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Becoming contextually responsive: taking hold of a shared vision for our profession Abstract Equitable access to life-giving occupational participation lies at the centre of occupational therapy’s mission and is pivotal to development in South Africa. Contextually responsive education, research, policy and practice are a means of achieving this. This, however, necessitates knowing how to be or become contextually responsive as individuals and as a profession. It also necessitates partnership between our ‘feet on the ground’ practitioners and ‘head in the cloud’ academics – a productive collision of reality and possibility. This commentary explores what it means to be contextually responsive, whether it’s possible for practitioners and scholars to do together, and poses recommendations for finding each other in the journey of becoming. Introduction Are you, like us, looking for a plain-language summary for “contextually responsive”? Do you instinctively agree to the idea of “responsiveness”, eager and appropriately resolute, while at the same time hearing your more pragmatic mind asking, “But what does it actually mean?” If you can relate, then perhaps you also want to move beyond the rhetoric and unpack what it means to be ‘contextually responsive’, and decide: is it imperative? Additionally, if we are challenging ourselves to become a contextually responsive profession, is it possible for our scholars or academics, and our clinicians to do it together? Can we orientate towards being ‘on the same page’, speaking a shared professional language, and journeying toward a shared vision? This commentary will explore these questions and propose ideas around our growth and development as a South African occupational therapy academy. Context: what are we responding to? Before we can talk about being “responsive”, we need to know what we are responding to. Occupation focused conceptual frameworks have drawn our attention to various aspects of the context and environment1 that influence occupation, whether it be the participation of our clients, or our own doing and being as a profession. The physical, social, cultural, institutional, temporal and economic elements of the context or environment (1–4) typically highlighted by occupational therapy theory. More recent occupational therapy conceptual Becoming contextually responsive: taking hold of a shared vision for our profession, 15 May 2021 frameworks have highlighted the importance of geopolitical elements of the environment(5). The Participatory Occupational Justice Framework(6), which specifically seeks to guide practitioners in addressing occupational injustice, conceptualise contextual drivers of occupation as operating within concentric frames. The model considers the local practice and systems context, as well as the political, socio-cultural and economic contexts that exert influence at a global, regional and national level. The spiritual context of occupation is an element that is central to many worldviews. Although the person is acknowledged as a spiritual being by some conceptual frameworks(4) the spiritual context or environment is, to our knowledge, an aspect of the environment that still needs to be described. Already highlighted by local and international scholars, the social determinants of health offer an additional lens through which the invisible influences of the context and environment can be analysed (7). These theoretical frameworks in occupational therapy all illustrate the foundation for occupational therapists being able to identify, recognise and integrate the many elements of complexity and systems, toward honouring the maxim of the profession: the intrinsic relation between occupation, health and well-being. Why is it then, we need to pose the reflexive question whether we are contextually responsive in our work? Are we, as an occupational therapy profession, responding to the multi-layered context in which our profession is suspended? Are we responding to the contexts in which our clients, both individual and collective, participate? Or do our own inevitable subjectivities press us to extract and understand only samples of our clients and their occupations, largely dissected from their environment? Have we perhaps unwittingly succumbed to the eroding global discourse of neoliberalism undergirded by a ‘possessive individualism’ where the individual is the owner of his/her space and ways of thinking, being and doing, assuming a freedom that is exempt from interdependence with others; a freedom that at once, also serves as a form of possession?(8) Perhaps the enclaves of possessive individualism hinder our ability to maintain a 365-degree gaze on the grid of holism - the very foundation of our theories. When we reclaim our ability to lift our gaze and see the bigger picture, we may recognise the effects of the past, the present and the future. In terms of the past, local evidence would suggest that we are only beginning to appreciate the way in which occupations of South African populations are deeply embedded in, or bound by, the social and historical context10. Socioeconomic and political factors of the past continue to exert a moulding force on the current occupational choice of clients and communities11. Hence, in the present we have witnessed in full force the accentuation of Becoming contextually responsive: taking hold of a shared vision for our profession, 15 May 2021 inequalities along the usual fault lines of race, gender and socio-economic standing. And the future? We need to ask ourselves what insights we have garnered and what foresight we need to strike the balance anew, between remaining relevant as a health care profession within the ambit of the bio-medical model (NHI), while addressing the social determinants of health as a critical area for occupational therapy intervention?(7). Another important feature of the environment that occupational science scholars draw our attention to is the influence that power relations exercise on occupation(6). An ability to perceive this and exercise habitual sensitivity to the dynamics of power and dominance evident in, and entrenched by occupations, has recently been conceptualised as occupational consciousness(9). All environments support or hinder occupational participation(10) and may create or perpetuate occupational injustice(6). A consciousness of the complex, dynaminc and multi-layered context of occupation helps the occupational therapist to understand ‘the ecological nature of disability’(10):176 and positions them and their clients to achieve participation equity through the ‘critique and change’(10):176 of disabling environments (10). Occupation focussed conceptual frameworks equip us to know about the context and environment and its transaction with human occupation. But have we developed the senosry skill to truly see it? This sensory reception and perception is a precursor of responsiveness. Responsiveness: who does this mean? So we have knowledge of human occupation and the environment exerting reciprocal influences on one another, but we are struggling to “see” it. We are not completely there yet. So how do we get there? A simplified look at the human body’s sensorimotor systems provides a familiar analogy and possibly some guidance. A human body analogy Responsiveness conveys the idea of a fitting reaction to a perceived reality. A simplified look at the human body’s sensorimotor systems provides an analogy for the concept: The sensory system receives information from the environment through a number of different avenues. This information is or interpreted, before a motor response is generated. Limiting the sensory reception within an environment can result in an inappropriate motor response. Failing to hear the sound of bicycle wheels of a group of cyclists before executing the motor response of crossing a road can have disastrous results. Poor reception can lead to inappropriate action. Difficulty may also arise at the level of perception, or interpretation of Becoming contextually responsive: taking hold of a shared vision for our profession, 15 May 2021 information. We process sensory information based on past experience. Sensory input that is being faultily interpreted requires a process of relearning. This analogy is helpful: We are required to be responsiveness to the environments in which our clients, individual and collective, are embedded as occupational beings. Firstly, our senses need to be trained to be receptive through exposure, necessitating opportunities for experiential learning. This exposure is ideally through interaction with the environment, necessitating exposure to, and engagement within diverse South African contexts. This is perhaps not as straightforward as it sounds. An autobiographical study of a South African therapist found that developing this receptive ability was a process of “seeing and feeling the invisible”(7):4. Essential to developing this ability was the therapist being immersed in a context characterised by social inequality and poverty. Exposure to clients in context enabled the therapist to “zoom out” and see that the client did not (just) need an splint (sling), they had a deep need “to live a dignified life” (7):4. Her realisation challenges us: Are we satisfied with preventing a painful shoulder subluxation while urgent calls are being made to address social injustice? Are we too easily satisfied with an over-reductionist focus when we are being called to serve the “people of nothing”(11) who wait patiently for justice? Beyond developing a receptive sensitivity, our perceptions are shaped by how we process or make sense of the information that we receive, though reception and perception are not distinctly separate functions. Perception, or interpretation, may strengthen or weaken receptive sensitivity. Similarly, motor responses are directly linked to these sensory functions. Richards and Galvaan propose that critical reflexivity and participatory approaches are essentially a means to developing contextually responsive “motor responses” in practice(7). The same researchers described the importance of therapists realising their “common humanity and shared citizenship with clients” (7):4. This realisation facilitated a participatory approach in which client and therapist work as “equals working for change” (7):4 and are able to collaboratively act in response to a “shared understanding of the client’s situation” (7):4. As a profession: boots in the mud and head in the clouds? To think through being contextually responsive as a profession, we’d ask for a little creative licence to extend the human body analogy, likening the South African occupational therapy academy to a human being – a person. This person is dressed for bad weather with a pair of sturdy, work-worn boots and is set to clear a course through a treacherous marshland. The Becoming contextually responsive: taking hold of a shared vision for our profession, 15 May 2021 person’s legs are wading, calf-deep through mud, straining against the viscosity of the sludge, pelting rain and fierce wind. The legs’ endurance-trained muscles strain and twitch with effort, preventing the person from sinking, but achieving slow progress across the seemingly endless swamp. Dark clouds swirl and promise more bad weather but these legs are resolute in out-muscling the mud. The weight of our profession’s practice reality is borne by our legs - our clinicians. Now shift your gaze upwards, from this person’s boots to their head: the person’s torso is long – propelling their head high above the clouds. The sun is shining here, radiating hope for the mission. From this view, the threatening hazards of the terrain are met with promising possibilities. One possibility is to replace the mission of clearing a course through the swamp with a vision of restoring the wetland ecosystem to protect local human and animal life from frequent flooding in the area. The opportunity to reintroduce rare fish species that will support the economic activities of nearby villagers holds promise2. This lofty perspective proliferates possibility. Unencumbered by sticky reality, the head, our scholars, have freedom to cast a vision and formulate a mission for the body. This analogy, though admittedly limiting in many ways, conveys the challenge of navigating a shared journey as practitioners and scholars when our lived experience of the profession may be very different. The jarring encounter between these two realities was aptly dubbed by Australian colleagues as “utopian visions/dystopian realities”(12). It is easy to see how instructions from the ‘head‘ to the ‘feet’ could be received with incredulity, and how feedback from the feet could be met with disdain. Is it possible to flourish as a profession with our ‘head in the clouds’ and ‘feet on the ground’ when it’s sometimes difficult to feel like we are part of the same body? We propose that is possible by offering some “doable” directions for action. Recommendations and Conclusion: Becoming a contextually responsive academy Numerous priority actions have been identified that are essential to the transformation of the South African occupational therapy academy. Diversifying the academy is critical(13) and university curricula need to facilitate this and be shaped by diversity. Pursuing epistemic freedom by humbly interrogating the ways that we ‘think, speak and do’, and collectively 2 National Geographic Education Resource Library Encyclopedic Entry: Swamp. [Online] https://www.nationalgeographic.org/encyclopedia/swamp/. Accessed 11 May 2021. Becoming contextually responsive: taking hold of a shared vision for our profession, 15 May 2021 imagining new narratives, is vital to this(14). Collective pursuit of the newly articulated Occupational Therapy research priorities for South Africa is another critical action. These priorities, and means to pursuing them, warrant robust discussion beyond the scope of this contribution. Here we would like to highlight just four recommendations that speak specifically to how we, as scholars and clinicians, can navigate the journey of becoming contextually responsive together. Context lenses: developing our ability to intervene at an environmental level Echoing Mary Law’s perennial recommendation, we need to focus on the environment(10). Theory has equipped us to look at the environment, but we struggle to see the tectonic environmental influences that shape occupation and perpetuate occupational injustice. Our profession’s scales have long tipped in favour of intervention that targets the person. Intentionally equipping ourselves for environmental intervention is not proposed as an alternative to this, but rather a means to bringing balance and increasing our impact(10). Our students should be taught how to analyse clients’ occupational participation (individual and collective) using frameworks that create sharp lenses for identifying the transaction between human occupation and the environment. Our undergraduate research students could generate valuable knowledge around the occupations of South African populations by analysing this participation using a framework of the social determinants of health. Additionally, undertaking such analysis in collaboration with clients or research participants will support the development of participatory behaviours and approaches. Continuous professional development opportunities can facilitate similar activities for practicing clinicians where contemporary occupation-focused conceptual frameworks are used as tools to evaluate practice and collaboratively generate visions for wider impact. We need to find ways of funding posts that target environmental change and proliferate the evidence for the invaluable role of occupational therapy across sectors for achieving national development goals. Communities of Praxis Communities of practice (CoP) have become useful vehicles for growth and development through regular engagement with others. Regular constructive engagement between our professions ‘head’ and ‘feet’ is essential if we are to build trusting partnerships that can weather the transformation journey that is inevitably both uncomfortable and exciting. Communities of practice, or communities of praxis, are proposed as a vehicle through which a group of about twelve clinicians and scholars meet on a monthly basis to collaboratively reflect on their practice, engage with Becoming contextually responsive: taking hold of a shared vision for our profession, 15 May 2021 contemporary theory and pilot actions that are responsive to both. This cycle of theory, action and reflection holds promise for developing critical reflexivity. Through facilitation, potential exists within such groups to develop a participatory posture or where clients are partners in identifying intervention priorities and actions. Some evidence exists to suggest that communities of practice with an occupational justice and human rights focus can increase therapist’s awareness of human and occupational rights and equip them for action(12). This vehicle could also be used to engage with emerging practice areas and include clients and stakeholders from diverse sectors. The imminent implementation of revised CPD guidelines with a focus on demonstrating learning invites us to explore new mechanisms for our profession’s growth and transformation. Accrediting learning through a CoP also incentivises participation. Rising to a ‘just-right’ challenge: building up the body Uniting in pursuit of contextual responsiveness will synergise our impact and challenging one another will sharpen our individual contributions to the whole. But as we engage one another, we propose that we need to be cognisant of facilitating a “just-right” challenge that calls for both action and caution by our ‘head’ and ‘feet’. An environmental challenge or press that is overwhelming will lead one to surviving the growth opportunity, rather than experiencing it (10). Excessive force, inappropriate methods, apathy or indifference will stunt the transformation process. We need to challenge one another with the view to strengthening the whole. This will require that we: ? Assume a critical posture and humble disposition: to be contextually responsive means to be critical – critical of dominant discourses or socially prevalent ideas; critical of taken-for-granted norms and assumptions. For the profession to benefit optimally from this individual and collective posture of inquiry, we will need to confront each other regardfully. While not entertaining apathy or the perpetuation of injustice, acting in the power of humility and respect is essential as we confront each other’s assumptions and beliefs. We should assume that change is possible for the individual and collective, and give each other opportunity and help to change. We should engage with one another on the basis of our shared humanity and intrinsic dignity with an openness to learn and be challenged. ? Seek to understand each other’s lived experience: It is easy to judge a pair of boots that you have never walked in. Living in each other’s reality enables us to feel the fatigue of walking through resistant mud or experiencing freedom from muddy constraints that allows for renewed perspective and possibility. CPD Becoming contextually responsive: taking hold of a shared vision for our profession, 15 May 2021 accredited therapist exchange programmes may offer a simple way of facilitating learning and conceptualising practice beyond our own comfort zone (eg. emerging practice settings, rural community-based rehabilitation, community service placements). Experiencing each others practice while engaging reflectively with theory will not only facilitate personal growth but will build the trust and non-judgementalism that is required to enable collective growth. ? Pursue epistemic freedom by recognising everyone as a legitimate carrier of knowledge: Our knowledge creation should be accessible to all and we should avoid alienating parts of our professional body with inaccessible terminology or unexplained concepts. All contributions should be authentically acknowledged. We should interrogate our local ideological divides and guard against intellectual superiority. ? Befriend discomfort: transformation is a disruptive process and we should be prepared for the discomfort it will bring. This will require us to open ourselves to desensitization and lower our defences that make it difficult to see things from a different angle. We should acknowledge that transformation is a process, which we will not always have the answers, that there will be periods of ‘getting stuck’. ? Be careful of serving efficiency over justice: Buttressed by neoliberalism’s hypernorm of subsuming economic market values (i.e. valuing that which can be counted and gained for person benefit) into all spheres of life(15), our working environments typically reward, or fiercely demand, productivity. We thus have to mindful of creating time and space for critical reflection in our practice. Instead of doing more, we should attend to what really matters and will position our labour for addressing injustice or responding to professional priorities strategically rather then feverishly. Conclusion Is contextual responsiveness a process, a product, a posture, or a description of transformation? We would propose that it is all of these. If these reflections have left you with more questions than answers, we ask that you keep asking them with us as we interrogate what this means for our practice, policy, education and life-long learning, and our research. Contextual responsiveness is an imperative pursuit – a journey that we must take – a journey we must take together. What is there to be gained, you may ask? Impact. Justice. Change. Being part of the living, breathing and beating heart of a profession. Becoming contextually responsive: taking hold of a shared vision for our profession, 15 May 2021 References 1. Iwama MK, Thomson NA, MacDonald RM. The Kawa model: The power of culturally responsive occupational therapy. Disability and Rehabilitation. [Online] 2009;31(14): 1125–1135. Available from: doi:10.1080/09638280902773711 2. Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts L. The person- environment-occupation model: a transactive approach to occupational performance. Canadian Journal of Occupational Therapy. 1996;63: 9–23. 3. Dunn W, Brown C, McGuigan A. The ecology of human performance: a framework for considering the effect of context. 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