A call to action, to be critically reflective of ourselves and our practice

Micah Perez

In today’s ever-evolving climate, the abuse and/or neglect of human rights of various populations is becoming increasingly evident, thanks in part to brave voices and advocates of social justice bringing this to our awareness. There is, therefore, a real need for us, as OTs, to critically reflect on ourselves and our practice, and the impact of our practice on the rights and needs of our clients.

An important part of critical reflection, in my opinion, is to first consider our bias and positionality. Nixon (2019) proposes a coin model of privilege, whereby coins are used to conceptualise systems of inequality that give individuals advantages and disadvantages, depending on what side of the coin they are on. After we have reflected on our bias and positionality, we can then reflect on the impact of these on the way we practice occupational therapy, and the way in which we establish and maintain a therapeutic relationship with our clients. I believe this form of critical reflection is especially important when we work with clients with disability who are neurodivergent (confirmed and suspected) and have culturally and linguistically diverse backgrounds.

For example:

• Am I biased towards neurotypicality, ableism and Western culture? If so, how does this bias impact my expectations, communication, and interactions with neurodivergent (confirmed and/or suspected) clients with disability, who have culturally and linguistically diverse backgrounds?

• Do I come from a position of unearned power and privilege? If so, how does my position impact and/or inform my therapeutic relationship and expectations of my clients?

A reflection on the neurodiversity movement

Momentum appears to be gathering for OTs to join the neurodiversity movement. I’m excited about this, because I am very much on a journey of resonating with the neurodiversity movement and moving towards neurodiversity affirming occupational therapy practice. My journey began with a process of critical reflection, like I have outlined in the section above.

According to Dallman et al. (2022), neurodiversity affirming OTs must critically question the following:

Are your goals targeting reducing or changing diverse behaviours central to your client’s personhood and important for their wellbeing?

When I reflected on this question when working with my paediatric clients, it prompted me to think about whether I was being client-centred in relation to the child or the child’s parents, and this has since informed the way I approach goal setting and intervention planning. When I reflected on it when working with adult clients, it prompted me to think about the expectations I had and the basis of those expectations, and to question what wellbeing means for each client. I have since come to appreciate how diverse the definition of wellbeing is for my clients.

Proponents of the neurodiversity movement argue current therapeutic and medical practices often attempt to normalise behaviours and ways of participation that originate from these differences in neurology and contribute to an individual’s sense of identity. Dallman et al. (2022) argue that an ethical and morally just occupational therapy practice should affirm neurodivergent ways of being, and OTs must be agents of change by listening to and collaborating with their neurodivergent clients.

A neurodiversity affirming perspective, according to Dallman et al. (2022), requires:

1. Respect for your clients as having a unique style of neurological processing that leads to differences in sensing and operating in their environments;

2. Listening and consulting with neurodivergent individuals to determine the meaning of their behaviours and occupations;

3. Framing neurodivergent behaviours as natural and valid responses to a specific situation, given the skills, abilities, and preferences of each individual;

4. Having goals that prioritise emotional wellbeing and positive engagement, rather than therapy compliance;

5. Respecting the right of neurodivergent individuals to physically engage with a task or move their bodies during therapy;

6. Guaranteeing social agency and the right to socially engage in ways that are comfortable to them; whereby you, as a therapist, must seek to understand neurodivergent social rules, norms and communication styles that can best support your clients;

7. Validating, encouraging, and honouring all forms of communication (e.g., verbal AND non-verbal); and

8. Being reflexive and acknowledging how your own understanding of behavioural norms aligns or differs from your clients’ ways of being.

As a neurodivergent individual, I really resonate with the above list, and strongly encourage all OTs to consider all these points when working with neurodivergent people.

Neurodiversity affirming occupational therapy

The evidence supporting neurodiversity affirming occupational therapy for neurodivergent individuals is compelling, yet still emerging. Available evidence comprises research studies, clinical trials, and systematic reviews. What I can glean from the evidence (e.g., from the American Occupational Therapy Association, WFOT, and the Journal of Autism and Developmental Disorders) is that neurodiversity affirming occupational therapy can result in improved functional outcomes across various life domains, enhanced self-regulation, and a positive impact on executive function. It involves:

1. Individualised assessments – To gain a holistic understanding of strengths and difficulties, through evaluations that seek to understand the unique needs, preferences, and goals of each individual;

2. Sensory techniques – To support individuals to regulate their sensory experiences and develop adaptive responses within their environments, and to promote self-regulation;

3. Skill development strategies – To enhance an individual’s functional abilities in self-care, productivity, leisure, and social participation, and to empower an individual to lead a fulfilling life (based on what they identify is important to their personhood and wellbeing); and

4. Environmental modifications –To create supportive and inclusive environments that accommodate the unique needs of individuals.

My experiences as a neurodivergent OT providing neurodiversity affirming therapy to neurodivergent families

I have seen firsthand how neurodiversity affirming occupational therapy has helped my clients achieve goals related to:

• Functional outcomes including self-care, learning, play, leisure, and social participation;

• Improvements in self-regulation and co-regulation between caregivers and children;

• Improvements in executive function (i.e., cognitive, behavioural and/ or emotional regulation);

• Deeper understanding, appreciation, and validation of the uniqueness of their personhood and wellbeing; and

• Validation and willingness to self-advocate for their desires and needs, according to their personhood and wellbeing.

However, I have also experienced challenges, including (but not limited to):

• Undertaking robust assessment when available standardised assessments are not suitable for neurodivergent and culturally and linguistically diverse clients;

• Undertaking consistent progress reviews with available standardised assessments not suitable for neurodivergent and culturally and linguistically diverse clients;

• Navigating a therapeutic relationship when the expectations of the parents are different to my own (e.g., the amount of parent involvement in sessions and follow-up at home, openness to receiving parent coaching, deciding whether other family member involvement is beneficial in sessions); and

• Providing evidence based and/ or appropriate culturally safe and responsive practice to culturally and linguistically diverse clients.

Where to from here?

Within the occupational therapy profession, I have seen examples of neurodiversity affirming occupational therapy practice in our American colleagues, such as Meg

Proctor from Learn Play Thrive (https:// learnplaythrive.com/instructors/megproctor-ms-otr-l/). This includes her Two Sides of the Spectrum podcast (https:// learnplaythrive.com/podcast/).

In Australia, there is an OTA Neurodivergent Affirming OT Practice Special Interest Group convened by Janine Langley (https://otaus. com.au/member-resources/interest-groups/ neurodivergent-affirming-ot-practice).

Doing a search on LinkedIn and Google yields results for services claiming to use neurodiversity affirming practices within and outside of Australia. Furthermore, there was a panel discussion session included in OTA’s 2023 National Conference & Exhibition in Cairns. This discussion provided what I felt was a small jumping off point to hear about examples of neurodiversity affirming practice with adult autistic clients.

I hope this article will inspire you to undertake critical reflection of your own biases and positionality and the impact of these on your practice, and to consider taking a step (small, medium, or large) towards neurodiversity affirming occupational therapy practice.

About the author

I am a neurodivergent female (she/ her) Filipino-Australian, who has lived in Queensland since I was three years old. I am a chronic migraine warrior with Attention Deficit Hyperactivity Disorder, Anxiety and Depression.

I have over ten years of experience as an occupational therapist, working in the private and public sectors, with a varied caseload extending from toddlers to older adults. I also provide clinical education support to occupational therapy students at Griffith University.

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