The Concept of Oppression and Occupational Therapy: A Critical Interpretive Synthesis

The Concept of Oppression

Oppression is a concept that developed “in the shadows” of concepts such as equity and justice (Cudd, 2006, p. 4). Theorists and social scientists in both the global North and global South use the term oppression and some have argued that oppression should be one of the primary terms used to conceptualize injustice (Freire, 1970/2000; Young, 1990). In fields such as education and social work, anti-oppressive practice has an extensive history (e.g., Delpit, 1988; Dominelli, 1996; Freire, 1970/2000). Oppression always involves harm due to social group membership, always involves the corresponding benefit to a different group, is always systemic or structured within a society, and is always rooted historically (Cudd, 2006; David & Derthick, 2018; Freire, 1970/2000; Young, 1990). Whether the harm is intentional or unintentional, overt or covert, and unconscious or conscious (David & Derthick, 2018), if the situation involves these characteristics, it is oppression. Narrower foci such as prejudice (biased prejudgments) and discrimination (actions and inactions arising from prejudice) may point toward solutions (such as education or legislation), but without understanding of oppression, may not attend to root causes (Dovidio et al., 2010). Naming oppression necessitates attention to systematic relations of power implicating multiple interconnected social structures, such as media, education, legal systems, housing, politics, and the economy (Cudd, 2006; Freire, 1970/2000). Whether oppression operates through ideologies, laws, policies, institutional practices, or interpersonal interactions (often called “microaggressions”), there may be direct effects on occupations. Specifically, microaggressions are the innocuous everyday communications that convey negative messages of marginality to members of subordinated groups, resting on broader historical and contemporary social power relations (Sue et al., 2007).

Power is central to the operation of oppression (Harvey, 2010), maintained through force, ideologies, social policies, the threat of violence, and ways of thinking that become so dominant as to appear inevitable and uncontestable (Clifford, 2016; Collins, 2000). Power relations of domination and subordination are usually socially approved, backed by norms of status and authority (Harvey, 2010). Power is identified within specific systems of oppression, such as racism, ableism, and sexism, that lead to experiences of social marginalization, exploitation, powerlessness, violence, and/or cultural imperialism—the imposition of dominant worldviews that render one's own life invisible or inferior (Young, 1990). In situations of oppression, harmful inequities arise “systemically as the result of enduring concentrations of power and resources in the hands of some social groups at the expense of others” embodied “in concrete structural, institutional and organisational as well as psychological realities” (Clifford, 2016, p. 5).

The concept of intersectionality (Crenshaw, 1989) captures how simultaneous membership in multiple social groups—some oppressed, some privileged—shapes experiences of power and oppression in complex non-additive ways. Emerging from a rich heritage of advocacy and scholarship by Black women, intersectionality describes “how complexities of intersecting systems of power complicated everything in their lives” (Collins, 2015, p. 2350). For example, when White women in the global North were encouraged to stay home with children, most Black women were required to work outside their homes (Collins, 2015). Both are intersections of racism and sexism. Similarly, living with disability intersects with financial status to affect very different experiences and outcomes by social class (Stabile & Allin, 2012).

Oppression, by virtue of naming a moral wrong, invokes responsibility for action (Cudd, 2006). In his classic text on oppression, Freire (1970/2000) argues that the first step in considering action is conscious raising (conscientizaçao), a process in which experiences of oppression and their causes are identified. Oppression can then be understood “not as a closed world from which there is no exit, but as a limiting situation which [people] can transform” (Freire, 1970/2000, p. 49). This is an inherent part of praxis defined by Freire as “reflection and action upon the world in order to transform it” (Freire, 1970/2000, p. 51), transforming not just consciousness, but oppressive systems and social structures.

Oppression and Occupational Therapy

Although theories of oppression come from beyond occupational therapy, related concepts have been considered within occupational therapy and occupational science (e.g., Gupta and Garber, 2017). Occupational scholars have examined structural forces that limit and demand occupational participation (Hammell, 2020). They have considered intersectionality (Angell, 2014), consciousness raising and occupational consciousness (Ramugondo, 2015), and the effects of power (Kiepek et al., 2019; Pyatak & Muccitelli, 2011). Scholars have encouraged therapists to seek justice, to name and address root causes of inequities, and to be aware of systemic influences (Farias et al., 2016; Gupta & Garber, 2017; Ramugondo, 2015; Silvestrini et al., 2019). Therapists have been challenged to consider the impact of oppression on occupational engagement (Angell, 2014; Ramugondo, 2015) and whether they perpetuate oppression with colleagues (Chacala et al., 2014) and clients (Kirsh et al., 2006). Occupational therapists have been asked to stand against oppression while promoting inclusion and equity (Carlsson, 2009). Most recently, literature in occupational therapy has begun to challenge the pervasiveness of dominant worldviews within the profession, those of White supremacy (Grenier, 2020), those of settler colonialism (e.g., Emery-Whittington & Te Maro, 2018; Fijal & Beagan, 2019; Gerlach et al., 2018; Gibson, 2020; Occupational Therapy Association of South Africa, 2020; White & Beagan, 2020), those of normative ableism (e.g., Gappmayer, 2021; Grenier, 2021), and those of class privilege (e.g., Hocking, 2019).

Yet, despite attention to ideas and concepts related to oppression, the term itself has been largely absent, at best implicit, in occupational therapy and science literature. An April 2021 search of the Combined Index of Nursing and Allied Health Literature (CINAHL) with oppression, occupational therapy, and occupational science as keywords returned only 11 citations, four of them from journals in the global South; all but one have never been cited or have been cited only once or twice, though two papers date back to 1996. Perhaps “oppression” has been too strong a term for the profession (Beagan, 2020)? The recent literature identified above indicates that the profession is attending to structured power relations. The concept of oppression, with its insistence on systemic causes, interrogation of domination and privilege, and identification of harm due to social identities, may add to this discourse and contribute to a needed plurality of ways to examine harm and opportunities for change (Guajardo Córdoba, 2020). Clarity about what constitutes oppression (ongoing benefit or harm to social groups, historically rooted, embedded in multiple interlocking social systems) may also help to avoid seeing every instance of discomfort or underrepresentation as a social justice concern (e.g., seeing the small number of men entering traditionally feminine jobs as discrimination; Beagan and Fredericks, 2018). Research on specific axes of oppression—racism, colonialism, sexism, ableism, classism, ageism—is valuable and necessary, yet there may also be an important place for the concept of “oppression” in the conceptual toolbox of occupational therapy.

This CIS examines how the concept of oppression, and terms naming axes of oppression, have been used in occupational literature. We explore whether explicit attention to oppression might contribute to understanding of injustice within occupational therapy. Attending to oppression at multiple levels in occupational therapy, scholarship, and teaching may benefit learners and practitioners who need to navigate constraints and opportunities of their practice settings and also the broader social power relations within which they are inevitably located.

Methodology

CIS uses a critical perspective to create a synthesizing argument or theoretical proposal, grounded logically and plausibly in the data (Dixon-Woods et al., 2006). Beginning from a subjective idealist epistemological position (Barnett-Page & Thomas, 2009), researchers use a broad literature search strategy and tentative research question to find relevant literature. The process is iterative and recursive, with overlapping data collection and analysis, and may employ sampling strategies that maximize variation (Entwistle et al., 2012). In response to the emerging findings, non-linear processes of analysis and critique are selected and theoretical saturation may determine when the literature has been sufficiently examined (Dixon-Woods et al., 2006). Analytic processes are not prescribed but are to be critical, reflexive, dialogic, and creative as information is interpreted and themes are recognized (Dixon-Woods et al., 2006).

In keeping with critical traditions, as authors, we acknowledge that our positionality shapes our values and beliefs in ways that become inseparable from the research process. The first author is an experienced occupational therapist well-read in occupational justice, injustice, and rights, who nonetheless felt ill-prepared to engage with the realities of oppression in practice. Her commitment to social change, occasioned first by sustained engagement with the words and ideas of Indigenous peoples, pushed her to examine multiple approaches to critical thinking and acting. The second author teaches about oppression in occupational therapy. Both authors identify as settler, white, cisgender, currently middle-class, able-bodied women; the second author also identifies as a lesbian of lower class origins.

Sampling

Unlike a scoping review, intended to survey existing literature comprehensively (Arksey & O’Malley, 2005), CIS proposes non-linear, purposeful sampling, not aspiring to representativeness so much as interpretive potential (Dixon-Woods et al., 2006). For this CIS, the databases CINAHL, PsycINFO, PubMed, and Scopus were searched (1998–2019) for occupational therapy/therapist(s) or occupational science and oppress* as keywords. Finding almost nothing, the search was run with more specific keywords sexism, racism, classism, ableism, disablism, ageism, heterosexism, and colonialism, to retrieve papers that might address oppression without using that language. Articles were retained if they were peer-reviewed and English language, resulting in 104 articles. After exclusion criteria were applied (eliminating articles that did not contain any of the keywords, those with no reference to occupational therapy or science, and published in journals outside those fields), 73 articles remained. Abstract and/or full-text review was used to determine the depth to which oppression was explored within individual articles. This reading informed the selection process within a sampling frame. To obtain the articles for inclusion, the articles were divided by subject (oppression, racism, sexism, ableism, heterosexism, classism, ageism, intersectionality) and time period (1998–2005, 2006–2012, and 2013–2019). One article was selected from each of these 24 subject/time groups (where possible; some categories contained no articles), with occasional additional articles added to enhance depth of analysis and diversity of literature included. The final selection of 25 articles was done by the first author in dialogue with the second.

Data Analysis, Rigour, Limitations

The sample of 25 articles was read multiple times while examining their conceptual framing. A full-text review of three articles was used to shape the data collection process, which was then expanded to include ideas from oppression theories. For each article, a brief interpretive summary was created to encapsulate how naming oppression contributed to the article. Quotes were extracted that illustrate the choice of terms used to clarify the experience of oppression, the actions people take following experiences of oppression, how power is addressed, and how occupational therapy and occupational justice terms are used by the authors. Throughout the data collection process, reflective comments were recorded in a journal and reflexive, critical discussion between authors supported the iterative analysis.

Considerations of saturation were left until the initial data had been fully examined so that emerging insights could influence the process (Dixon-Woods et al., 2006). When assessing saturation, three additional peer-reviewed, English language articles written by authors not included in any of the initial 25 studies were chosen (for a total of 28 included articles). The information in these articles did not challenge the analysis arising from the initial set of articles nor require the creation of additional categories to express key oppression-related content; it was determined that theoretical saturation had been attained.

Although efforts to ensure rigour were undertaken, there are limitations to this research. First, this CIS focuses on work published in English, peer-reviewed journals. Other sources (i.e., conference proceedings) were briefly reviewed, but not included. Second, the number of similar terms available in English, as well as any stigma associated with particular terms, may have affected results. For example, scholars sometimes use culture instead of race, or class inequity instead of classism and this study was limited to sources using the “ism” terms. Third, database design limits the articles that can be accessed. Databases are biased toward Western/Northern journals and may prioritize quantitative or positivistic constructs over social concepts (Patin et al., 2020). Finally, time and resource constraints may have limited the creative nature of the CIS processes. Although all of these factors limit the analysis presented, it is also true that occupational therapy and occupational science literature that directly addresses oppression is a finite volume. The analysis presented captures the gestalt or overall character of that body of literature, even if it misses some individual pieces.

Oppression and Everyday Doing

As Ramugondo (2015) has stated, “everyday doing intersects with oppression” (p. 495). Whether they were examining ageism, ableism, classism, colonialism, heterosexism, racism, sexism, or intersectional experiences, the authors included in this CIS described numerous ways everyday occupations were altered by oppression. In a study of racism, one participant stated, “It impacts everything I do, everything I say, everything I wear, everything I eat, people I talk to . . . most life activities. It's so pervasive” (Beagan & Etowa, 2009, p. 288). Forms of oppression were shown to affect everyday occupations from riding in taxis (Bergan-Gander & von Kürthy, 2006), to accessing health care (Gerlach, 2008), from interactions with professional colleagues (Chacala et al., 2014) to farming practices (Simaan, 2017). Authors described experiences that involve exploitation in work and hospital environments (Bailliard, 2013; Crabtree, 2005; Howarth & Jones, 1999), marginalization in educational, health, and community settings (Angell, 2014; Joubert, 2010; Trentham & Neysmith, 2018) and fear of violence (Gerlach, 2008; Wicks, 2001).

Many of the incidents described can be seen as microaggressions (Sue et al., 2007), which may shift the meaning of occupations. For example, for racialized or disabled children, being teased mercilessly can take the joy out of schoolyard games (Angell, 2014). For Latino migrants, enduring the gaze of strangers who “look at you as if you were a cockroach” (Bailliard, 2013, p. 351) can infuse work, driving, or any daily occupation with lack of belonging. Similarly, for racialized women, “being ignored, being followed, being treated disrespectfully, not being taken seriously” (Beagan & Etowa, 2009, p. 288), can obliterate any pleasure experienced while shopping. Experiences of health care can be negatively affected by practitioner attitudes such as when a racialized client is treated patronizingly, assumed not to speak English (Kirsh et al., 2006).

In addition to microaggressions, the papers examined here explored how occupations may be affected by invisibility, internalization of oppression, and fear of violence. In one study, a participant shared that due to ageism, “our lives as citizens are rendered invisible and we battle to find the language, let alone define strategies, to delineate alternatives” (Trentham & Neysmith, 2018, p. 181). When a stigmatized aspect of identity is highlighted, other aspects can be rendered invisible, constraining occupational opportunities: “They looked at my disability, not my brain” (Joubert, 2010, p. 24). The authors also examined how racism, sexism, heterosexism, ageism, and ableism may be internalized, leading people to “choose” to constrain or alter their own occupations. For example, internalized ageism can lead to efforts to appear younger (Trentham & Neysmith, 2018), and internalized gender roles may “become encoded as individual self-expression and individual choice” (Beagan & Fredericks, 2018, p. 141). Most overtly, perhaps, violence and fear of violence may circumscribe occupations. For example, Latino migrants afraid of police hostility avoided travel for groceries, relying on canned goods that reduced gustatory pleasure and cultural continuity (Bailliard, 2013).

Effects of Structures and Power

With all forms of oppression, harm may be experienced at an individual level, but the causes of such harms reside in social and institutional structures and systematic power relations. Attention to structures that result in oppressive harm is apparent in this group of articles, as authors identify harms rooted historically and contemporarily in legislation such as the Indian Act in Canada (Gerlach, 2008), the REAL ID Act in the United States (Bailliard, 2013), and the British mandate in Palestine (Simaan, 2017). Such “macro” level structures influence “meso” levels, shaping policy and organizations. Within the selected studies, the authors examine such institutional processes as welfare policies (Boland & Cunningham, 2019), paternalistic organizational practices with older mental health consumers (Fortune et al., 2007), and funding mechanisms that mandate individual responsibility for “productive aging” (Laliberte Rudman & Molke, 2009).

The selected articles include examples of relationships between structures and occupation, showing how oppression can lead to unwanted occupation when resources and opportunities are distributed in ways that benefit some people instead of others. For example, limited work options available to undocumented workers lead to exploitation: “If you don’t want it, another will come who does . . . you submit” (Bailliard, 2013, p. 350). Policies can create marginalizing conditions by limiting who can live in certain neighbourhoods (Pyatak & Muccitelli, 2011) or work in certain locations (Simaan, 2017). Such structures and policies create powerlessness, wherein people have insufficient influence to implement their occupational preferences (Boland & Cunningham, 2019; Young, 1990).

Power operates not only through structures and material resources but also through the circulation of dominant ideas as “normal” and “common sense” (Collins, 2000). The selected articles examine numerous instances where dominant beliefs constrain occupation, including messages about which age groups should be productive (Laliberte Rudman & Molke, 2009), which people are presumed independent (Chacala et al., 2014), and whose disruptive behavior is dismissed as natural, such as “boys will be boys” (Angell, 2014, p. 112). Authors draw connections between ideas of “normal” gender or class expectations and job choices or hiring practices; those employment patterns then recursively reproduce gender and class oppression (Beagan & Fredericks, 2018; Hammell, 2013).

Responding and Resisting

The authors of the selected articles also attend to how people make difficult “choices” to respond to and/or resist oppression. Participants might not respond to protect themselves against harm, might accommodate oppressive circumstances to ease daily living, and/or might act to resist or reduce oppression. Attending to occupational responses and resistance recognizes the agency of people in situations of oppression, yet these can all still be considered constrained choices (Angell, 2014; Simaan, 2017).

The constraints imposed by oppressive structures were evident when authors explored people's “choice” not to respond to oppression. In one study, parents taught children to avoid reacting to racism: “Let it roll off because you’re going to have it in your everyday life, eventually, all the time” (Beagan & Etowa, 2009, p. 291). For Latino migrants, eliminating activities reduced opportunities to encounter harm (Bailliard, 2013), while for homeless people refusing participation in activities organized for them “demonstrated agency and identity against the oppressive rules” (Boland & Cunningham, 2019, p. 312). Some study participants strived to make situations more tolerable by making constrained choices such as “passing” as members of a non-stigmatized group such as heterosexuals (Bergan-Gander & von Kürthy, 2006) or non-seniors (Trentham & Neysmith, 2018), or by reappropriating racist terms (Pyatak & Muccitelli, 2011). Commonly, occupational engagement involved discerning when to take action: “You forgive fast and move on. Sometimes I call out the racism, sometimes I sit back and hope my allies will” (Emery-Whittington & Te Maro, 2018, p. 18).

When resisting oppression, raising consciousness proves a frequent starting point (Emery-Whittington & Te Maro, 2018; Joubert, 2010; Pyatak & Muccitelli, 2011; Townsend et al., 2000). Ramugondo (2015) argues that occupational consciousness is essential to recognize the influence of dominant practices sustained by and through everyday occupations. Actions to resist oppression could be fleeting, such as the deliberate behaviour of Black boys to disrupt power dynamics in the classroom (Angell, 2014), or steadfast and obdurate, such as relentlessly replanting trees on occupied lands “until the aggressors give up” (Simaan, 2017, p. 518). Resistance could be directed at immediate situations or aimed at improving broader social and policy contexts, such as seniors producing advocacy materials on ageism, support services, and funding structures (Trentham & Neysmith, 2018). Resistance occupations may take the form of protest and activism (Nelson, 2007), or producing art: “Rap music has developed as a means of resistance by which Black Americans can call attention to the political, social, and economic conditions faced by their communities and the postcolonial racist practices that serve to sustain these conditions” (Pyatak & Muccitelli, 2011, p. 51). Deciding when, whether, and how to respond to oppression, in the context of ongoing constraints, can be emotionally exhausting—as noted by one participant resisting racism, “I went and challenged them . . . that's very, very stressful to have to go through that” (Beagan & Etowa, 2009, p. 289).

Oppression Within Occupational Therapy

As an institution, the profession of occupational therapy has perpetuated oppressive harms. Articles in this CIS document ableism, ageism, colonialism, racism, and sexism within occupational therapy examining experiences of clients, therapists, and students. Within these articles, a therapist is dehumanized and called a fire hazard (Chacala et al., 2014, p. 112), clients describe feeling invisible (Kirsh et al., 2006), bias toward male clients is found in an assessment (Jong et al., 2012), and therapists realize the discordance between the occupations they anticipate for themselves in older adulthood and the occupations they expect for clients (Alden & Toth-Cohen, 2015) (see also Table 1). The authors examine how power dynamics such as those present in ableism and colonialism shaped the profession's development and continue to influence interactions (Joubert, 2010; Nelson, 2007). Theoretical frameworks employed include critical discourse analysis (Laliberte Rudman & Molke, 2009), Black feminist theory (Angell, 2014), and decolonial theory (Emery-Whittington & Te Maro, 2018), demonstrating several authors’ commitment to incorporate power as a central part of their theoretical lens.

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Table 1.

Examples of Oppression Experienced in Occupational Therapy Settings

System of Oppression	Example of Oppression
Ableism	A blind occupational therapist recounts: “I’ve been called a fire hazard, I’ve been stopped going on courses. Just horrific, some of the comments.” (Chacala et al., 2014)
Ageism	Through workshops, occupational therapists “realized they had different expectations for themselves than for their clients” (Alden and Toth-Cohen, 2015, p. 11).
Colonialism	Maori occupational therapists in a keynote address tell colleagues “We bear witness to resounding silence when we question assumptions and put up with regular assessment of our ‘Maori-ness’ on an imaginary scale of authenticity” (Emery-Whittington and Te Maro, 2018, p. 13).
Racism	Clients described “A sense of ‘invisibility’, of being excluded from the occupational therapy process” (Kirsh et al., 2006, p. 310).
Sexism	An assessment tool with a bias toward male occupations may contribute to a gender bias in access to services (Jong et al., 2012).

Calls for change, proposed by the authors of the selected studies, insist that therapists create a critical, reflexive discipline (Angell, 2014), ask critical questions (Beagan & Etowa, 2009; Townsend et al., 2000), and develop “networks of critical friends and safe reflective spaces” (Nicholls & Elliot, 2019, p. 10). Authors advocate that therapists interrogate their assumptions about who should participate in particular occupations (Laliberte Rudman & Molke, 2009), and question how they may be interpreting structural inequities as individual client failings (Beagan & Etowa, 2009). Such critical self-questioning may necessitate “deep and sometimes painful interrogation” (Joubert, 2010, p. 21; see also Nicholls & Elliot, 2019). On the other hand, as Steed (2014) documents, even extended educational interventions may not shift entrenched racist beliefs of occupational therapy students. Alden and Toth-Cohen (2015) found similar results with education to reduce therapist ageism and “elderspeak.”

Scholars’ recommendations for occupational therapists reflect their desire for change and include creating space for clients to discuss the impact of oppression, and assuming client occupations are affected by ageism (Trentham & Neysmith, 2018), racism (Beagan & Etowa, 2009), and heterosexism (Bergan-Gander & von Kürthy, 2006). At the community level, therapists/activists (Pyatak & Muccitelli, 2011) are encouraged to advocate for occupational rights and justice (Boland & Cunningham, 2019). Within the profession, therapists are urged to promote respectful interactions by challenging oppressive assumptions (Chacala et al., 2014; Howarth & Jones, 1999; Townsend et al., 2000), ensuring they are not reinforcing stereotypes (Alden & Toth-Cohen, 2015; Beagan & Etowa, 2009; Steed, 2014), and creating student experiences that disrupt social norms (Stewart et al., 2005). Therapists and scholars are pressed to address oppression embedded in policy (Howarth & Jones, 1999), data collection (Beagan & Fredericks, 2018; Stewart et al., 2005), written texts (Laliberte Rudman & Molke, 2009), assessment tools (Jong et al., 2012), evaluation frameworks (Fortune et al., 2007), and dominant professional epistemologies (Gerlach, 2008; Nicholls & Elliot, 2019). Compared to the wide-ranging scope of recommendations, the selected articles describing actual changes denote relatively small initiatives such as creating a research group in a mental health day program (Townsend et al., 2000), advocacy work with senior citizens (Trentham & Neysmith, 2018), and implementing education programs for current/future therapists (Alden & Toth-Cohen, 2015; Steed, 2014).