
• Funding Source
  The manuscript is partly based on research funded by the Canadian Institutes of Health Research (CIHR) grant # PJT-159664.

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Edited by

• Section editor
  Profa. Dra. Ana Paula Serrata Malfitano

Publication Dates

• Publication in this collection
  21 Oct 2024
• Date of issue
  2024

History

• Received
  24 May 2024
• Reviewed
  12 June 2024
• Accepted
  08 Sept 2024