Narrative Theater to Examine and Mitigate Anti-Black Racism Within Occupational Therapy

Abstract

Theater has long-standing roots in social justice and holds promise for reducing racist attitudes and behaviors. Objectives of this study were to (a) collect and theatrically portray narratives from Black occupational therapy students and practitioners to a national audience and (b) examine the impact of the theatrical performance on anti-Black racism among attendees. The Identity Development Evolution and Sharing (IDEAS) model guided translation of narratives into a filmed performance. Paired t-test of pre/post administration of the Acceptance and Action Questionnaire–Stigma (AAQ-S) measured changes in stigma beliefs. Qualitative thematic analysis of an open-ended post-survey question elucidated experiences of the performance. The performance engendered significant decreases in stigma; qualitative data elucidated potential mechanisms of change. This study provides insight into experiences of anti-Black racism within occupational therapy and offers a promising means for occupational therapists to engage in anti-Black racism.

Introduction

The profession of occupational therapy is committed to supporting occupational justice, defined as “the right of every individual to be able to meet basic needs and to have equal opportunities and life chances to reach toward their potential but specific to the individual’s engagement in diverse and meaningful occupation” (Wilcock & Townsend, 2009, p. 193). Racism impedes occupational justice for Black Americans. Black people report daily microaggressions while engaging in everyday occupations such as work, education, shopping, and in receiving health care services (Wasmuth et al., 2020). Institutions and systems that “reinforce, justify, and perpetuate racial hierarchy” (Williams et al., 2019, p. 106), such as the stop and frisk legal policies that condoned racial profiling, have produced massively unjust incarcerations of Black people, harming Black families, communities, and individuals. Health care inequities have produced alarming statistics, such as that of Black women dying at a rate 2 to 3 times higher than White women during childbirth (Antender, 2020).

While the field of occupational therapy espouses its dedication to occupational justice, the profession both historically and currently has consisted primarily of White women. Growing recognition of the narrow lens through which theory and practice have been constructed has recently given rise to dedicated efforts to increase diversity and inclusion within occupational therapy governance and to provide resources for practitioners to enhance equitable service delivery (American Occupational Therapy Association [AOTA], 2020). However, the profession’s limited ability to effectively represent and advocate for a diverse population of Black, Indigenous, and other people of color (BIPOC) has been detrimental within and outside the profession (AOTA, 2021). While anti-Black racism exists within the field of occupational therapy, literature such as Ramugondo’s (2015) work on “occupational consciousness” suggests examining how hegemony and dominant practices can show up as harmful power relations. In other words, racism in the field can be addressed through a collective willingness to interrogate how occupation functions as a site and perpetuator of racism. An examination of the inherent role of anti-Black racism in our health and social systems, including the rhetorical investment in diversity, equity, and inclusion by professional associations, is critical (Johnson et al., 2021; Johnson & Lavalley, 2020; Lavalley & Johnson, 2020).

Purpose

Toward the larger goal of examining and mitigating anti-Black racism within occupational therapy, this project addressed two objectives: (a) to collect and theatrically portray narratives from Black occupational therapy students and practitioners to a national audience; and (b) to analyze the impact of the theatrical performance on attendees. These objectives were addressed using a previously piloted translational science theater-based protocol referred to as Identity Development Evolution and Sharing (IDEAS; Wasmuth et al., 2021). Using the IDEAS protocol, a Black occupational therapy doctoral student conducted narrative interviews with Black occupational therapy students and practitioners. A Black playwright translated these narratives into a theatrical script which was then cast and read by professional Black actors during a nationally advertised, live webinar play reading. A moderated discussion followed the play reading and centered on racism within the field and action-oriented responses for practitioners, institutions, and organizations to consider. The moderator spoke directly with interviewees, theater personnel such as the playwright and director, and experts in the field. The audience also engaged via the chat function throughout the entire event. As described below, quantitative and qualitative data were collected to examine the impact of the event on psychological flexibility related to stigma beliefs and perceived response to the performance.

Rationale

An IDEAS performance is an opportunity to attune to/witness others’ stories, which provides viewers the opportunity to privately witness and confront their own implicit biases (Wasmuth et al., 2020, 2021). By becoming aware of and grappling with one’s own biases, viewers gain flexibility regarding their responses to those biases in-the-moment with clients, coworkers, and people in general; by contrast, being unaware of one’s own biases can result in problematic interpersonal interactions such as committing microaggressions, embodying a stigmatizing or alienating demeanor, and/or making inequitable, harmful decisions regarding client care (Levin et al., 2014). There is a long-standing tradition of using theater to promote social change. Augusto Boal’s “Theatre of the Oppressed” was foundational in establishing the theatrical stage as a platform for audiences to actively engage with and discuss social justice issues. Similar theater approaches have been used to reduce stigma for other populations such as Indigenous communities (Baldwin, 2009) and people with HIV (Moyo & Sibanda, 2019). Solomon (2019) suggested that the use of “entertainment” could “inspire audiences to re-think their own prejudices, biases, and preconceived notions about groups they may consider ‘other’” (p. 178) in ways that less entertaining media could not. Wasmuth et al. (2020) have used theater to illuminate Black women’s experiences of anti-Black racism, with quantitative audience survey scores indicating increased conceptual understanding of the impacts of anti-Black racism on equity within their communities and increased intention to implement personal changes.

As a profession committed to occupational justice (AOTA, 2020), a deepening awareness of the impacts of anti-Black racism in the United States on Black occupational therapy students and practitioners is imperative. The overarching aim of this study was to shed light on anti-Black racism experienced within occupational therapy to engender positive change.

Method

This translational research presented qualitative data collected through interviews with Black occupational therapy students and practitioners via a theatrical performance and used concurrent explanatory mixed-methods (Creswell & Zhang, 2009) to examine the performance’s impact on stigma beliefs of audience members. All procedures were approved by the institutional review boards of the two participating institutions conducting research. All interviewees and survey respondents (audience members) provided informed consent to participate.

Participants

This study included two participant groups: (a) Black occupational therapy students and practitioners who shared their stories via narrative interviews and (b) adults who viewed the “Black Voices in Occupational Therapy” performance and completed the consent statement and pre/post-tests. Interviewees for participant group 1 were recruited using convenience and chain sampling via social media posts, personal contacts, and participant referrals. Attendees for participant group 2 were recruited by advertising the performance on social media and within several occupational therapy departments in the United States and Canada.

Data Collection

The co-PI and second author, a Black, ability-typical, cis-gender, heterosexual woman, and occupational therapy doctoral student, conducted semi-structured interviews with Black occupational therapy students and practitioners. The interview was constructed by the co-PI based on knowledge gained from a review of the literature and prior works (e.g., Wasmuth et al., 2020). The co-PI’s experiences as a Black occupational therapy student also informed interview guide development. Interview questions are listed in Supplemental Table 1. The second author conducted interviews via Zoom and provided a $50 gift card honorarium to each participant. Researchers at an additional institution who were conducting a study on the experiences of Black occupational therapy practitioners contributed to this data set by sharing six of their de-identified transcripts. Their research question(s) and interview guide are detailed in Supplemental Table 2.

A second data set was collected from people who attended the online “Black Voices in Occupational Therapy” performance. The registration information for the event contained a link to an anonymous pre-survey, consisting of all questions from the Acceptance and Action Questionnaire–Stigma (AAQ-S; Levin et al., 2014) as well as demographic questions and an informed consent statement and check box allowing participants to decline or acknowledge their willingness of research participation. AAQ-S questions are available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255270/table/T1/. Following the performance, an anonymous online survey link was distributed in the chat and emailed to registered participants. It contained AAQ-S questions for comparison with pre-test responses, and the following open-ended question: “Please describe your experience of watching this performance; what moments stood out to you most, and why?” An anonymous code linked participant pre- and post-surveys to facilitate paired samples t-tests of pre/post responses. Qualitative responses to the open-ended question were thematically analyzed to enhance quantitative findings.

Program Overview

The first and last two authors reviewed interview transcripts, highlighting overlapping thematic content and writing memos to illuminate occupational participation and injustices within stories. The last author, a Black, cis-gender, heterosexual, ability-typical woman, was the playwright. She maintained the interviewee’s words from the transcripts aside from occasional changes for clarity and theatrical flow. As described in Wasmuth et al. (2021), in these projects

the playwright’s role was not to write the story of the play, but rather, to use her professional theatre training to organize the content in a way that created theatre that captivated and drew audience members into (rather than alienating them from) the inherent tension and conflict of the stories. (p. 5)

The final characters portrayed several stories, including that of a practitioner who had been repeatedly denied management positions; a student’s experiences of microaggressions and lack of representation in the classroom; experiences of abuse, neglect, and racism during fieldwork; and an overarching conversation of where and how to find support.

More than 200 occupational therapists and others from across the United States (as well as from Canada and the United Kingdom) gathered virtually for the online play reading in the midst of the COVID-19 pandemic. The platform was BeLIVE—an online program touted by theater professionals as superior to Zoom for qualities such as the ability for multiple speakers’ words to overlap—a feature important for a theatrical production. The PIs alternated welcoming people as they joined the platform. The chat function was enabled on the online platform and was lively with excited anticipations and greetings between fellow occupational therapy practitioners, students, and academic colleagues. When it was time for the performance to begin, the PIs explained that the play-reading was the product of narrative interviews collected from Black occupational therapy students and practitioners over the past 6 months that had been transcribed and arranged by a playwright into a script for a staged reading. The PIs provided a trigger warning to alert audience members that the performance contained descriptions of microaggressions and anti-Black racism within the field that could be distressing, especially for Black occupational therapists who may resonate with the experiences being described.

The performance began with three actors individually appearing on the screen. Two actors portrayed Black occupational therapy practitioners and one portrayed an occupational therapy student. The play was set on Zoom in the format of an informal support session among friends, meeting up to unwind through sharing struggles regarding anti-Black racism and microaggressions at work and in school and to support one another through humor and comradery. When the performance ended, a moderator led a panel discussion with an expert in the field on occupational science, justice, and anti-Black racism within occupational therapy (fourth author), two of the occupational therapists who were interviewed to create the performance, the playwright, the director, and the occupational therapist who conducted interviews (second author). The performance was livestreamed on March 25, 2021, and has since been seen by 1,374 viewers as of September 2021. The performance is available here: https://www.youtube.com/watch?v=OeTAUYhJXzc

Data Analyses

Descriptive analyses (N, %) were conducted to assess the age, ethnicity, and education of the final overall cohort of survey respondents who watched the performance. A paired samples t-test was conducted to assess the change in mean AAQ-S scores following interventions. Normality of overall pre-test (p = .10) and post-test (p > .15) AAQ-S scores was validated with Kolmogorov–Smirnov goodness-of-fit test. To adjust for the possibility of confounding due to racial differences, we stratified our overall AAQ-S analyses by race. For those who identified as Asian, Black, LatinX, Pacific Islander, other, or White, normality of pre-test (p > .15) and post-test (p > .09) AAQ-S scores was individually validated for each race with Kolmogorov–Smirnov goodness-of-fit test. Due to the small number of participants who identified as LatinX, Pacific Islander, and/or other, these were combined into a single category (N = 3) to assess normality of data. Data were analyzed using SAS statistical software version 9.4.

The first two authors conducted inductive thematic analysis (Clarke & Braun, 2014) of the open-ended post-test survey question. They read all participants’ responses to the open-ended item to familiarize themselves with the data. Several significant themes were readily apparent. The authors re-read the first two (of seven) pages of single-spaced data transcripts, outlining initial themes and coding data with these themes while remaining open new theme emergence. Upon reaching page 4, existing themes were comprehensive for coding the remaining data. A final review of coded data illuminated how data from White occupational therapy students and practitioners differed from that of Black counterparts, and how both differed from data from participants who identified as Indigenous, Hispanic, LatinX, Asian, and/or Pacific Islander. Salient themes with exemplar quotations and data highlighting outliers are described below.

Results

Participant group 1 consisted of 19 participants from eight U.S. states; seven were occupational therapy students, and 12 were occupational therapy practitioners. These interviews were transcribed and informed the development of the theatrical performance as described above.

Quantitative Findings

A total of 261 survey respondents/attendees of the performance were assessed for eligibility for participant group 2, and 60 were included in the final analysis. Reasons for exclusion from participant group 2 are detailed in Figure 1 and include not checking the informed consent box, only completing a pre-survey, and missing data. Table 1 shows sociodemographic characteristics and mean AAQ-S scores for all participants. No significant between group differences were found at baseline. Regarding impact of the performance on our primary outcome measure for the overall cohort, mean baseline AAQ-S (M = 78.72, SD = 10.14, interquartile range [IQR] = 13.00) was higher than mean follow-up AAQ-S (M = 64.47, SD = 12.07, IQR = 17.50). We found a statistically significant decrease (t = 11.76, df = 59, M = 14.25, 95% Confidence Limit: [11.83, 16.68], p < .0001) in average AAQ-S after intervention indicating decreased stigma beliefs and/or increased psychological flexibility with regard to stigma beliefs.

Figure 1.

Cohort flow diagram for overall participants.

Note. Two follow-up participants were excluded from analysis due to impossible AAQ-S scores. AAQ-S = Acceptance and Action Questionnaire–Stigma.

Table 1.

Cohort Characteristics and Pre/Post Scores: Overall and Stratified by Race.

Other demographics and outcome measure scores	Race
	Asian (N = 6)	Black (N = 16)	Other (N = 3)	White (N = 35)	Total (N = 60)	P value
Age
18–24	00 (000.00%)	01 (006.25%)	00 (000.00%)	03 (008.57%)	04 (06.67%)	.61
25–34	04 (066.67%)	05 (031.25%)	01 (033.33%)	07 (020.00%)	17 (28.33%)
35–44	02 (033.33%)	04 (025.00%)	00 (000.00%)	06 (017.14%)	12 (20.00%)
45–54	00 (000.00%)	01 (006.25%)	01 (033.33%)	10 (028.57%)	12 (20.00%)
55–64	00 (000.00%)	03 (018.75%)	00 (000.00%)	04 (011.43%)	07 (11.67%)
65–74	00 (000.00%)	02 (012.50%)	01 (033.33%)	03 (008.57%)	06 (10.00%)
75–84	00 (000.00%)	00 (000.00%)	00 (000.00%)	02 (005.71%)	02 (03.33%)
Hispanic
Hispanic	00 (000.00%)	00 (000.00%)	01 (033.33%)	01 (002.86%)	02 (03.33%)	.16
Not Hispanic	06 (100.00%)	16 (100.00%)	02 (066.67%)	34 (097.14%)	58 (96.67%)
Highest level of education
Associate’s degree	00 (000.00%)	01 (006.25%)	00 (000.00%)	00 (000.00%)	01 (01.67%)	.77
Bachelor’s degree	04 (066.67%)	04 (025.00%)	01 (033.33%)	10 (028.57%)	19 (31.67%)
Doctorate degree	01 (016.67%)	05 (031.25%)	01 (033.33%)	13 (037.14%)	20 (33.33%)
High School or GED	00 (000.00%)	00 (000.00%)	00 (000.00%)	01 (002.86%)	01 (01.67%)
Master’s degree	01 (016.67%)	06 (037.50%)	01 (033.33%)	11 (031.43%)	19 (31.67%)
AAQ-S Baseline Score
M (SD)	81.83 (4.26)	80.69 (9.89)	83.67 (13.80)	76.86 (10.58)	78.72 (10.14)	.39
AAQ-S Follow-up Score
M (SD)	65.17 (8.01)	63.63 (14.21)	67.67 (20.65)	64.46 (11.30)	64.47 (12.07)	.96

Note. Fisher’s Exact test performed when number of cells with expected frequency is <5. Otherwise, categorical data was analyzed using chi-square. GED = general education department; AAQ-S = Acceptance and Action Questionnaire–Stigma; SD = standard deviation.

P values for continuous variables were computed using ANOVA.

Our stratified analysis controlled for differences in race that may have been an important source of confounding. The stratified analysis included full data for 60 participants, but AAQ-S scores were analyzed using subgroups for those who identified as Asian, Black, Other, and White. These participants had similar sociodemographic factors and AAQ-S scores at baseline regardless of which race they identified with (Table 1). Among those identifying as Asian, we found a statistically significant decrease (t = 7.14.76, df = 5, M = 16.67, 95% Confidence Limit: [10.67, 22.66], p = .0008) in average AAQ-S after intervention. Among those identifying as Black, we found a statistically significant decrease (t = 5.29, df = 15, M = 17.06, 95% Confidence Limit: [10.18, 23.94], p < .0001) in average AAQ-S after intervention. Among those identifying as other, we found average AAQ-S scores after intervention approached a statistically significant decrease (t = 4.00, df = 2, M = 16.00, 95% Confidence Limit: [−1.21, 33.21], p = .06) in average AAQ-S after intervention. Among those identifying as White, we found a statistically significant decrease (t = 9.22, df = 34, M = 12.40, 95% Confidence Limit: [9.67, 15.13], p < .0001) in average AAQ-S after intervention.

Qualitative Findings

Inductive thematic analysis of the single-item open-ended question resulted in the following salient themes: Identifying; valuing (sub-themes: discovering, self-examining, utilizing, gaining insight); challenging; and enjoying.

Identifying

Black occupational therapists spoke to the universality of the experiences in the play: Everything I wish I could say out loud to non-black clinicians . . . it’s almost as if we all live the same microaggressions. This sentiment was repeatedly expressed by Black survey respondents. By contrast, White respondents identified with the play by recognizing past, unintentional microaggressions similar to those depicted in the performance. They also identified with White people alluded to in the play who did not speak out against inequity in problematic scenarios. One participant noted, Lots of examples resonated and/or caused me to think or question my own behavior and how I helped or did not help in previous situations.

Valuing

Many expressed that they valued the opportunity to attend the performance. Three sub-themes distinguish the ways in which this value was expressed by White participants: self-examining, utilizing, and gaining insight. “Self-examining” was used when participants described rethinking personal attitudes and actions. For example,

I’m sure I’ve said things that were harmful to others. Of course, what hurts the most now is to realize how unaware I have been in the wake of damage I was responsible for.

Another expressed,

One of the things that stood out to me was the extent to which I could easily imagine the scenarios actually happening. As a White woman, to me that represents something complex in how my awareness of racism has been operating for a long time “under the surface” but the fact that I could be active in generating a useful response has not. I really appreciated the emphasis on actions, both small and large, as I too am tiring of just talking about this.

“Utilizing” was employed when participants described changes they planned to undertake after viewing the performance, and “gaining insight” was used when participants described learning something new. Some comments reflected more than one subtheme. For example, this statement reflects the subthemes of gaining insight and utilizing:

As a faculty member where we often have one or two Black students in the class, I appreciated hearing about how things feel from a student perspective. The feeling of being alone, not understood, held to a different standard, questioning yourself, all sound like things my students have probably felt. I think I can do more to reach out to my Black students and be there for them, support them, advocate to admit more Black students, figure out how to get AOTA to help build the pipeline of Black applicants so we can admit more students.

Black respondents valued the performance as a launching point for making microaggressions and anti-Black racism more visible within the profession. They spoke about the performance as a call to further action and valued the experience of feeling seen and heard. In one participant’s words,

Even though current students and practitioners continue to have the same experiences as did those of us who entered the profession in the early 70s, I am encouraged by Black Voices and this presentation. Continue to bring voice to your lived experiences as you demand change and hold the profession accountable. I am ever so proud of you all for the work that you are doing. The struggle continues! As our great ancestor Frederick Douglas said when asked “how does one bring about change?”—“Agitate! Agitate! Agitate!”

Challenging

Data from White participants illustrated how the performance challenged their thoughts, beliefs, and past actions, noting the difficulty in attending to uncomfortable or emotionally charged circumstances that Black people experience that they, as a White person, may have contributed to or failed to mitigate. The performance rendered a broader awareness of the difference between singular experiences White people may occasionally have of feeling alienated versus the continual experiences of microaggressions and stigma that Black people have had to face:

I felt like my heart stopped for a moment when they were able to find humor in a story about a White girl crying while thinking that all White people were regarded as racist—because I felt like I could connect to the girl in the story’s experience. I was also able to quickly recognize that many Black people are frequently assumed to be negative things based only on the color of their skin . . . and I understood that Black people listening to this retelling in their private space did not have any responsibility to hold space for this person’s singular experience which they have encountered countless times.

By contrast, some of the challenges that Black participants described were in response the frightening scenarios the play revealed, illustrating the ways in which anti-Black racism within occupational therapy has produced neglect, physical harm, and unsafe circumstances:

The fact that one of the practitioners sustained bodily injury because of the neglect and aggression of her clinical instructor during fieldwork is the moment that stood out most to me. It causes me anxiety for my future fieldwork experiences, and it disturbed me that a situation like that could even be a possibility.

Enjoying

Several participants expressed positive remarks related to enjoying several aspects of the performance, particularly its authenticity: “As a White person, at times I felt like I was hearing conversations that weren’t for my ears, but I felt grateful for the authenticity.” Another appreciated the communal experience that the performance offered:

This was groundbreaking in so many ways. Such a great use of theatre as a way to make emotional experiences of Black occupational therapists accessible and informative on a human level and in a persuasive way. I felt closer and closer to the actors and their stories as the performance continued. I also loved the panels and the electronic shout-outs [in the chat]! Above all, I felt energized to see so many Black occupational therapists and students in one place talking about things that I know must be happening and that require all of us together to change.

Finally, another echoed appreciation of the authenticity, stating:

The uncensored real talk, passion, pain, humor, and release was SO needed—I hope leaders in our field were watching and able to witness raw experiences/perspectives without tone policing. We can NOT let this offering go to waste! We need to step up as a profession to radically shift the demographics of our profession to reflect our communities. Thank you to everyone involved in this phenomenal project! (original emphases)

BIPOC reflections

Data from those who identified as Indigenous, Hispanic, LatinX, Asian, and/or Pacific Islander are limited, but reflect a sense of commitment to be an ally against anti-Black racism, and reflection on experiences of being from “a visible minority group”—as described by the following participant:

I am not Black but I am a member of a visible minority group in Canada. I experienced instances of racism as an occupational therapist while practicing, and this play identified other experiences I had too, not knowing I had experienced racism at the time. Thank you for the experience. It has reaffirmed my intention to be a better ally and in my current position, where I can make a difference in increasing diversity in our profession.

Similarly, the following quote also underscores the play’s impact on re-emphasizing the importance of allyship:

The scene where the Black student talked about her fellow peers not standing up for her in the moment, when her professor said something offensive, stood out to me. As an Asian-American, I need to stand up for my Black peers, colleagues, and friends.

Concurrent Explanatory Mixed-Methods

A concurrent explanatory mixed-methods design involves concurrent collection of quantitative and qualitative data, and use of qualitative data to help explain quantitative findings (Creswell & Zhang, 2009). Among the two largest participant groups, Black and White survey respondents, AAQ-S change scores were highest among White participants (t = 9.22), compared to Black participants (t = 5.29). The representation of themes among different race groups illuminates how the impact of the performance differed for each group. Data from White people commonly reflected new awareness of the frequency and severity of anti-Black racism, and new realizations about their own complicity, possibly explaining their higher change scores. By contrast, prevalent themes among Black participant data centered on identification with shared experiences, and appreciation for the communal experience and call to action.

Discussion

In February 2020, the American Occupational Therapy Association launched a Diversity, Equity, and Inclusion task force to advance initiatives for mitigating discrimination and stigma impacts within the United States. They also hosted a series of listening sessions and released the AOTA Guide: Acknowledging the Impact of Discrimination, Stigma, and Implicit Bias on Provision of Services, which offers resources for practitioners to address issues of discrimination and to “enhance care, improve treatment outcomes, and advocate for equity in service provision” (AOTA, 2020, para. 7). Furthermore, the AOTA Governance Enhancement Task Force (AOTA, 2021) formed to address the lack of diversity and inclusion in the profession, examining, among other questions, whether “the structure and processes support inclusive engagement” (p. 2).

This study supports inclusive engagement within occupational therapy by addressing priorities outlined in the 2020 AOTA Guide. Specifically, this project provided a practical means for “acknowledging and addressing personal, implicit biases” (AOTA, 2020, p. 2). Quantitative findings, expanded by qualitative results in this study, illustrate how this performance contributed to the goal of attending to others’ experiences to mitigate harms stemming from implicit biases. Significant reductions in stigma, increased psychological flexibility regarding stigma, and the concrete action steps identified within the performance and survey response data suggest promise for this approach. This study suggests the performance supported the larger goal within AOTA of making positive changes toward diversity, equity, inclusion, justice, and creating an overarching sense of belonging within the field of occupational therapy.

As mentioned earlier, employing theater for social change is not new. For example, Douxami (2019) describes Teatro Experimental do Negro (Black Experimental Theater), a Black political movement against racism that arose as early as 1944 and viewed theater as a means for transforming Brazilian society. However, scientific measurement of the impacts of theater on racism and bias is limited in literature—a gap this study addresses through use of the AAQ-S.

Significant changes in AAQ-S scores seen in this study expand on findings from a prior study of IDEAS that used a single post-test design (Wasmuth et al., 2020). Both studies suggest new insights and positive reflections among audience members following the performance. However, the addition of the pre/post AAQ-S adds merit to the claim that change occurred in audience members and that the change(s) resulted from IDEAS.

How Does IDEAS Compare to Other Methods of Stigma Reduction?

According to a recent scoping review by Brottman and colleagues (2020), numerous educational methods targeting health care provider cultural competence have been employed to address implicit biases and anti-Black racism. However, fewer than half had favorable outcomes, and those that did relied on provider self-report. This study’s use of the AAQ-S exceeds self-report measures by utilizing the AAQ-S. Literature also suggests the IDEAS model may be more beneficial than existing cultural competence and humility trainings because (a) it relies on the skills of theater professionals to create a compelling performance that engages its viewers and (b) it involves a panel discussion that allows viewers to engage in conversations and critical reflection, reinforcing the impacts of viewing the performance. These elements have been shown to increase the effects of narrative theater on audiences (Meineck, 2017; Solomon, 2019).

Implications

The Black Voices in OT performance offers a program for addressing implicit biases and anti-Black racism. Practitioners can use the filmed performance to engender critical conversations about race within occupational therapy and to enact positive changes by shining a light on existing racism within the field. With a growing body of evidence supporting its effectiveness, IDEAS offers a promising occupational justice-centered method for occupational therapists to adopt.

Limitations

External validity is limited because data were collected from a relatively small sample of Black occupational therapy students and practitioners in only eight U.S. states. While data revealed the salience of overarching themes—themes were readily apparent and vastly present across interviews—it will be important for future work to be based on a larger, more representative sample of Black people within the field. Another limitation in this study was the effect of technological imperfections on the quality of parts of the performance—actors at times appeared blurry or sound quality was compromised. Ideally, future work would entail funding to support a longer rehearsal process, better technology, and/or the capacity to present live performances across multiple U.S. sites and/or at national conferences.

Future Research

Future studies should incorporate a later follow-up to examine whether changes in AAQ-S scores were maintained over time. Exploratory work on what factors may contribute to or be needed for sustained change could provide useful information on whether/how to supplement this work. Some have suggested that a single experience of a theatrical performance, because of the nature of the medium, can have a strong and lasting impact on a person’s psyche and subsequent actions (Meineck, 2017). However, future research is needed to determine the lasting effects or lack thereof following an IDEAS performance.

The interviewees whose stories contributed to this project offered several suggestions for mitigating anti-Black racism and for creating a sense of belonging within occupational therapy for Black students and practitioners. Inductive thematic analyses of these interviews are underway and will be presented in a future manuscript. In addition, the occupational therapy department within the first and second authors’ academic institution is conducting a study to explore facilitators and barriers to implementing suggested changes that emerged from this study as well as other changes proposed by AOTA recent guidelines, tools, and resources. The results of this implementation study will also be presented in a future manuscript.

Conclusion

In narrative interviews, Black occupational therapy students and practitioners repeatedly described how they experienced occupational marginalization and/or alienation (Stadnyk et al., 2010), particularly when engaging in the occupations core to the profession itself, such as education and work. Translation of these interviews into a theatrical performance significantly affected audience members’ stigma beliefs, as AAQ-S results indicated greater psychological flexibility regarding stigma beliefs after participating in the Black Voices in Occupational Therapy online event. Qualitative survey responses post performance indicated important impacts including White participants gaining insight into the everyday microaggressions Black occupational therapists face and information supporting changed future actions. White attendees expressed gaining awareness of self-contribution to anti-Black racism within occupational therapy, and along with White attendees, other people of color expressed new or renewed dedication to allyship with Black people within the profession and beyond, acknowledging harms specific to anti-Black racism. Black attendees felt seen, heard, and affirmed by the performance. While some content elicited feelings of sadness and/or fear, Black attendees’ responses were overwhelmingly positive in the collected qualitative data. This study contributes to the evidence base for translational methods that affect changed beliefs, attitudes and actions toward the goal of diversity, equity, justice, and inclusion within occupational therapy.