Article Canadian Journal of Occupational Therapy

2020, Vol. 87(5) 400-411

DOI: 10.1177/0008417420965741

Making Choices from the Choices we ª CAOT 2020

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of Occupational Choice
Faire des choix parmi les choix qui s’offrent à nous :
l’enchâssement contextuel à des choix occupationnels

Karen Whalley Hammell

Key words: Neoliberalism; Occupational therapy; Theory.

Mots clés : Néolibéralisme; Ergothérapie; Théorie.

Abstract
Background. “Choice” is central to occupational therapy’s theoretical tradition, which maintains that individuals can impact
their well-being through wisely choosing their occupations. However, the assumption that opportunities to choose are universally
available is negated by research evidence. Purpose. To review the ideology of “choice” in occupational therapy theory, and to
encourage more critical approaches toward determinants of occupational opportunity and choice. Key Issues. Evidence
indicates that within Canada, and throughout the world, opportunities to make occupational choices are inequitably
distributed among people of different socioeconomic classes, castes, genders, races, abilities, sexualities, citizenship statuses,
and experiences of colonialism. Implications. Because occupation is a determinant of health and well-being, social injustices that
create inequitable occupational choices are unfair violations of occupational rights. The occupational therapy profession’s
espoused aim of enhancing well-being through occupation demands theories that explicitly recognize the socially structured
and inequitable shaping of choice, and consequent impact on people’s occupational rights.

Abrégé
Description. « Le choix » est un aspect central de la tradition théorique en ergothérapie, qui soutient que les individus peuvent
avoir une influence sur leur bien-être en choisissant judicieusement leurs occupations. Toutefois, la supposition selon laquelle les
possibilités de choisir sont universellement accessibles est infirmée par des recherches scientifiques. But. Examiner l’idéologie du
« choix » dans les théories en ergothérapie et encourager le recours à des approches plus critiques pour examiner les
déterminants des possibilités et des choix occupationnels. Questions clés. Des données probantes indiquent qu’au Canada
et à travers le monde, les possibilités de faire des choix occupationnels sont distribuées inégalement entre les personnes selon
différents facteurs, comme le statut socioéconomique, les castes, le genre, la race, les capacités, l’orientation sexuelle, la
citoyenneté ou les effets du colonialisme. Conséquences. Puisque l’occupation est un déterminant de la santé et du bien-
être, les injustices sociales qui engendrent des choix occupationnels inéquitables représentent des violations injustes des droits
occupationnels. L’ergothérapie a pour but d’améliorer le bien-être grâce à l’occupation. Une telle volonté exige de reconnaitre
explicitement que les choix sont façonnés socialement, de manière inéquitable, ce qui entraı̂ne des violations des droits
occupationnels.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Corresponding author: Karen Whalley Hammell, Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British
Columbia, Vancouver, Canada. E-mail: ik.hammell@sasktel.net
Canadian Journal of Occupational Therapy 87(5) 401

Introduction not solely with families, friends, and colleagues, but with yoga
classes, cooking classes, language classes, music groups, and

T
he notion of “choice” is central to occupational ther-
choirs through in-home access to internet platforms; and to
apy’s theoretical tradition. For many decades, Western
enjoy exercise and relaxation in pleasant, safe greenspaces.
theorists have been declaring that individuals choose,
Those in less privileged social circumstances were more likely
shape, and “orchestrate”, or “compose” their everyday occupa-
to live in overcrowded housing; to be vulnerable to losing their
tions (e.g., Clark & Jackson, 1989; Doble & Caron Santha,
jobs or to be compelled to work in service jobs that signifi-
2008; Yerxa, 2000), and have portrayed occupational choice
cantly raised their risks of exposure to, and death from, the
as the product of individual volition and rational deliberation
virus (Hooper et al., 2020; van Dorn et al., 2020; Yancy,
(Kielhofner, 2008). Despite acknowledging the possibility of
2020); to be less likely to have home access to the internet
physical, social, cultural, and institutional influences on occu-
(Hooper, et al., 2020; Yancy, 2020); and to have inequitable
pational participation (Townsend & Polatajko, 2013), occupa-
(diminished) access to pleasant greenspaces in which to walk
tional therapy theorists have asserted that humans participate in
and relax, and in which their children might safely play (Fran-
occupations as autonomous agents (e.g. Stadnyk et al., 2010;
cis et al., 2012).
Townsend, 2012). These claims have been reaffirmed and rein-
Building upon the notions of individual volition and
forced by Wilcock and Hocking (2015), who pronounced that
rational deliberation that are ubiquitous among Western theor-
“through informed and wise choice of occupation, people can
ists embedded in neoliberal ideological environments (see
influence the state of their own and others’ health, reduce ill-
below), occupational scientists have recently delineated the
ness and disability directly or indirectly, and meet biological
concept of “occupational decision making” (Parnell et al.,
needs and potentials across the 24-hour active-rest continuum
2019). Employing research data derived from highly educated,
throughout life” (p. 429).
class-privileged women in a high-resource country who were
Clearly, these influential assertions presume that occu-
exploring and developing their career possibilities after having
pational choices are available to everyone, everywhere, and
children (which included the opportunity to decide not to
that the opportunities to act on these choices are also always
engage in paid employment), Parnell and colleagues character-
available. But these claims are not grounded in empirical
ized occupational decision making as an agentic, individual
evidence. To the contrary, researchers have noted that
process of melding current exigencies with future aspirations,
opportunities are unevenly distributed and that “people do
of “crafting an occupational repertoire and of creating and
not have equal choices to act” (Frohlich & Abel, 2014,
exploring a range of alternative occupational possibilities”
p. 210). Indeed, in an analysis of health justice, Venkata-
(p. 444). Clearly, occupational decision-making is predicated
puram (2011) concluded that “the choices we make depend
on having access to a range of occupational options from which
on the choices we have” (p. 63).
to craft an occupational repertoire, having the power to enact
Long-standing debates among sociologists (e.g. Berger &
occupational preferences, and having the privilege to envision
Luckman, 1966; Jary & Jary, 1991) concerning the relative
a possible occupational future.
importance of agency (the capacity of individuals indepen-
This conceptualization of occupational decision-making is
dently to enact their own choices) or of structure (the societal
inherently problematic for many people. For example, mem-
arrangements dictating the availability of choices and opportu-
bers of working class, and traditional and Indigenous cultures
nities) in determining human actions have rarely been noted by
that are characterized by a present temporal orientation
occupational therapy theorists. Indeed, Gallagher et al. (2015)
(Beagan, 2007; Iwama, 2006; King et al., 2007), may be unac-
contend that despite ubiquitous use of the term, little existent
customed to employing the necessary time perspective required
occupational therapy literature has sought to explore the con-
to formulate decisions about future occupational aspirations. It
cept or nature of occupational choice.
is also profoundly problematic for people who lack access,
While this paper was in preparation, measures taken to
power, and privilege, and whose occupational opportunities
slow the spread of the COVID-19 virus were severely limiting
are constrained by inequities that eclipse visions of expansive
the occupational choices available to the entire global popula-
occupational possibilities (Hammell, 2019). Globally, there
tion. Many people accustomed to the privilege of having pre-
are millions—perhaps billions—of people who do not have
dictable access to a wide array of occupational choices were
access to an expansive range of occupational options, whose
suddenly compelled to endure—albeit temporarily—the sort of
occupations are unplanned and instead responsive to current
deprivation of occupational opportunities habitually experi-
and changing situations, and whose present preoccupation and
enced by many millions of the world’s people—people who
future aspiration is simply to survive.
experience a lifetime of structural barriers that constrain their
Accordingly, this paper focuses, explicitly, on occupa-
opportunities and possible occupational choices (Hammell,
tional choice. It is relevant to the subject-matter of this paper
2020a). Yet even within a pandemic, occupational opportuni-
to declare my own social location as a highly educated, race
ties and the capabilities to enact occupational choices have
and class-privileged, heterosexual, cis-gendered female, with
been inequitably distributed. Many members of privileged
neither physical impairments nor mental health challenges,
social groups could choose to work at home; to enhance their
and who holds dual citizenships. Throughout my life, my occu-
children’s education using online learning resources; to engage
pational choices—and my opportunities to indulge in

Revue canadienne d’ergothérapie

402
“occupational decision-making”—have been limited by few
factors beyond my own inadequacies. I acknowledge that the
perspectives that derive from my privileged position and that
shape my ideas are inevitably blinkered, slanted and
incomplete.
The aim of this paper is to review the idea of occupational
“choice” in occupational therapy theory, highlight its fit with
dominant neoliberal ideology and its lack of fit with existing
research evidence, and thus to inspire occupational therapy
researchers, theorists, educators, and practitioners to embrace
more critical approaches toward those determinants of occupa-
tional opportunity and choice that impact people’s capabilities
to achieve health and well-being through their occupations.
“Choice” in Occupational Therapy Theory
One of the most frequently recited quotes in the occupational
therapy literature is attributed to Reilly (1962), whose gendered
and ableist assertion that “man, through the use of his hands as
energized by mind and will, can influence the state of his own
health” (p. 2) quickly morphed into a foundational belief. Cen-
tral to Reilly’s claim is the idea that all people have both the
ability and the opportunity to influence their health by applying
their mind and will to enact health-enhancing occupations—
that everyone can choose to do this (Hammell, 2009). The
fundamental belief that people can choose their everyday occu-
pations, and that they can change the state of their health and can
reduce their incidence of illness and disability “through informed
and wise choice of occupation” (Wilcock & Hocking, 2015,
p. 429) resonates throughout Western occupational therapy liter-
ature. However, the assumptions underpinning this belief are
challenged by critical epidemiologists and public health research-
ers, whose work on the social determinants of health demonstrates
that health behaviours and actions are not the products of free
choice and autonomous action, but result, instead, from inequi-
table social conditions and social structures that determine peo-
ple’s abilities and opportunities to engage in health-enhancing
behaviours or in “wise” occupational choices (Baum & Fisher,
2014; Frohlich & Abel, 2014; Marmot, 2015; Marmot & Bell,
2011). In line with this work, feminist theorists contend that it is
impossible to be autonomous and to feel able to exercise some
control over one’s life choices in the absence of supportive and
nurturing social circumstances (Nedelsky, 1989); Rudman (2005,
2010, 2015), an occupational therapy theorist, has advanced the
idea of “occupational possibilities” to draw attention to the ways
in which political, cultural, and social factors influence the occu-
pations people envision as ideal, realistic, or possible.
Occupational therapists have acknowledged that occupa-
tional engagement is impacted by multiple dimensions of the
environment (e.g. Townsend & Polatajko, 2013), yet few the-
orists have interrogated the ideological dimensions of the envi-
ronmental context in which occupational therapists are
situated, or have explored how this specific ideological context
shapes our theories and practices (although see Clouston, 2014;
Gerlach et al., 2018; Hammell, 2017, 2019; Kristensen et al.,
Canadian Journal of Occupational Therapy
Hammell
2017). Indeed, the widespread failure even to acknowledge the
existence of an underlying ideology has long been identified as
one of the central problems within the field of rehabilitation
(Oliver, 1996; Stiker, 1999). Perhaps the most pervasive and
pernicious influence on Western occupational therapy’s con-
struct of choice is the ideology of neoliberalism (Hammell,
2019, 2020b).
Neoliberalism, Choice and Occupational
Therapy
Neoliberalism is an economic and political ideology that has
dominated the Global North in the late 20th and early 21st
centuries (Harvey, 2006), and that informs an agenda commit-
ted to cutting taxes, reducing government spending on health
and social services, eliminating regulatory bodies, and foster-
ing a social, legal, and political environment that is favorable to
private business (Esposito & Perez, 2014). A neoliberal ideol-
ogy promotes individualism, independence, and self-reliance;
espouses notions of individual choice and personal responsi-
bility for one’s circumstances; and accordingly blames people
for the social problems, ill health, and economic woes that are
construed as being the products of irresponsibility and poor
choices (Collins & Bilge, 2016). The neoliberal ideology of
individualism shapes the myth of meritocracy, effectively rein-
forcing the belief that one’s group memberships (such as race
and gender) are irrelevant to one’s opportunities and achieve-
ments, thereby providing racist and sexist explanations for
inequalities and injustices (DiAngelo, 2018; McLean, 2018).
Cognisant of the hegemonic nature of neoliberal ideology, and
its axiomatic emphasis on individual “choice,” critical nursing
scholars have astutely observed that “the discourse of choice is
a flag for blaming individuals for their life circumstances”
(Varcoe et al., 2014, p. 275).
Nonetheless, a perception of unfettered choice is central to
neoliberalism. Thus, for example, hegemonic discourses sur-
rounding climate change focus on encouraging individuals to
make wise and responsible consumer choices—as if the public
can buy their way out of this global crisis—instead of addres-
sing the monumental political and corporate changes that will
be required if any meaningful progress is to be achieved (Mon-
biot, 2019). Moreover, the very notion of individual choice is
illusionary, being circumscribed by opportunities already lim-
ited or eliminated by political policies and corporate decisions.
In the Canadian province of Saskatchewan, for example, pas-
senger rail services were terminated many decades ago. More
recently, the Saskatchewan Government shut down the provin-
cial bus service that was the only form of public transport
linking rural and northern communities to each other and to
the health-care, education, recreation, and retail services that
are only available in urban centres, perhaps hundreds of kilo-
metres away. Reflecting a neoliberal ideology, the provincial
government postulated that private businesses would fill the
transportation void and provide a network of buses to serve
Canadian Journal of Occupational Therapy 87(5)
rural areas, but this did not happen (Leader Post, 2018). Rheto-
ric suggesting that individuals in that province can make wise
and responsible transportation choices that will effectively
reduce their collective carbon footprint is deliberately mislead-
ing when no choices exist. Moreover, this rhetoric is particu-
larly offensive for many young, elderly, ill, disabled, or
economically deprived people in rural Saskatchewan who do
not have access to a private vehicle and who now have no
transportation options at all.
Critical occupational therapists have recently endeavoured
to highlight some of the ways in which neoliberal ideologies of
individualism, independence, self-management, individual
choice, and personal responsibility inform and shape the work
of occupational therapists (e.g. Clouston, 2014; Gerlach, et al.,
2018; Hammell, 2017, 2019; Kristensen, et al., 2017).
Choices and Occupations: Exploring the
Evidence
Evidence derived by critical researchers makes clear that
opportunities to choose and to act are inequitably distributed,
and that inequities arising from social structures constrain the
occupational choices of some groups of people while effectively
enhancing the occupational choices and advantages of privileged
group members, as they are intended to do. Specific policies,
practices, and institutional arrangements are designed by the
dominant social group in ways that create, foster, and perpetuate
systemic inequities and institutional injustices that preserve the
unearned privileges and augment the unearned advantages of
those already in positions of power (e.g. Bonilla-Silva, 1997;
Feagin & Bennefield, 2014); this is not a consequence of
happenstance. The very brief exploration that follows aims to
provide a glimpse of the abundant evidence contesting the
assumption that all people are positioned to make wise
choices—or any choices—about their daily occupations.
Occupational Choice in the Context of Class
Status
Social groups that are accorded high class status enjoy dispropor-
tionate access to the services and resources within a society; hav-
ing inequitable (enhanced) opportunities to choose among a
variety of occupational, educational, and transportation options
(Angell, 2012; Sakellariou & Pollard, 2009), and inequitable
(enhanced) access to engage in these occupations in healthy places
and spaces (e.g. Mitchell & Popham, 2008). A lack of occupational
choice is endemic among people who have low socio-economic
status, and this lack of choice has been correlated with signifi-
cantly elevated rates of physical/mental illness, reduced lifespans,
and suicide (Marmot, 2015; Wilkinson & Pickett, 2010).
Occupational Choice in the Context of Poverty
People whose lives are circumscribed by poverty have inequi-
table (restricted) opportunities to choose among a variety of
403
occupational, educational, or transportation options (Sakellar-
iou & Pollard, 2009) and have inequitable (restricted) access to
engage in occupations in healthy places and spaces. Children
living in poverty, for example, are frequently deprived of
access to safe outdoor spaces in which they might choose to
play (Leadley & Hocking, 2017); and poverty may compel
disenfranchised people to engage in occupations, such as street
vending, that entail exposure to high levels of air pollutants and
other hazards (Gamieldien & van Niekerk, 2017).
Occupational Choice in the Context of Human
Trafficking
The predicament of millions of women, men, and children who
are victims of “human trafficking” (the term commonly
employed to describe the present-day slave trade), and espe-
cially those—predominantly young women and children—traf-
ficked for sexual abuse, exploitation, and prostitution (Hodge
& Lietz, 2007), clearly demonstrates that opportunities to
choose occupations are not universally available, that inequi-
ties abound for those in desperate poverty, and that many peo-
ple lack the power to choose not to engage in occupations that
imperil their health, well-being, and survival. Indeed, inherent
to human trafficking is the reality of “forced occupation”
(George & Stanley, 2019): occupations imposed through coer-
cion, deception, threats, abuse, confinement, extreme physical
and sexual violence, and torture (Gentleman, 2019; Hodge &
Lietz, 2007).
Occupational Choice in the Context of Caste
Discrimination
Although officially abolished by the Indian Government, the
Hindu caste system continues to delimit and dictate the pos-
sible occupations available to members accorded different
caste statuses, especially in rural areas (Murthi & Hammell,
2018). Members of the Dalit (or “non-status”) community are
still compelled to clean toilets and sewage-filled gutters, often
using their bare hands (Guardian Weekly, 2018; Royte, 2017).
Dalits are unable to choose to engage in cultural activities,
events, and festivals; unable to choose to participate in reli-
gious processions or to enter Hindu temples; and unable to
choose to draw water from public wells (Armstrong, 2013;
Raghuram, 2001; Thorat, 2002): occupations that would
undoubtedly contribute positively to their health and well-
being. Indeed, the occupations of those accorded low caste
status are chosen, shaped, and orchestrated by members of
higher castes, and are often enforced through brutal physical
and sexual violence (Murthi & Hammell, 2018; Raghuram,
2001; Thorat, 2002).
Occupational Choice in the Context of Racism
As with class and caste hierarchies, “race” is a socially con-
structed form of categorization, used throughout history as a
tool to preserve power, privilege, control over lands, resources,
Revue canadienne d’ergothérapie
404
and services, and to perpetuate inequitable (enhanced) access
to opportunities (Miles & Brown, 2003; Pease, 2010). Fanon
(1967) cautioned against viewing racism as the product of a
“psychological flaw” within some individuals, emphasizing,
instead, its structural or systemic nature. “Systemic racism”
(sometimes named “institutionalized racism”, Hammell,
2020b; Quinn, 2009) thus refers to the ways in which govern-
ments, businesses, and professions employ a structure of poli-
cies, practices, and decisions that are created, shaped, and
maintained to entrench white supremacy, preserve unearned
advantages, reproduce material inequalities, and embed racial
subordination and inequities in all aspects of social life, includ-
ing education, housing, employment, health care, and justice
(Feagin & Bennefield, 2014). These systems—that are invisi-
ble to most white people—permeate the structure of society
and shape the availability of life chances and choices
(Bonilla-Silva, 1997). Research has highlighted the role of
racism in inequitably shaping people’s opportunities to choose
their occupations (Beagan & Etowa, 2009), especially when
racism intersects with poverty (Galvaan, 2012, 2015; Gamiel-
dien & van Niekerk, 2017; Leadley & Hocking, 2017).
Occupational Choice in the Context
of Gender-Based Discrimination
Gender-based assumptions that certain occupations and inter-
ests are more appropriate for members of a certain gender
effectively restrict the available occupational choices for mem-
bers of all genders (Björnsdóttir & Traustadóttir, 2010), most
particularly females and transgendered people. Inequitable
access to economic and community resources, and to occupa-
tional and educational opportunities resulting from patriarchy,
sexism, misogyny, and oppressive religious traditions, nega-
tively impacts girls and women in every society throughout the
world (King & King, 2011; Marmot et al., 2008; Murthi &
Hammell, 2020; Raghuram, 2001), especially in rural and
remote areas (Kambhampati & Rajan, 2008). For disabled
women in many lower and middle-income countries, gender
discrimination is an even more formidable barrier to occupa-
tional choice than disability discrimination (Trani et al., 2018).
In societies informed by patriarchal ideology, men are empow-
ered to control women’s lives (Guardian Weekly, 2019) and to
employ extreme sexual and physical violence against those
girls and women who strive to make their own occupational
choices (Armstrong, 2013; Murthi & Hammell, 2020).
Forbidden to drive until 2018, women in Saudi Arabia, for
example, have also been denied the opportunity to freely
choose any occupations that occurred outside the confines of
their homes, rendering them unable to choose occupations such
as participation in social or cultural events, paid employment,
or travel without the permission and accompaniment of a male
family member (Mobaraki & Söderfeldt, 2010). Indeed,
throughout the world, the occupations of many millions of
women are chosen, shaped, and orchestrated by men (Ham-
mell, 2019).
Canadian Journal of Occupational Therapy
Hammell
Occupational Choice in the Context of Ableism
and Disablism
In every part of the world, disabled people experience dis-
proportionate levels of poverty (especially abject poverty)
and inequitable access to education, employment, transpor-
tation, buildings, technology, green spaces, arts, cultural,
religious, social, recreational, and other community
resources due to the specific ways societies are structured
and organised to benefit the dominant population (e.g.,
Groce et al., 2011; Read et al., 2006; Stienstra, 2012). Spe-
cific policies, and the procedures favoured by institutions
and their employees, render many disabled people unable
even to choose where, when, how, and by whom their per-
sonal care occupations are shaped and organized (Hammell,
2006). Indeed, the vast body of research documenting dis-
abled people’s inequitable opportunities to choose and shape
their occupations ought to prompt serious introspection
within a profession that proclaims the universal capability
of humans both to participate in occupations as autonomous
agents and to enact wise occupational choices.
Occupational Choice in the Context of
Heterosexism, Homophobia and Transphobia
LGBTQ2þ people and other sexual minorities share with
disabled people a history of injustice and of discrimination
in employment, education, and social participation (Sandahl,
2003). A growing body of research evidence reveals inequi-
table (enhanced) access to opportunities, resources, and ben-
efits afforded to cis-gendered people and heterosexuals (e.g.
Pachankis et al., 2014), and inequitable (diminished) and
discriminatory constraints imposed upon the opportunities
and preferred occupational choices of many LGBTQ2þ
people (Beagan, et al., 2012; Bergan-Gander & von
Kürthey, 2006; Schneider, Page, & van Ness, et al.,
2019)—inequities that may be enforced through violence
(Dowers et al., 2019).
Occupational Choice in the Context of
Citizenship Status
Research among displaced people, refugees, asylum seekers,
and undocumented migrants has highlighted the inequitable
occupational opportunities encountered by people who do not
have citizenship status, with specific government policies and
other structural constraints significantly limiting their possibi-
lities to choose to participate in valued occupations that would
promote their well-being and that would accord with human
rights (Bailliard, 2013; Crawford et al., 2016; Ingvarsson et al.,
2016). Moreover, such geo-political situations as political
instability, military occupation, war, and displacement can rob
entire communities of the opportunity to choose occupations
that would contribute positively to their well-being—occupa-
tions in which they may yearn to participate (e.g. McElroy
et al., 2012; Simaan, 2017).
Canadian Journal of Occupational Therapy 87(5)
Occupational Choice in the Context of
Colonialism
The international occupational therapy profession has not
demonstrated significant interest in the historical and ongoing
legacy of colonization that includes devastating structural
inequalities, cultural genocide, and chronic and inter-
generational adversity (Gerlach et al., 2014; Nelson, 2009;
Nelson & Iwama, 2010), nor of its impact on the occupational
aspirations, opportunities, and choices of First Nations and
Indigenous peoples (although see Jull & Giles, 2012; Restall
et al., 2016; Thomas et al., 2011). Thus, while it is known that
many Indigenous people value occupations through which
they may enact, uphold, celebrate, connect with and transmit
cultural and spiritual traditions, affirm their cultural identi-
ties, honour and respect their ancestors, and care for their land
and oceans as they would care for any other family member—
occupations that support physical/mental health and that sig-
nificantly reduce the incidence of suicide (e.g. Burgess et al.,
2009; Chandler & Lalonde, 2009; Kral et al., 2009; McNeill,
2017)—occupational therapy’s theorists and researchers have
focused little critical attention on the real opportunities
available to Indigenous people to choose to engage in life-
affirming, culturally-important occupations in a place,
manner, and time they might have reason to value. Indeed,
occupational therapy’s theorists and researchers have focused
little critical attention on the real opportunities available to
Indigenous people to choose to engage in any occupations
they might have reason to value.
Intersecting Disadvantages
Although the previous, very brief, examples have been pre-
sented within simplistic categories, many people simultane-
ously occupy several devalued categories that effectively
compound their disadvantages and exacerbate their inequitable
occupational opportunities—a reality that critical theorists
have named “intersectionality” (Collins & Bilge, 2016; Cren-
shaw, 1991). The impact of intersecting oppressions on the real
availability of occupational choices has been explored by few
occupational therapy researchers, but exemplars do exist. For
example, Björnsdóttir and Traustadóttir (2010) explored the
compounding disadvantages experienced by people whose
learning difficulties intersected with devalued class, gender,
and religious positions; Santos et al. (2019) described the scar-
city of occupational choices available to female domestic
workers in Brazil as a consequence of historically entrenched
gender, class, and race inequalities; and Murthi and Hammell
(2020) illuminated the dearth of occupational opportunities
available to women in India as a consequence of patriarchy
as this intersects with devalued caste statuses.
Occupational Choice: Further Critiques
Some further points need to be made about the notion of occu-
pational “choice,” as this has traditionally been used within the
occupational therapy literature. Importantly, when people do
405
not appear to make “wise” occupational choices (Wilcock &
Hocking, 2015), they should not be deemed to be deficient in
volition or will-power, devoid of determination or resilience,
nor to be helpless victims of circumstances. Rather, they may
live in conditions of inequity and injustice that significantly
limit the availability of opportunities and options from which
occupational choices—wise or otherwise—might be made
(Hammell, 2020b).
Further, many of the world’s people, and especially rural
women, are compelled to expend most of their time and energy
on survival activities—such as collecting firewood and water,
and searching for food and for the resources needed for them-
selves and their families—thereby significantly limiting the
possible scope of their occupational choices (e.g. McAdam
et al., 2019). In North America, disabled people and others
facing precarious economic circumstances may expend an
inordinate amount of time and energy in identifying and obtain-
ing the shelter, food, income supplements, goods, and services
required to meet basic survival needs (Aldrich et al., 2017;
Illman et al., 2013; Magasi, 2012), thereby significantly limit-
ing their opportunities to enact a wide range of occupational
choices. Indeed, evidence suggests that many people do not
deliberately choose their daily occupations, instead doing what
needs to be done based on the seasonal, contextual, and con-
stantly shifting demands and challenges of their everyday lives
(Hammell, 2020b).
Moreover, the belief that individuals choose, shape, and
orchestrate their everyday occupations is obviously based on
two assumptions: that occupational choices are always made
by individuals, and that all people value individual choices.
Cross-cultural evidence suggests that these are ethnocentric
assumptions, and that many of the world’s people make choices
within couples, families, and communities, either collabora-
tively and cooperatively, or as a consequence of coercion and
compulsion (e.g. Al Busaidy & Borthwick, 2012; Trani et al.,
2009). Although a Western worldview values independence
and individualism and thus promotes the notion of freedom
of choice, people holding a traditional African worldview tend
to value interdependence, and thus share accountability with
community members for shaping personal choices (Mshanga
et al., 2019). Indeed, research indicates that the idea of being in
control of one’s everyday choices may be a uniquely Western,
urban construct that is neither prioritized nor understood within
traditional Eastern and Indigenous cultures that value interde-
pendency and collectivity (Lo, et al., 2001).
In addition, the cultural context of an individual, family,
group, or community—which includes shared beliefs, values,
perspectives, and norms—significantly shapes and informs
people’s choices and actions (Ferraro, 1995; Hammell,
2020b; Peoples & Bailey, 1994). This context supplies a reper-
toire of cultural “templates” or “scripts” that frame and con-
strain the available occupational aspirations and expectations
for members of a cultural community (Goffman, 1959; Somers,
1994; Stein & Stein, 2006), and thus the occupational choices
that people are able to envision and to make (Santos, et al.,
2019; Trani, et al., 2009). Thus, Galvaan (2012, 2015) drew
Revue canadienne d’ergothérapie
406
from research among marginalized young people in South
Africa to illustrate how a community’s familiar and habitual
patterns of occupational engagement informed the socio-
cultural expectations—or scripts—that shaped the occupational
choices the young people viewed as available, realistic, or
possible within their own lives. This resonates with Rudman’s
(2005, 2010, 2015) conceptualization of “occupational possi-
bilities”: the occupations people view as ideal or possible
within their particular political, cultural, and social contexts.
For people whose race and class privileges afford seemingly
unbounded opportunities, cultural scripts may promise a limit-
less range of occupational possibilities. In contrast, critical
scholars have highlighted the noxious impact of cultural scripts
that derive from resource-poor environments, structural
inequalities, and historically entrenched patterns of racism and
colonialism, and that combine to limit both present and future
occupational possibilities (Gallagher, et al., 2015; Galvaan,
2012, 2015; Rudman, 2010; Trani, et al., 2009). Thus, occupa-
tional possibilities play a fundamental role in determining the
range of occupational choices that people are able to envision
as realistic options for themselves.
Although the concept of choice has tended to be framed
individualistically within the occupational therapy literature—
as if it is entirely a product of volition and will-power—Gal-
vaan (2012, 2015) has employed critical perspectives to
advance a more nuanced understanding of occupational choice
as a contextually situated phenomenon that acknowledges
inequities of opportunity, privilege, power, and access, and that
enables consideration of occupational options and engagement
among people who inhabit a diversity of social positions. This
more socially attuned and nuanced approach to understanding
occupational choice fits with the occupational therapy profes-
sion’s aspirations to provide client-centred services that reflect
both cultural humility and structural competence (Hammell,
2013, 2015, 2019), and that focus clearly on the importance
of assuring the occupational rights to which all people are
entitled (Hammell, 2008; Hammell & Iwama, 2012).
Implications for Practice
The issues raised in this paper indicate the imperative for
occupational therapy researchers to design and undertake
research in ways that enable identification of the inequitable
factors shaping, constraining, and dictating the occupations in
which people have the opportunity to choose to engage; for
both researchers and theorists to embrace more critical
approaches toward those social determinants of occupational
opportunity and choice that impact people’s rights to achieve
health and well-being through their occupations (Hammell,
2020c); and for educators to consistently convey this knowl-
edge to students.
Bailliard (2016) has suggested that “if students become
habituated to critically assessing how power structures and
systems of oppression shape clients’ situations, then they will
become sensitive to how everyday professional practices are
Canadian Journal of Occupational Therapy
Hammell
issues of rights and justice” (p. 13). A profession habituated to
critically appraising how clients’ choices are shaped by inequi-
table opportunities, discriminatory power structures, and sys-
tems of oppression will be less likely to insist that all clients
can wisely shape their own circumstances by virtue of their
occupational choices, and thus less likely to expound and pro-
mote ideologies that effectively contribute to oppression
through the attribution of blame for occupational choices
deemed “unwise.”
Limitations
Critical feminist theorists, critical race theorists, post-colonial
theorists and philosophers, and historians of science and med-
icine are among those who have contested the “antiquated”
(Goldenberg, 2006, p. 2622) positivist belief that the develop-
ment of knowledge can be a neutral, impartial, objective, and
value-free endeavour in which the impact of scholars’ assump-
tions and social positions, or the effects of culture and context,
can be erased (e.g. Collins, 1991; Haraway, 1988; Okasha,
2002; Said, 1993), contending, instead, that knowledge is
“culturally and racially biased, socially situated and partial”
(Moreton-Robinson, 2004, p. 88). This paper is undeniably lim-
ited by its author’s position. Privileged white, class, cis-
gendered, heterosexual, and able-bodied biases, blinkers, and
blind spots have contributed to the incomplete and partial under-
standings reflected in this paper. I also acknowledge that this
paper was motivated by my commitment to social justice and to
contesting white supremacy, systemic racism, colonialism, patri-
archy, ableism, injustices targeting LGBTQ2þ people, and other
odious forms of oppression and domination that are manifested
within our profession’s theories and assumptions, and it thus also
reflects specific values and deeply-held beliefs.
Furthermore, it is important to acknowledge significant
advances being made within critical occupational therapy scho-
larship. In recent years, an increasing number of researchers
have committed to exploring and exposing inequitable occupa-
tional opportunities and choices available on the basis of sys-
temic injustices, and some of their exemplary work is cited
throughout this paper.
Conclusion: Occupational Choice and
Occupational Therapy
The Lancet-University of Oslo Commission on Global Govern-
ance for Health (Ottersen, et al., 2014) concluded that “the
context in which all human activity takes place presents pre-
conditions that limit the range of choice and constrain action”
(p. 635). Although very brief, the examples from research evi-
dence sketched in this paper suggest that the ability to envision
occupational choices and to act on these choices is not solely a
function of individual will and ability, but of real opportunity;
and that the availability of opportunities is shaped by context;
Canadian Journal of Occupational Therapy 87(5)
by social structures and systemic inequities. These findings
provide a robust challenge to the neoliberal-inspired ideology
of unconstrained individual choice that has so effectively
informed and shaped occupational therapy’s theories. The
occupational therapy profession’s espoused aim of enhancing
well-being through occupation demands research-informed
theories; theories that explicitly recognize the socially struc-
tured and inequitable shaping of choice, and of the impact of
these inequities on people’s unconditional right to the occupa-
tional opportunities necessary to meet human needs, access
human rights, and maintain health.
Key messages
 Occupational therapy’s theoretical tradition, informed by a
dominant neoliberal ideology, maintains that individuals
can impact their well-being though wisely choosing and
shaping their occupations.
 Evidence indicates that opportunities to make occupational
choices are inequitably distributed and that many people
have few or no occupational choices.
 Occupational therapy’s theorists, researchers, practitioners,
educators, and students require a critically informed under-
standing of the socially structured and inequitable shaping
of choice.
Acknowledgments
This paper is based on the COTF “Lunch with a scholar” lecture
presented at the CAOT Virtual 2020 conference. I am grateful to Dr
Ben Mortenson for his helpful and insightful suggestions on an early
draft of this paper.
ORCID iD
Karen Whalley Hammell https://orcid.org/0000-0001-7946-2862
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Author Biography
Karen Whalley Hammell, PhD, OT(C), is honorary professor,
Department of Occupational Science and Occupational
Therapy, Faculty of Medicine, University of British
Columbia, Vancouver, BC, Canada.
Revue canadienne d’ergothérapie