The perceived superiority of western worldviews in occupational therapy education: the experiences of Indigenous occupational therapists

A percebida superioridade das visões de mundo ocidentais na formação em terapia ocupacional: as experiências de terapeutas ocupacionais indígenas

Abstract

Introduction  As a response to the Truth and Reconciliation Commission of Canadas Calls to Action, Indigenous students are increasingly being recruited into occupational therapy programs. However, the occupational therapy profession relies almost exclusively on western worldviews and does not sufficiently consider the value of multiple ways of knowing and doing. How Indigenous students fare in these western educational systems is largely unexplored and undocumented. This work is part of a larger study exploring the experiences of Indigenous occupational therapists in Canada.

Objective  This manuscript explores the retrospective educational experiences of Indigenous occupational therapists.

Methods  This study was collaborative in nature with Indigenous occupational therapists across the country, using both Indigenous and western methods of inquiry. Stage 1 used individual storytelling sessions (n=13) to hear about participants everyday experiences. Stage 2 consisted of an in-person sharing circle gathering (n=8) to build relationships and community, and to refine data from Stage 1.

Results  Indigenous occupational therapists experienced imposed isolation, lack of support, exclusion, a devaluing of merit and skill, and ‘jagged worldviews colliding’ in their programs. These experiences are underpinned by the cultural imperialism perpetuated by the profession.

Conclusion  To truly fulfill our commitment to reconciliation, the occupational therapy profession must move beyond Indigenous inclusion in programs towards decolonial Indigenization, which asks for a divesting of colonial privilege and ideologies towards something dynamic and new. Deeply considering the value of, and need for, multiple perspectives (Two-Eyed Seeing (Etuaptmumk)) and drawing on the expertise and experiences of Indigenous students, occupational therapists, researchers, and educators for this work is urgently needed.

Keywords:
Occupational Therapy; Health of Indigenous Peoples; Universities; Colonialism; Indigenous Epistemologies; Teaching and Learning

Resumo

Introdução  Em resposta à Ação da Verdade e Reconciliação, cada vez mais estudantes indígenas estão sendo recrutados para programas de terapia ocupacional. No entanto, a profissão depende quase exclusivamente das visões de mundo ocidentais e não considera suficientemente o valor de múltiplas formas de saber e fazer. Como os estudantes indígenas se saem nesses sistemas educacionais ocidentais é amplamente inexplorado e não documentado.

Objetivo  Este trabalho integra um estudo maior que explora as experiências de terapeutas ocupacionais indígenas no Canadá. Explora-se aqui as experiências educacionais retrospectivas de terapeutas ocupacionais indígenas.

Métodos  Estudo colaborativo, envolvendo terapeutas ocupacionais indígenas canadenses, utilizando métodos de pesquisa tanto indígenas quanto ocidentais. A Fase 1 utilizou sessões individuais de narração de histórias (n=13) para ouvir as experiências cotidianas dos participantes. A Fase 2 consistiu em um círculo de compartilhamento presencial (n=8) para construir relações e comunidade e para refinar os dados da Fase 1.

Resultados  Os terapeutas ocupacionais indígenas experimentaram isolamento imposto, falta de apoio, exclusão, desvalorização do mérito e habilidade e "visões de mundo fragmentadas" em seus programas. Essas experiências são sustentadas pelo imperialismo cultural perpetuado pela profissão.

Conclusão  Para realmente cumprir nosso compromisso com a reconciliação, a profissão deve ir além da inclusão indígena nos programas, em direção à Indigenização decolonial, que exige a renúncia ao privilégio colonial e às ideologias em direção a algo dinâmico e novo. Considerar profundamente o valor e a necessidade de múltiplas perspectivas (Etuaptmumk) e se apoiar na experiência e conhecimento de estudantes, terapeutas ocupacionais, pesquisadores e educadores indígenas para esse trabalho é urgentemente necessário.

Palavras-chave:
Terapia Ocupacional; Saúde Indígena; Educação Superior; Colonialismo; Cultura Indígena; Formação

Introduction

Colonialism and Canadian health care

In what is now called Canada, Indigenous Peoples have relied on the land and their communities to both conceptualize and practice health and wellbeing for thousands of years (Steeves, 2021). Unfortunately, many of these knowledges and practices have been systematically repressed by settler-colonial governments and institutions over millennia (Matheson et al., 2022; Smith, 2018). As a result, the modern delivery of health care in Canada draws almost exclusively upon western¹ understandings of health (Horrill et al., 2018; Shaheen-Hussain, 2021). Health care institutions have been designed to fit the needs of settler populations: notably those who are white, cisgender, heterosexual, upper to middle to class, and not disabled, and the majority of health care workers in the colonial healthcare system represent dominant characteristics. Therefore, Indigenous conceptualizations of health and wellbeing are not sufficiently reflected in the delivery of healthcare institutions, policies, and programs in the settler-colonial state of Canada (Allan & Smylie, 2015; Jongbloed et al., 2023; Martin et al., 2018).

Structural racism in the Canadian health care system has deep and long-lasting impacts for Indigenous Peoples who seek health services and supports. It contributes to the health inequities Indigenous Peoples already experience – creating conditions of avoidance, fear, the internalization of discrimination and stigma (Allan & Smylie, 2015; Browne et al., 2011; Government of British Columbia, 2020; Pilarinos et al., 2023) and increased vigilance when accessing services (Stuber et al., 2008). Anti-Indigenous racism and discrimination has contributed to deaths of Indigenous individuals seeking care, as exemplified by the deaths of Brian Sinclair (Geary, 2017) and Joyce Echaquan (Lowrie & Malone, 2020). Additionally, while the underrepresentation of Indigenous health professionals must be addressed, colonialism and anti-Indigenous racism that infuse Canadian health care largely contribute to inequities in complex and often unacknowledged ways as well (Allan & Smylie, 2015; Horrill et al., 2018; Smith, 2018). In this paper we examine the retrospective reflections of Indigenous occupational therapists on their journeys through their occupational therapy training in Canada. For the purposes of this paper, when we use the term Indigenous in relation to the Canadian context, we are referring to First Nations, Métis, and Inuit².

Health professional education: Steeped in western ideologies

Healthcare professions in Canada rely almost entirely on post-secondary institutions in educating and training health professionals (Pride et al., 2022). Like the health care system, post-secondary institutions in Canada have been founded on euro-western ideologies, values, epistemologies, and assumptions (Horrill et al., 2018; Pride et al., 2022). Acknowledging this, and moving away from it, has proven to be challenging (Gaudry & Lorenz, 2018). Fewer Indigenous people pursue post-secondary education compared to non-Indigenous people (Gallop & Bastien, 2016), though in recent decades this gap is closing due to extensive advocacy and work from Indigenous Peoples and communities. Indigenous students who enter post-secondary education are often first in their family to do so (Gore, 2017), one of few Indigenous people in their program (Smith et al., 2011) and may experience alienation, discrimination, and racism (Currie et al., 2014; Battiste, 2017). They are often coerced into assimilating into euro-western worldviews (Battiste, 2017; Wilson et al., 2011).

In the health professions, retention of Indigenous students is hindered by complexities such as the long-standing impacts of colonialism, limited and urban locations of healthcare programs, financial barriers, cultural discontinuity due to living away from their families and communities, and a lack of Indigenous-specific supports (Rimmer, 2017; Slayter et al., 2016; Wilson et al., 2011). When Indigenous students do not feel supported in their efforts to stay, this directly harms them by reinforcing feelings of alienation and isolation. It also indirectly perpetuates harms to Indigenous clients who rarely or never encounter Indigenous care providers (Allan & Smylie, 2015; Browne et al., 2011; Pilarinos et al., 2023). In response to the 2015 Truth and Reconciliation Commission [TRC] of Canadas Calls to Action (TRC, 2015a), health professional programs across Canada have begun initiatives to counter coloniality and support Indigenous learners and presumably contribute to improved healthcare outcomes for Indigenous Peoples (Hojjati et al., 2018). It is critical to carefully question and assess these initiatives.

Gaudry & Lorenz (2018) outline a framework that contextualizes Indigenization and decolonization efforts in the Canadian academy using three categories of action. They can be conceived along a continuum: Indigenous inclusion supports increasing Indigenous participation, and subsequent adaptation, into current structures; reconciliation Indigenization includes bringing together Indigenous and euro-western knowledges to develop new understandings and support relationship-building; and decolonial Indigenization refers to a complete overhaul of structures and institutions to balance power relations, creating something dynamic and new, meeting the needs of all people. This framework provides a helpful way to critically assess efforts and progress relating to Indigenous experiences in post-secondary education, including health professional programs.

Occupational therapy, Indigenous learners, and Indigenous professionals

Within the health professions, occupational therapy is a field of practice that helps clients solve problems and address barriers to engaging in occupations (World Federation of Occupational Therapists, 2012). Occupations are understood as everyday activities that occupy time, energy and attention, and can be things like fostering connecting with family and communities, paid work, caregiving, and engaging with the land, for example (Hammell, 2021). Notably, the meaning one associates with their occupations is inherently influenced by one’s worldviews (Kiepek et al., 2022), yet this is not sufficiently discussed in relation to Canadian occupational therapy. Further, despite the broad scope and flexibility of occupational therapy practice, occupational therapists in Canada have historically been implicated in colonialism by working in Indian Day Hospitals (Meijer Drees, 2013) and currently, by participating in a profession that continually privileges euro-western worldviews (Beagan et al., 2022a, 2022b; Córdoba, 2020; Grenier, 2020; Hammell, 2011; Hunter & Pride, 2021; Jacek et al., 2023; Price & Pride, 2023; Porto & Silva, 2023; Turcotte & Holmes, 2023a; 2023b). Occupational therapy perpetuates colonialism through its admissions processes, theories, epistemologies, assessments, interventions, and outcomes (Beagan et al., 2022c; Hammell, 2019; MacLachlan et al., 2019) and it is our responsibility to challenge the knowledges and practices that dominate the profession (Hammell, 2023).

Occupational therapy in Canada has declared commitment to improving Indigenous health and supporting reconciliation and decolonization (e.g., Association of Canadian Occupational Therapy Regulatory Organizations, 2022; Canadian Association of Occupational Therapists, 2018; Gerlach et al., 2018), and has created the Occupational Therapy Truth and Reconciliation Task Force (OT TRC Task Force, 2023). While Indigenous occupational therapy clients have a vital vantage point to assess decolonizing efforts, Indigenous therapists and students also have valuable perspectives. First-hand accounts of Indigenous therapists in Canada document the loneliness, isolation, and lack of belonging that begin in professional education programs (Clyne, 2023; Reid & Pride, 2023; Valavaara, 2012). Indigenous occupational therapists across Canada have begun writing and presenting collectively, documenting their experiences in colonial systems and institutions, while also identifying directions for change (e.g., Phenix & Valavaara, 2017; Pride et al., 2023; White et al., 2021). These messages echo accounts of Indigenous occupational therapists in other settler colonial states like Australia and Aotearoa (e.g., Emery-Whittington, 2021; Gibson, 2020; Gibson et al., 2015) which, for the authors of this present paper, provides motivation to similarly share our stories and advocate for change.

In Canada, the Indigenous occupational therapy community is small. Further, the historical lack of Indigenous specific or even race based data collected poses a barrier to better understanding the demographics and needs of the workforce (Rice et al., 2023). With academic institutions focusing on equitable admissions and diversity initiatives, it is anticipated that more Indigenous people will be entering the profession in the coming years. Despite often negative experiences within occupational therapy education and professional practice, informal conversations among Indigenous occupational therapists in Canada point to promise within the profession. Many of the Indigenous people who collaborated on the analyses presented here are working in areas relating to Indigenous health and wellbeing or working directly with Indigenous clients and communities. Many experience a divide between their own Indigenous cultures and values and those of the profession and express a desire for change.

This manuscript aims to illuminate the educational experiences of Indigenous occupational therapists in Canada after they had completed their training. As a first of its kind empirical study, sharing these experiences has a twofold purpose: First, it as an act of resistance to the dismissal and devaluation of Indigenous Peoples’ experiences within the profession. Second, it contributes to a shared understanding of how the profession can fulfill its declared commitments to advancing Indigenous health and fulfilling the Truth and Reconciliation Commission of Canada Calls to Action (TRC, 2015a) as well as address the commitment statement from the Occupational Therapy Truth and Reconciliation Task Force (OT TRC Task Force, 2023). The authors of this manuscript are Indigenous and come from diverse Nations and communities across the country. We have all committed to ongoing collaboration and relationship building amongst one another to move towards creating community for Indigenous learners and clinicians in the occupational therapy profession.

Methods

The current analysis is part of a larger study of the lead author’s PhD dissertation. The overall project was participatory, employing Indigenous methods (Indigenous storytelling and sharing circles). The motivation for this project stems from numerous conversations among Indigenous occupational therapists over the past 3-4 years, sharing our perspectives and observations. This project obtained research ethics approval through Mi’kmaw Ethics Watch and Dalhousie University. Informed consent was obtained prior to the individual storytelling sessions and sharing circles, with ongoing consent sought throughout data analysis and knowledge translation activities.

Etuaptmumk (Bartlett et al., 2012), a Mi’kmaq word that loosely translates in English to “Two-Eyed Seeing” was used as a guiding principle throughout this study. This guiding principle describes the need to value contributions from multiple perspectives, and therefore, this study draws on the strengths of the occupational therapy profession (e.g., challenge to the biomedical model, holistic perspectives, consideration of spirituality) while keeping Indigenous worldviews and epistemologies at the forefront. This work aims to challenge the profession’s tendency to rely largely on euro-western perspectives, values, and ideologies to instead be one that lives up to declared commitments towards reconciliation. To do this, the profession needs to be open to doing significant restructuring, from the ground up. The profession has clearly articulated commitment to this work and must now take seriously the advice generated and work already being done by Indigenous students, occupational therapists, researchers, and educators. If this does not occur, there is a risk of continuing to perpetuate ongoing colonial processes and maintaining the status quo.

Data collection methods and analysis

Participants for this study were recruited by purposive and snowball sampling among therapists who self-identify as Indigenous (e.g., First Nations, Métis, or Inuit) and who are registered occupational therapists in Canada. No restriction on area of practice or type of employment was set to ensure that the findings represented experiences across geographic and practice contexts. No limit was set for the number of participants who could partake in individual storytelling sessions given the small number of Indigenous occupational therapists in Canada. The majority of participants had practiced for less than 4 years and identified as First Nation. There was a roughly even split between participants currently residing in Eastern, Central, and Western Canada. Please see Table 1 for demographics.

Table 1
Participant demographics.

Demographic	Number of Participants
Indigenous identity1
First Nation	8
Métis	5
Years in Practice
0-4 years	8
5-9 years	1
10+ years	4
Region
Eastern Canada	4
Central Canada	5
Western Canada	4

• Note¹ Although there are three distinct Indigenous groups in Canada, there were no Inuit occupational therapists who participated in this study.

Indigenous storytelling, or storywork (Archibald, 2008), was used to elicit individual narratives. Key underpinnings of Indigenous knowledges were centered and integrated throughout the research process (initial relationship building, storytelling sessions, data analysis, and the sharing of the findings) to ensure this research respected Indigenous worldviews. Participants (n=13) were asked to share their stories and experiences pursuing occupational therapy education. Sessions were conducted in-person or virtually depending on the geographic location of the participant. These individual stories were documented as they were told, and efforts were made throughout the data analysis and findings to keep these stories intact, an important factor for using Indigenous storytelling in research (Archibald, 2008). Noted above, the first author conducted this work as her PhD dissertation. She was positioned both as researcher and co-participant. This meant that she participated in a recorded storytelling session led by another Indigenous occupational therapist.

After preliminary analysis of the individual storytelling sessions (see description of analysis in next paragraph), a sharing circle gathering occurred to bring together diverse experiences and perspectives to deepen analysis and build relationships. Eight participants engaged in a two-day sharing circle in Mi’kma’ki. A Mi’kmaw Elder conducted an opening smudge ceremony, participated in the discussion, and closed the sharing circle. Some components of the sharing circle were recorded, some were not, in alignment with the protection of Indigenous knowledges, stories, and relationship building principles.

Data was first compiled and uploaded into AtlasTi8. Thematic analysis was used to develop themes across the data set (Braun & Clarke, 2006). The first author analyzed transcripts of the conversations using Braun & Clarke’s six-phase thematic approach. Preliminary themes from the individual storytelling sessions were presented at the sharing circle gathering for further analysis. Participants at the sharing circle provided feedback on preliminary themes and participated in knowledge sharing and generation, identifying directions for future change efforts. Feedback was incorporated and the themes were subsequently finalized. Once the themes were finalized, they were categorized using Gaudry & Lorenz’s (2018) framework to contextualize experiences based on efforts at the Indigenous inclusion, reconciliation Indigenization, and decolonial Indigenization levels. This categorization was helpful in understanding efforts and subsequently recommendations for occupational therapy programs. While the individual stories and the collective analyses addressed practice experiences as well as aspirations for change-making, participants’ experiences of their entry to practice occupational therapy education became a major storyline. It is the sole focus in this paper.

Results

In exploring the participants’ educational experiences, the results below are organized to tell a story, beginning with why participants got into the occupational therapy profession and the value they saw in it. Immediately following will be an exploration of their experiences within educational programs. We will then contextualize these experiences in relation to the main theme that emerged, cultural imperialism. Cultural imperialism is the domination of one worldview (e.g., euro-western ways of knowing, being, and doing) over another - positioning this knowledge system as superior (Smith, 2018).

Participants were drawn to the profession in differing ways. Some knew of occupational therapy from personal or familial experiences, others knew little. Some noted that they “loved how holistic it was” (OT7), relative to other health professions, which they hoped would allow them to work “from the heart” (OT2). For many, the values espoused by occupational therapy, seemed congruent with their own core values, including Indigenous perspectives. Reflecting on the medicine wheel, OT5 felt the profession could be one that considers all directions of health and wellbeing for an individual and/or collective. Once they entered their entry to practice occupational therapy education, participants often did not experience this congruence of values.

Attending occupational therapy programs

I was the only Indigenous student in my class. I browsed through the list of faculty members as I was starting to get more familiar with the program, and also quickly realized that there were no Indigenous Instructors or Professors in the school either… I felt a bit isolated… I heard classmates making stereotypical and harmful comments about Indigenous Peoples, and had to reflect on my own ability and wellbeing to intervene. I often just didn’t, in those moments, have the energy to speak up and fight. I was just trying to survive… I started to wonder if I truly belonged in this profession… I spent a lot of time learning about models, theories, and assessments that didn’t really resonate with the way I saw the world and was brought up… I thought about quitting, frequently… I did not feel supported as an Indigenous learner and did not see myself or my own values reflected back to me at all in my degree.

In keeping with Indigenous methodologies, a collective narrative was created to encapsulate the storytelling sessions - an excerpt is included above. An overarching storyline among all participants – who attended educational programs across the country – was imposed isolation. We begin there. Just as Charlote Reading, an Indigenous health scholar, and Fred Wein, an allied Indigenous health scholar (Reading, 2015; Reading & Wien, 2009) identify how proximal (closer-to-hand) social determinants of Indigenous health (like poor nutrition) are rooted in distal (more distant) determinants (like colonialism), here we identify the negative educational experiences of Indigenous participants as being rooted in cultural imperialism. Figure 1 shows the five main storylines of our analysis built on that grounding. We examine each below.

Figure 1
Storylines or themes regarding Indigenous occupational therapists’ educational experiences. This figure was adapted from Reading & Wien’s (2009) article on the proximal, intermediate, and distal determinants of health.

Imposed isolation

Many participants spoke about being the only one or one of few Indigenous students in their class. OT1 did not know if there were other Indigenous students in their cohort as it was never discussed. Some (OT2, OT3, OT5, OT6, OT8 and OT12) were the only Indigenous students in their classes; some (OT4, OT7, OT10) did have other Indigenous students in their cohorts. For those who did have other Indigenous students in their program, participants noted that some left the program, others felt they did not have time to build relationships with one another or simply “didn’t really click” (OT10). Being the only one or one of few Indigenous students heightened the sense of responsibility participants felt to represent their People. Reflecting on an activity where students were asked to disclose identities, OT2 commented:

It turns out I was the only one in this group that actually put their hand up ... it didn’t impact my, I want to say it didn’t impact my relationships, but it definitely impacted my sense of maybe, my sense of, that I was holding the importance of Indigenous health on my shoulders in my class.

This resulted in feelings of being ‘othered’ and illuminated who is the ‘expected’ OT student in these spaces. Participants – even recent graduates – recalled that the overwhelming majority of their classmates were non-Indigenous: “They’re all predominately white, white upper class, like you know, higher, you know, came from very privileged backgrounds” (OT3). OT10 had a hard time relating to their classmates because, “probably 99% of my class, a lot of them were white.”

Isolated among their classmates, participants also recalled that instructors and guest speakers in were from “a certain demographic” (OT6). They did not see themselves in their professors; most could not recall any Indigenous faculty. When there were instructors from diverse backgrounds, OT3 noted that “they [white students] were not very nice to them.” This may be a major barrier to meaningfully incorporating Indigenous knowledges in the profession as well as recruiting Indigenous scholars to fill existing gaps, if they are disrespected, dismissed and/or overtly mistreated. Without Indigenous classmates or instructors, Indigenous students felt different, isolated, and underappreciated in their program, surrounded by white settler people and worldviews. This seriously undermined feelings of belonging: “I just thought ‘[o]kay, I’m just, this is not for me’” (OT3). This imposed isolation directly links to experiences of exclusion that Indigenous occupational therapy learners experienced.

Exclusion

If those within the occupational therapy profession operate from and privilege one particular worldview, it demands that those who embody other worldviews change or assimilate to fit into a space where they do not see themselves reflected back. During the storytelling sessions, participants were directly asked about whether they felt like they belonged in their occupational therapy program. Most simply did not.

For example, when asked specifically about belonging in their program, OT13 quickly stated, “No. Hell no.” OT12 said, “Right from the get-go… I didn’t think I really belonged there.” Even absence in textbooks and other sources highlighted lack of belonging for OT6. OT3 reported not feeling like they particularly belonged, yet also said, “But that’s all right,” emphasizing that they did get through the program, going on to practice as a clinician. OT11 described seriously considering leaving the program along with another student, who had already made the decision to do so:

There was a girl who quit in the first week, because she’s like, ‘Oh, this is not for me.’ And I remember having this, like, huge conversation with her, outside the course, the school. We were outside the building, and it’s like, ‘You know, I completely agree. This is horrible. I want to get out of here. I’m jealous.’ But I just, I can’t do that. If I start it, I’ll just finish it.

Although OT11 ended up staying in the program, she is not the only participant who thought about leaving. This sentiment was also brought up by OT10, OT12, and OT13, with OT13 going on to say that they felt “a lot of isolation” and “felt like shit in every OT class.” The lack of belonging and safe space for Indigenous learners actively caused harm: “I felt lonely. It was also, like, could be, like, actually traumatic… and overall, would never recommend it” (OT13).

Loneliness, often due to being imposed isolation, deeply impacted these participants’ sense of belonging in their educational programs. Some took actions to enhance their feelings of belonging. For example, OT5 spent some time in their educational journey, “trying to fit in, trying to blend in,” and shared how difficult that was for them. Others similarly talked about the ways in which they went about trying to belong, such as OT8 who shared: “I kind of talk myself up and I tell myself that I belong. You know?” The same participant described the importance of going into Indigenous community: “That helped me feel like I belonged, because I knew those people, right?”

Sense of belonging is heavily dependent on who we surround ourselves with, what we share about ourselves, and the degree to which we have control over identity disclosures. OT13, in reflecting on where they are now, feels as though they do belong in the profession as they have carved out a space for themselves as an independent OT practitioner, working directly with Indigenous communities. A powerful quote from OT5 describes her journey to belonging as an OT: “I’m way better as an OT who’s challenging the system, than I am as an OT belonging in the system… Because there is no challenging when I’m just trying to conform and fit in.” A lack of belonging and exclusion was also compounded by the lack of support available to Indigenous learners in occupational therapy programs.

Lack of support

Most – but not all – participants noted a serious lack of support in their respective programs. This began right at the onset of admission, as OT1 shared: “I self-identified, but nothing really came out of it; I don’t actually know if there were any other Indigenous students in my class.” OT13 similarly felt the lack of support early on in her program, comparing it to her undergraduate degree and saying she felt, “significantly less support” noting that relationship-building was lacking. This is at odds with much of what the profession boasts about as core values. This lack of relationality was also prevalent for OT5, who didn’t feel anyone was giving her the message of “it’s not just you” when she was struggling.

The lack of support continued throughout their journeys, with OT5 highlighting that they did not really have anyone to turn to. One participant shared a story of a racist comment being made by a classmate, and despite the instructor hearing it, they did not address it at all and instead tried to move on quickly rather than addressing it. Another had to take time away due to a family situation, which included needing to support an Elder, and the school was unwilling to accommodate or support this request in any way. Importantly, this lack of support is compounded by Indigenous students often being the first in their family to attend post-secondary education. Both OT5 and OT1 highlighted the fact that they had no family members who had gone through university prior to them, which left them with few places to turn for solutions and support with difficulties. Conversely, some participants who were not the first in their family to attend post-secondary reported that this prior familial experience of university helped them in their education.

In contrast, a few participants did feel they were relatively well supported in their learning. OT6 benefitted from the nurturing and support of individual instructors they got along well with. Similarly, OT8 had good connections with the majority of their instructors, although there were still, “moments of awkwardness and inappropriateness.” Interestingly, these participants come from the same geographic area, which could suggest education programs in some regions may be finding more effective ways to support Indigenous learners.

Given experiences of imposed isolation, exclusion, and a lack of support, Indigenous learners felt like they were having to be in two worlds. This led to the experience of ‘jagged worldviews colliding,’ to borrow a phrase from Blackfoot researcher Leroy Little Bear (2000). This phrase describes the tension Indigenous people experience in colonial systems as they try to make sense of their cultural identity in spaces and places that have excluded and deliberately erased Indigenous worldviews.

Jagged worldviews colliding

Participants emphasized the need to operate at the intersection of two cultures to survive their occupational therapy education. OT2, who is of mixed ancestry, felt they were “kind of being stuck in the middle where you have your colonizer roots, but you also have your Indigenous roots, but you don’t quite fit into either one of them.” OT7 described a similar feeling of being “caught between two worlds.” OT4 argued that occupational therapy was entirely separate from Indigenous paradigms; they could occupy one world or the other, but not both simultaneously. OT10 similarly reflected, “There was a lot of things that I realized that my culture, or a part of me, were not accepted at the western OT level.” OT13 pondered the teacher/student relationship in their culture and how sacred it is and must be treated as such. She recognized that in OT entry to practice programs, this relationship is not seen in the same way, which has grave impacts on the outcomes of those relationships. The teacher/student relationship is often seen as a one-way transmission of knowledge, with the teacher being the expert and the student taking in knowledge. Notably, a hierarchy is at play. In trying to navigate between worldviews, OT5 employed the term “institutional trauma” to describe the demand that they assimilate into the western ideals of the profession.

Participants were left feeling alienated in their programs. The two worlds they lived were not valued equally, where western colonial norms and rules were held out as universal. OT10 described the intolerance for other cultural ways: “They [OT Instructors] said I wasn’t very good at communicating. But, it’s just that I wasn’t very good at communicating with using a western standard.” Both OT1 and OT13 experienced personal crises relating to family and community that made it difficult to be a full-time student in a rigid professional program that displayed little understanding of Indigenous Peoples’ histories and current realities that give rise to the central importance of family, community, and relationships.

The expectation that Indigenous students must assimilate, must leave their ways of knowing, being, and doing at the door when they enter occupational therapy education is highly problematic and does a disservice to the skills, strengths and knowledges they bring with them. It also does harm to the profession, which could greatly benefit from seeing, recognizing, and valuing diverse ways of doing. Nonetheless, OT5 raised an important reminder about ensuring we maintain our values in these spaces and use our knowledge for the betterment of our People: “The reason that I’m good at what I do is because I still live it. I still live it. I still get it.”

Requiring Indigenous learners to teeter back and forth between their jagged worldviews colliding, when one of those worldviews is privileged in everyway within the profession, has consequences.It ultimately does a disservice to the unique and valuable knowledge Indigenous people bring into health professional programs. If the profession makes Indigenous learners feel as though they cannot bring their own selves into their education, it results in Indigenous learners feeling as though they and their knowledges and experiences are not valued.

Devaluing of merit and skills

As Indigenous learners are increasingly recruited into post-secondary spaces, many health professional programs have begun to employ affirmative action policies for admissions. Such approaches are intended to recognize the distinct challenges Indigenous students have thriving in colonial higher education contexts, particularly given the legacy of Residential facilities that were labelled schools for over 160 years (TRC, 2015b). They are also intended to recognize the added value Indigenous students bring to education programs and to the professions, enhancing and expanding learning and practice with distinct experiences, knowledges and perspectives. Yet affirmative action or ‘equity’ processes have at times resulted in backlash largely due to myths relating to being underqualified or getting an unfair advantage (Premdas, 2016; Henry et al., 2017, Beagan et al., 2024). This backlash is displayed through devaluing and questioning the merit and skills of Indigenous learners, a doubt that can be internalized, further undermining any sense of belonging.At the time that OT1 and OT2 applied to their programs, there was a commitment in place to recruit more Indigenous students. OT2 felt “lucky” to be accepted in their first application, whereas OT1 reflected on whether they got into OT solely because of their Indigeneity, or whether it had to do with the hard work they had put in. These sentiments suggest a questioning of their own place in these programs. OT7 raised a similar doubt regarding their admission into the OT program, asking, “Is it my competence level or is it because of what I look like?”

This uncertainty about the basis for admission led some participants to question whether they were good enough. OT12 reflected on this by sharing the following in relation to belonging in OT school:

Just kind of like, ‘Okay. I’m obviously the weirdo here because this is – You know what I mean? I put it on myself, that it’s like ‘Oh wow. I’m not good enough’ or ‘I don’t belong in these spaces and I have to change the way that I am, in order to – ‘ cause everyone else seems to be, like – they get along great, and they seem to enjoy themselves and they like, have all these friends and people.

This kind of institutionally structured self-doubt, meaning that the institutional structures, policies, procedures, and resulting stereotypes that people uphold was terribly undermining.

Some participants entered their programs at a time when Indigenous recruitment was less prevalent in the health professions. OT5 questioned whether they would have gotten into the progression after it moved from a Bachelor’s to a Master’s program, despite having years of lived experience to bring to the table. They emphasized that she felt forced to downplay her differences: “Tried to sound as white as I could, as normal as I could.” This is a particularly powerful quote showing that participants understand deeply that they must ‘play the game’ to get into particular spaces. This came up in OT10’s storytelling session as well. As a recent graduate they described having to “fake it to make it” and get through. This idea of faking it, pretending competence even when doubting oneself, again alludes to questioning of their own value or place in relation to what they have to offer the profession. Self-doubt and questioning may be common experiences in professional programs, but for these Indigenous learners, the internalized questioning and doubt was layered onto a myriad of other experiences that conveyed not-belonging:

I feel like people have said all kinds of racist stuff around me, assuming I’m just, I don’t know, maybe they just don’t care. I’ve felt invisible many times. And so that’s been painful. Like I just really internalized all my failures for a long time of systemic racism and micro aggressions, and just dealing with all the stuff (OT10).

This theme did not entirely resonate with all participants, suggesting that strong cultural connections may act as a buffer. For example, during the Stage 2 sharing circle gathering, some felt that they did have strong grounding in their culture and traditions and realized that they were trying to place their unique skills and knowledge into a box where they just did not fit. This meant that they did not necessarily feel they ever questioned their own value or right to be where they were – but rather were unsure if this was the best place for them.

Importantly, this questioning of one’s worth, merit and skills, which was prevalent for many participants in this study, relates directly to the assumptions and norms perpetuated by colonial education systems. How can we see value in our skills and knowledge when we are continually told that what we bring to the table is less valuable, or even irrelevant, to occupational therapy? All of the above-mentioned experiences are underpinned by cultural imperialism which permeates the profession.

Cultural imperialism

The roots of imposed isolation, of feeling ‘this is not for me’, is cultural imperialism, the perceived superiority of euro-western worldviews (Smith, 2018). Occupational therapy is derived from and continues to privilege a singular way of knowing, grounded in western settler-colonial worldviews, which renders all other ways of knowing invisible, invalid, or lesser than (Beagan et al., 2023; Grenier, 2020). Every participant in this study noted the cultural imperialism of the profession. Reflecting on what knowledge is privileged in the profession, its western roots, OT12 said, “I mean, and that makes sense. It [the profession] was created by a bunch of white ladies.” OT2 similarly stated that, “Everything we do is sadly really built from that [western perspective].” A constant (if implicit) refrain throughout OT1’s education was, “This is the way that it is, and there is no other way to do things.” Even attempts to extend beyond the dominant cultural ways of doing, being and knowing resulted in othering. For example, when OT11 had a session on cultural safety, “Honest to goodness, what we learned about was like, if your patient is Ukrainian, learn about making perogies and babushkas and stuff. I was like, ‘This is so stereotypical. This is– what?!’ So, I remember learning that and kind of cringing.”

Not only were participants having to learn and adapt to a cultural worldview that was unacknowledged yet infused everything about the profession, they also found that worldview clashed with their own.

Very early on into the program, I just realized how frustrating things would be. And when I say that, I mean, some of the, just some things don’t align, like in OT. Like the OT values, I guess, just don’t necessarily add up, with my own views (OT3).

OT4 shared these sentiments, highlighting the “individualistic” nature of western paradigms of health and illuminating a gap between the way they grew up and the expectations placed on them as a clinician to work from a particular lens. Participants recognized that the values and ways of knowing of the profession are culture-specific, “based on, largely non-Indigenous people and notions” (OT7), steeped in colonial cultural perspectives that are presented as universal: “They didn’t really talk about how different cultures or different ways of being brought up impacted your own understandings of OT, which is where I think I really struggled” (OT1).

For most participants, this ‘one way of knowing’ meant their own knowledge and life experiences had no place in their education programs: “I had a shit ton of life experience, but I was trying to hide it, because it wasn’t valued knowledge, or valued information” (OT5). OT6 emphasized the expectation that students adapt to what they were being taught, when they do not meet the expected norms. The lack of recognition that occupational therapy is culture-bound, and a colonial imposition, made learning some of the material more challenging. For example, some participants struggled to grasp occupational therapy theories; OT12 recalled always questioning, “How is this relevant for me?” Some participants struggled with fieldwork experiences where they were expected to join in anti-Indigenous racism. OT3’s clinical instructor, when knocking on the door of a client’s home, joked, “They’re probably not answering because I look like a cop.” OT3 responded, “Well, of course, that’s fair.” Similarly, OT4 said when seeing an Indigenous client their clinical instructor asked them to reflect on “assumptions we could make about that,” gesturing as if the client were drinking a bottle of booze and laughing.

Participants reflected on how widespread, unacknowledged cultural imperialism impacted their ability to succeed in professional education. Those who had bridged cultures in their personal lives drew on those histories as strengths. For example, OT6 grew up removed from their community and thought being raised with western influences helped them survive their occupational therapy program. OT1 similarly commented, “I probably teeter in both worlds more easily than someone, you know, who grew up in community or someone who grew up from, you know, solely a traditional way of knowing.” The imposition of one (dominant) way of knowing, this professional cultural imperialism, directly creates imposed isolation, exclusion, lack of support, a devaluing of merit and skill, and the need for Indigenous learners to be in two worlds throughout their educational journeys.

Discussion

The educational experiences shared by participants illustrate how isolation, exclusion, devaluing and lack of support were rooted in a deep-seated cultural imperialism (Smith, 2018) which left Indigenous learners positioned between ‘jagged worldviews colliding’ (Little Bear, 2000). Their experiences echo literature from other health professions (Etowa et al., 2011; Martin & Seguire, 2013; Rimmer, 2017; Slayter et al., 2016; Smith et al., 2011) over the past 10+ years. Interestingly, these experiences in occupational therapy education are still occurring, despite the fact that several participants were educated after the Truth and Reconciliation Commission of Canada released their final report (TRC, 2015b) and institutions are declaring commitments to (and sharing successes of), change to better support Indigenous students. The Truth and Reconciliation Commission of Canadas Calls to Action (TRC, 2015a) identify explicit directions for health care and education, which led to a surge in change-initiatives within health professions programs. Calls to Action #18, #19 and #22 link current health inequities for Indigenous Peoples to colonial practices and demand steps to narrow gaps in health outcomes. Calls to Action #10, #23 and #24 insist on changes in education, guided by Indigenous Peoples, to develop culturally appropriate curricula, to teach health professionals about colonialism, and to increase the number of Indigenous health professionals and retain them. In 2019 the final report of the National Inquiry into Missing and Murdered Indigenous Women and Girls echoed some of these demands in their Calls to Justice, especially Calls 7.1-7.9 on health services (Missing and Murdered Indigenous Women, Girls, and Two-Spirit People, 2019). They emphasized the importance of health professionals being educated on colonialism and racism, as well as the vital need to “recruit, hire, train, and retain” Indigenous health professionals, “recogniz[ing] that Indigenous Peoples – First Nations, Inuit, and Métis, including 2SLGBTQQIA people – are the experts in caring for and healing themselves, and that health and wellness services are most effective when they are designed and delivered by the Indigenous Peoples they are supposed to serve” (Missing and Murdered Indigenous Women, Girls, and Two-Spirit People, 2019).

The occupational therapy profession in Canada has declared its commitment to addressing the Truth and Reconciliation Canada Calls to Action (e.g., Association of Canadian Occupational Therapy Regulatory Organizations, 2022; Canadian Association of Occupational Therapists, 2018; OT TRC Task Force, 2023). Given the cultural imperialism that infused the educational experiences of Indigenous occupational therapists in this study, occupational therapy programs across Canada have a responsibility to ensure not only their students, but also the faculty and staff they employ, have been educated on, and understand, the root causes of Indigenous health inequities (Bauer et al., 2022). Moves within the profession must support Indigenous sovereignty and self-determination. There have, for example, been calls for better data on Indigenous health indicators (Gerlach et al., 2022; Rice et al., 2023) to begin addressing gaps that communities know exist. It has also been made clear that the changes needed to make space for Indigenous learners to enter and succeed in their programs are not minor tweaks; we must do things differently when working alongside Indigenous Peoples (Emery-Whittington, 2021; Gibson, 2020; Hunter & Pride, 2021; Price & Pride, 2023; Reichert et al., 2023; Ryall et al., 2021; White & Beagan, 2020). This includes transforming the material conditions of learning, power relationships between students (as knowledge holders) and educators (as learners), and connections to lands and communities.

Indigenous inclusion, reconciliation Indigenization, and decolonial Indigenization

As health professions move towards reconciliation and contesting colonialism within, critical assessment of change-efforts is essential (see Battiste, 2017; Smith, 2018). Not everyone is persuaded we can truly decolonize health care and education systems built on colonial ideologies and worldviews. However, the act of theorising ways in which to decolonize occupational therapy is a decolonial act in and of itself that aims to disrupt the status quo (Ahmed-Landeryou, 2024). Gaudry & Lorenz’s (2018) framework suggest change-efforts within the academy range from Indigenous inclusion, to reconciliation Indigenization, to ultimately, decolonial Indigenization. We would argue that the efforts within occupational therapy programs reflected in our study data fall into the Indigenous inclusion category, meaning the ‘add and stir’ approach (Battiste, 2017). Even when efforts at inclusion are made, glaring concerns remain. Content and approaches may be inappropriate and may not be derived from Indigenous Peoples themselves. Assimilation may still be expected. How do we ensure Indigenous content being incorporated is deeply considered, using methods carefully and deliberately chosen? How do we move past Indigenous inclusion towards reconciliation and decolonial Indigenization?

Efforts to create and incorporate Indigenous curricula are moving ahead, recognizing the urgent need in Canadian universities (Gaudry & Lorenz, 2018). The process, however, is as important as the content. Indigenous occupational therapists are well-positioned to be leading this national effort, through systematic consultation that cannot be done for free. This means that they should be approached for contributions to this work and taken seriously when they question methods or processes. Change efforts cannot be done under the guise of ‘business as usual’ and must allow for a reconfiguration of processes and policies. The status quo is colonial.

A significant challenge that all health professional programs are encountering is lack of capacity. We need to better recruit and retain Indigenous students, while also needing more Indigenous faculty and staff to support Indigenous students. At the same time, there is a need to provide cultural safety and Indigenous specific content for non-Indigenous students, faculty and staff to support Indigenous students and future clients. The quality of these initiatives are important to advance reconciliation and support improved health outcomes for Indigenous Peoples. Some healthcare programs have moved toward mandatory courses on Indigenous health, with mixed results. For example, in one study with 335 learners in health professional programs, one cohort showed improved beliefs and attitudes, while another showed an increased tendency to blame Indigenous Peoples for health inequities (Melro et al., 2023). In occupational therapy, a study by Jamieson et al. (2017) pilot tested an intervention on cultural safety and Indigenous health curriculum in Canada and found that participants knowledge was positively impacted; albeit this study was largely focused on notions of cultural competency (Bauer et al., 2022), which has been problematized (Grenier, 2020). A feature of that positive learning experience was stated to be the educator and their ability to teach the content. Importantly, faculty teaching content related to Indigenous Peoples’ health must also be supported, as there is evidence that Indigenous cultural safety facilitators experience unsafe environments and burnout when running training programs (Erb & Loppie, 2023).

As Indigenous health content is embedded into occupational therapy programs, we must be critical of how it is presented, and how we evaluate its success, while ensuring we support Indigenous people who are engaged in and leading this work. One step in moving from Indigenous inclusion toward reconciliation Indigenization (Gaudry & Lorenz, 2018) involves deep recognition of the worldviews and perspectives embedded in occupational therapy knowledge, values and skills that are taught as culture-neutral and universal but are neither (Bauer et al., 2022). This is an initial step in divesting from cultural imperialism. If reconciliation Indigenization means bringing together Indigenous and euro-western knowledges to develop new understandings and relationships, that means recognizing the harm done by assuming there is ‘only one [correct] way’ of knowing, doing and being. Etuaptmumk, is a helpful guiding principle.

Etuaptmumk and the need for multiple perspectives in occupational therapy

Etuaptmumk, a guiding principle identified by Mi’kmaw Elders Drs. Albert and Murdena Marshall (Bartlett et al., 2012), centers the gift of multiple perspectives, inviting all to employ both the strengths of Indigenous knowledges and ways of knowing, and the strengths of western knowledges and ways of knowing. Learning to see from both perspectives benefits all, though it may require colonial settlers to relinquish power and the monopoly they have held for decades over knowledge systems and institutions, as well as to humbly consider that their ways of knowing and doing are just one way. Forcing others to assimilate into one way of seeing the world does a great disservice to our ability, collectively, to be able to tackle the biggest problems facing our society and our planet today. The occupational therapy profession is at an intersection where there is increasing openness in research, scholarship and education about how best to draw in other ways of knowing, being, and doing. For example, recent work by Indigenous and allied scholars have provided critiques of assessments and frameworks based on their lived experience and ways of knowing and started offering recommendations for culturally safer, equitable care for Indigenous Peoples (Hunter & Pride, 2021; MacLachlan et al., 2019; Price & Pride, 2023).

Although study participants did not necessarily use the term Etuaptmumk, all of them moved back-and-forth between worldviews and perspectives during their occupational therapy education, and continue to do so in practice. As Indigenous Peoples living in a society dominated by western colonialisms, we are required to do this to engage with mainstream spaces. Simply put, this is something that we are now asking settlers to do.

Conclusion

In their education programs, Indigenous occupational therapists in this study shared experiences of imposed isolation, lack of support, exclusion, a devaluing of their merit and skills, and the need to navigate between two worldviews. This was rooted in the cultural imperialism that grounds the occupational therapy profession (Córdoba, 2020; Grenier, 2020; Hammell, 2011; Hunter & Pride, 2021; Price & Pride, 2023; Porto & Silva, 2023; Turcotte & Holmes, 2023a, 2023b). Alongside increased recruitment of Indigenous students into health professional programs, Indigenous learners experience significant challenges, discrimination, and racism. Moving beyond Indigenous inclusion towards a deep consideration and appreciation of the unique knowledges Indigenous learners bring requires a relinquishing of power, humble attention to differing perspectives, openness to learning from Indigenous occupational therapists, clients and communities, and willingness to abandon singular ways of seeing to create new ways.

We end this paper with a quote by Heidi Kiiwetinepinesiik Stark that highlight the important contribution of Indigenous knowledge:

When western scientific knowledge fails to provide insights for how to live in a precarious world affected by devastating natural events such as earthquakes and tsunamis, attention will be given to Indigenous knowledge systems, recognizing that Indigenous Peoples have had to contend with these concerns since time immemorial. Yet, even when western thinkers are willing to consider the stories that detail these historic events that are absent from the western historical record, they often fail to give consideration to how Indigenous knowledges posit we are a part of the web of relationships that give rise to these moments. Instead, western divisions between human and nature are reified even while considering the Indigenous stories that work against this categorization and binary by detailing the interconnectedness of Creation. These tendencies minimize or contain the transformative potential of Indigenous knowledge, rendering it easier to incorporate and assimilate into western categories of knowledge. It is not enough to make space for Indigenous knowledge. We must allow for this space to be reconfigured by Indigenous knowledge. (Kiiwetinepinesiik Stark, 2023).

• 1
  We have deliberately chosen not to capitalize the term western throughout to minimize power. This is an act of moving forward decolonization.
• 2
  As authors writing from the Canadian context, we are utilizing terminology representing the three groups of Indigenous Peoples as recognized by the Canadian Constitution. For the purposes of writing this manuscript, we utilize the term “Indigenous” broadly to capture the three Indigenous Peoples in Canada. We acknowledge that by doing this, the diversity and unique differences between Indigenous Peoples is not captured.
• How to cite:
  Pride T, Valavaara, K., Favel, K., Phenix, A., Starr, D., Reid, H., Turner, J., & Clyne, C. (2025). The perceived superiority of western worldviews in occupational therapy education: the experiences of Indigenous occupational therapists. Cadernos Brasileiros de Terapia Ocupacional, 33, e3817. https://doi.org/10.1590/2526-8910.ctoAO394538172
• Funding Source
  Tara Pride was funded by the Social Sciences and Humanities Research Council Doctoral Fellowship and the Atlantic Indigenous Mentorship Network – Doctoral Scholarship during their doctoral training. Holly Reid’s doctoral studies have been funded in part by the Social Sciences and Humanities Research Council (CGS-D) and a British Columbia NEIHR Research Development Grant. Justin Turner’s doctoral studies have been funded in part by the following organizations, listed alphabetically: Brain Canada Foundation, British Columbia Lung Association, Canadian Institutes of Health Research - Institute of Circulatory and Respiratory Health, and Heart & Stroke Foundation of Canada.

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Edited by

• Section editor
  Prof. Dr. Pier-Luc Torcotte

Publication Dates

• Publication in this collection
  07 Apr 2025
• Date of issue
  2025

History

• Received
  11 Apr 2024
• Reviewed
  30 Apr 2024
• Accepted
  18 Nov 2024