The shadow side of occupational therapy: Necropower, state racism and colonialism

Abstract

Background

In the Global North, advances in occupational therapy benefitted unduly from the oppression, disablement and suffering of thousands of people in the South (and beyond). To prevent the recurrence of these injustices, history must be unveiled and occupational therapists urged to come to terms with their own involvement and responsibility.

Objective and Method

Utilising Achille Mbembe’s concept of necropolitics, this academic essay blends select historical and philosophical perspectives to explore occupational therapy’s concealed role in manifestations of institutionalised violence.

Results

By examining its roles in World War II and France’s colonisation of Algeria, we make visible the development of occupational therapy’s distinct ‘shadow side’. In Nazi Germany’s Euthanasia Programme, it became a tool for identifying which lives were deemed ‘worthy of living’ and which were not, which indirectly contributed to the killing of 200,000 disabled persons. Under France’s colonial medical system, occupational therapy imposed Western standards that alienated and completely depersonalised Algerian patients.

Conclusion and Significance

Entrenched in a (bio)economy that has endured beyond these events, occupational therapists must exercise vigilance, remaining mindful of the potential to unintentionally overlook individuals labelled as ‘unproductive’. This requires confronting the profession’s assumptions of inherent ‘goodness’ and acknowledging and addressing its shadow side.

Keywords:

• Ableism
• care
• death
• disability
• pharmakon
• violence

All this gnawing at the existence of the colonised tends to make of life something resembling an incomplete death.

- Frantz Fanon (1965)

Introduction

Occupational therapy, like nursing, is usually understood to be a beneficial, peaceful and intrinsically harmless health profession [1]. This mainstream understanding often overlooks how violence, destruction and aggression are an integral part of this profession or, alternatively, views these aspects solely as the result of external influences, such as neoliberal, biomedical or managerial discourses [2]. While it is extremely difficult to challenge this assumed goodness, we suggest that occupational therapy’s beneficent aspects have always co-existed with their violent counterparts. Building upon the work of other health disciplines, the objective of this paper is to explore the role of occupational therapy in manifestations of institutionalised violence. Drawing on Achille Mbembe’s theory of ‘necropolitics’, we—the authors—demonstrate how occupational therapy contributed to violence during two major, extreme events, namely Nazi Germany’s Euthanasia Programme and France’s colonisation of Algeria. Though these two events might not immediately appear to be linked, we posit that occupational therapy has consistently operated within a (bio)economy that regards productivity as a measure of societal value and inadvertently neglects individuals categorised as ‘unproductive’ or expendable. Because the conditions for this type of violence outlasted these events, it appears crucial to understand the underlying mechanisms whereby occupational therapists may unconsciously reproduce this violence in their practice.

Rather than using a purely historical approach, this academic essay brings together select theoretical and empirical perspectives and weighs and compares relevant textual and contextual elements as well as our subjective standpoint [3]. Instead of a causal model (e.g. this person was influenced by that person or event), it constitutes a constellation of events, a spatial arrangement with no starting or ending point, where specific links can be apparent or concealed depend­ing on the observers’ viewpoint [4,5]. Being French-speaking, queer academics from a working class background, and having experience with neoliberal academia and ‘universal’ healthcare, our standpoint is rooted in the shame and revolt stemming from our own involvement in health professions that have historically and persistently depended on violence [6, 7].

Occupational therapy, a pharmakon

In Phaedrus’s¹ dialogue with Socrates, Plato introduced the concept of Pharmakon. In ancient Greek, the word ‘pharmakon’ has two meanings: it refers to an antidote (or a cure) but can also be a poison. Pharmakon may also refer to expiatory sacrificial rituals meant to drive evil from a body or a city, which indicates the healing virtue of sacrifice. Other thinkers like Jacques Derrida [8] and Frantz Fanon [9] subsequently built on this idea to examine how discourses and socio-political structures affect human lives. In deconstructing the binary opposition between cure and poison, Derrida [8] claimed that the pharmakon continually oscillates between beneficial and harmful, depending on circumstances. When discussing decolonisation, Fanon [9] contended that violent revolutions lead to inevitable destruction, but that this process could ultimately be therapeutic and create something new.

It is certainly unusual for a profession like occupational therapy to be portrayed as a pharmakon. Occupational therapy’s identity as a health profession has been widely reinforced by emphasising the ‘therapeutic’ virtue of human occupations [10]. In this way, the profession primarily exposed its well-intentioned ability to enable the lives of humans as occupational beings [11]. Seen in its socio-political context, this understanding of humans as occupational beings benefitted greatly from developments in countries in the Global North [12, 13]. In practice, enabling occupational lives meant supporting occupations sanctioned by Western norms as healthy and productive [14, 15]. In the Global North, however, the flourishing of these ‘occupational lives’ required extracting and appropriating resources and capital at the same time as subjugating, marginalising, exploiting and killing substantial portions of populations in the South [16] as well as Indigenous peoples in Australia, Canada and Aotearoa [17]. The flourishing of the latter peoples, on the other hand, was dependent on their rights being recognised and accommodated by settler-states if they were deemed reconcilable with colonial sovereignty and capitalism [18].

Accounting for this obscure, even involuntary, contribution may pose a direct challenge to the discipline’s imperative to be ‘positive’ [19] and threaten the professional identity of its practitioners [20]. Consciously or not, death structures every aspect of people’s occupational lives. In the Global North, it is rarely disputed that death and the fear of it may affect a person’s occupational choices [21]. However, not only are humans expected to engage in healthy and productive occupations in order to prevent and delay their own deaths [14], their lives are simultaneously and continually affected by the deaths of other humans. In Frames of War, Butler [22] maintained that “even if my life is not destroyed in war, something of my life is destroyed in war when other lives and living processes are destroyed in war” [p. 43]. In other words, humans resist the destruction of another’s life because it is a condition of who they are as persons, that is, being alive necessarily involves being connected with what exists beyond oneself. Again, the unequal distribution of human vulnerability to premature death depends on certain individuals being considered ‘human’ based on Western norms, while others are relegated to the status of being ‘infrahuman’, consistently exposed to the risk of death [23].

Since the nineteenth century, occupational therapy has been entangled in manifestations of institutionalised violence that proliferated throughout Europe and beyond (see Ernst [24]), labelled using various terms, such as ‘work therapies’ and ‘work cures’, which became synonymous with the exploitation of asylum patients [25]. Intended as substitutes for rest cures, the introduction of therapeutic occupations in asylums inadvertently cast its own shadow [26] that later extended beyond the confines of psychiatric facilities [27, 28]. On this shadow side, research highlighted the obscure and insidious mechanisms whereby even the most ‘peaceful’ health professions (e.g. medicine, nursing and occupational therapy) participated in eugenic policies such as those promoted in the Euthanasia Programme in Nazi Germany, which led to the killing of over 200,000 disabled people [29–31]. While it could be tempting to repudiate this history and defensively assert that these procedures bear no resemblance to contemporary ‘occupational therapy’, as Müller [32] shows, it may often be difficult to extricate therapeutic aspects from exploitative mechanisms such as those forcefully imposed by the profession’s originating institutions. Operating as a pharmakon, occupational therapy is thus not free of violence. Like other health disciplines [6], it was built on exploitative processes legitimised by a (bio)economy and a specific mode of (necro)political governance that still significantly envelop the profession today [16].

From biopolitics to necropolitics

The concept of ‘necropolitics’ was introduced by postcolonial theorist Achille Mbembe, whose critical work was influenced by thinkers like Frantz Fanon, Michel Foucault, Gilles Deleuze and Félix Guattari, George Bataille and Julia Kristeva. In his book Necropolitics, Mbembe [16] links the notions of ‘sovereign power’ and the ‘work of death’. Building on the work of Foucault, Mbembe argues that sovereign power not only morphed over time into disciplinary power and biopower, as Foucault asserted, but also now consists of what he called ‘necropower’ (term meaning power over death).

Foucault and biopower

In Discipline and Punish, Foucault [33] previously showed that the monarch in European societies progressively lost its traditional power of punishment, which allowed it to ‘take life and let live’. Through violent and spectacular public executions, the monarch used its ‘right to kill’ to eliminate those who resisted its authority, thereby enabling the lives of its most obedient subjects. When these outrageous expressions of state-sanctioned violence were no longer acceptable, biopower appeared as a subtler and gentler alternative [33]. As a ‘power over life’, biopower works differently by endeavouring to ‘make live and let die’. As summarised by Mbembe [16], biopower is “that domain of life over which power has asserted its control” [p. 66]. In this context, fear of death ensures that risks are avoided to protect life, which limits occupational possibilities for the sake of security [21]. Developing along two axes (anatamopolitics and biopolitics), these processes are internalised by individuals in addition to being integrated into social institutions, such as hospitals, schools, factories, prisons, etc. [33]. In societies where the monarch has lost its arbitrary control over life and death, sovereign power uses various technologies to exert control over bodies (anatomopolitics) and spreads its influence into and through institutions that render populations docile and obedient (biopolitics).

Employing technologies to classify, distribute, observe, adjust and normalise, biopower is used to manage and discipline individuals who pose a threat to the social order by looking after them vigilantly in order to restore general well-being [33]. Within disciplinary institutions, power focused on making bodies conform and be useful. Discipline is produced via ‘capillary’ forms of power that have been internalised in bodies so that it was no longer necessary to use violent or coercive means of correction [33]. This ‘social orthopedy’ requires constant and hierarchical observation, normalisation and examination. Observation renders every aspect of a person’s life visible in order to classify and order individuals according to a strict set of norms [33]. The political rationality is to “incite, reinforce, control, monitor, optimise and organise” with the possibility of making each body ever-more productive [33, p. 136]. Normalisation works to constrain these bodies to conform to the regime of norms through a system of rewards/penalties (micro-penalty): those who conform to the norm are rewarded while those who do not are punished/corrected. The latter are left to die only when it is known that everything has been done to prevent it. Death, in this context, is an unintended consequence of a broader (bio)political agenda that aims to foster the healthy and productive living of the social body. The concept of biopower has often been used in the health domain to critique the conduct of professionals in health institutions [34–36].

Mbembe and necropower

According to Mbembe [16], the concept of biopower is insufficient to fully account for contemporary forms of subjugation of life to the power of death. He believes that societies are now governed by a power that works with death (necropower). Under necropower, life no longer guides political actions; it is now subjugated to the power of death and some lives are sacrificed to ensure the survival/vitality of a minority [16]. According to Mbembe [16], necropower is the ultimate expression of sovereign power as it has “the capacity to define who matters and who does not, who is disposable and who is not” [p. 27]. In societies governed by necropower, risks are weapons that are unequally distributed in ways that maximise the destruction of life by creating death-worlds. For Mbembe [16], death-worlds expose vast populations to intolerable living conditions that make them the ‘living-dead’. In these societies, as a result of necropower, life and death co-exist: it is no longer ‘life then death’; now it is ‘death within life’.

To illustrate the idea of necropower, Mbembe [16] returns to the history of colonial wars when, long before the Nazi regime, concentration camps were established as sites for radical dehumanisation, repression, exclusion and death-work. Each of these camps is designed to gather ‘foreigners’ – detention camps, concentration camps, extermination camps and, more recently, filtration camps – and all work under the rules of necropower. Driven by the unconscious desire to annihilate the ‘Other’, the permanent work of separation in the colonial context makes it possible to view colonised humans as abject, undesirable and fearful objects that threaten the social order [16]. When forced into camps, these ‘enemies’ exist ‘outside the law’ and do not have any civil rights whatsoever; they lose their ‘right to have rights’, as Arendt famously put it. By creating a ‘state of exception’, these zones of ‘non-being’ deny the very idea of a shared humanity linked by the finitude of humans’ lives [16]. In this state of exception, the disabled, the poor, the racialised, the queer and the non-citizen are all seen as disposable, undeserving of dignity, and disproportionately exposed to the risk of death. For these humans to be recognised as subjects, necropower forces them to struggle with the risk of death as a path towards liberation; otherwise they remain at the level of objects [16].

Resisting necropower in occupational therapy requires (re)affirming new ways of relating to oneself and others while also recognising the conditions that make such destructive power possible, i.e. capitalism and colonialism [16]. At a global level, capitalism and colonialism widely benefitted the Global North, including the occupational therapy profession [17], to the detriment of vast populations in the South. Using Mbembe’s terminology, this corresponds to the ‘diurnal’ face of this profession. The diurnal body of occupational therapy has been widely studied, providing evidence for the profession’s contribution to enabling meaningful participation in the social world. While the light illuminated this side of the profession, it created a shadow [19], an obscurity or, using Mbembe’s terminology, a ‘nocturnal’ face, which can no longer be ignored. In the following text, we use concepts developed by Mbembe to reveal the shadow side of occupational therapy through its specific role in institutionalised forms of violence.

On the shadow side of occupational therapy

Through its role in Nazi Germany’s Euthanasia Programme and France’s colonisation of Algeria, occupational therapy contributed to institutionalised violence by determining whose lives were ‘worthy of living’ and whose were not. Uncovering the shameful past of occupational therapy may be painful and troubling for a profession used to showing its inherently good, diurnal face and not its violent or aggressive shadow side [19]. Out of shame or discomfort, it could be tempting to look away, ignore or distance ourselves from the roles this profession played in these historical events [26]. We contend that a mature profession should be able to confront this deplorable contribution and work to prevent its reproduction. While most attention is focused on these two events, it would be a misconception to believe that occupational therapy’s participation in such violence was confined to these geographical or temporal boundaries. As illustrated below, this shadow side endured because of a (bio)economy that persisted beyond the scope of these events.

Occupational therapy in the Nazi Euthanasia Programme

The Nazi Euthanasia Programme was established in Germany as part of a wider implementation of eugenic policies during World War II (WWII) [29]. While it culminated in Auschwitz and other death camps, the death-work established by the Nazis began with a lesser-known policy of direct medical killing, that is, killing carried out by doctors and nurses. The role of health professionals in direct medical killing in the Nazi Euthanasia Programme – also called Aktion T4 – has been demonstrated in several historical documents [29,31]. Although occupational therapy may not have been directly implicated in administering lethal doses, people employed as occupational therapists carried out the assessments that determined whose life was worthy of living and whose was not [30]. Apart from direct medical killing, the Nazi Euthanasia Programme encompassed other ways to destroy life (coercive sterilisation, killing of ‘impaired’ children and adults, later extended to mass killing in the Holocaust’s infamous extermination camps) [29]. While the word ‘euthanasia’ was a euphemism used to cover the mass murder of over 200,000 disabled persons over the period of the war [30], the medical killing apparatus existed before and after the war, suggesting that some violence may be inherent in the work of care [37].

The justification for putting these people to death was largely based on the concept of ‘life unworthy of living’ (lebensunwertes Leben) and carrying this rationale to its ‘therapeutic’ extreme [29]. The label ‘unworthy of living’ included not only the ‘incurably ill’ but also a large proportion of the mentally ill, the so-called ‘feebleminded’, ‘retarded’ or ‘deformed’ [30]. In this case, killing those ‘unworthy of living’ was not really killing them because their life was already deemed to be ‘unworthy’; in some ways, they were already dead, spiritually and socially. The document used to report those ‘unworthy of living’ to the T4 operation, called Registration Form 1, emphasised the importance of the type of ‘occupations’ in the asylums: “All patients are to be reported … who within the institution can be occupied not at all or only at the most mechanical work (picking, etc.)” [29, p. 69]. As awful as it sounds, destroying these lives was, in the Nazi discourse, conceived of as a form of ‘healing treatment’. This genocidal propaganda was internalised by health professionals who were convinced they were doing the right thing [29] and that it was not helping these patients to keep them alive [37]. This is a blatant demonstration of the internalised effects of biopower, a form of biopolitics carried to its extreme to regulate the ‘distribution’ of death and enable the state’s murderous function [16]. In Germany, this abusive exertion of (bio)power sought to maintain general well-being by ensuring the integrity of the ‘body’ of the Volk, i.e. the collectivity, people or nation defined by its ‘racial’ substance [29]. Aktion T4 formed the basis of the Nazi policy of ‘state racism’, driven by the unconscious desire to eliminate the ‘Other’, that is, to establish a border to keep out an enemy that would corrupt the pure ‘race’ of the Volk. Beyond Germany’s borders, endorsement from the global scientific community lent legitimacy to the Nazis’ actions [38–41] and facilitated the propagation of their eugenic policies [42].

Occupational therapy emerged almost by accident under the leadership of psychiatrist Hermann Simon (later known for his connivance with eugenic and fascist policies) [30]. After the First World War, care for the chronically ill was challenged by the need to reduce the costs of public institutions [30]. In the 1920s, the ability to contribute to society became a social marker of health, leading in the 1930s to a focus on productivity as a measure of social worth [43]. As a way to improve the psychiatrists’ image [30], the term ‘occupational therapy’ (Beschäftigungstherapie) was used interchangeably with ‘work therapy’ (Arbeitstherapie) [44]. However, these practices were linked primarily “by their being supervised by people calling themselves occupational therapists” [45, p. 70]. As elaborated by Ernst [27], by the 1920s, occupational therapy emerged as “the standard term for patient work in many institutions in Europe and North America” [p. 128-9]. When productive capacity became a criterion for identifying which patients were to be reported to the T4 operation, the development of ‘marketable skills’ through occupational therapy was instrumental for the Nazi regime [29]. As Cooper [43] shows, “occupational therapy created an environment in which those who were unable to work, or to advance beyond the more basic skill sets, were considered incurable and, therefore, inherently inferior” [p. 22]. Thus, in the asylums, occupational therapy took the form of work [25], while simultaneously serving “as a test of sanity and as a proof of insanity” [46, p. 311].

As a form of anatomopolitics of the human body, occupational therapy was used to classify patients according to the tasks they should/could perform [43]. Therapy worked by establishing a set of norms to which patients would be required to conform, in accordance with the imperative that work be productive and purposeful. Simon’s pedagogical approach was based on the underlying discourse that ‘life is activity’: everyone should be engaged in activities and these activities must be purposeful [30]. In this context, inactivity in those who do not perform meaningful tasks would be outside of ‘life’, ‘unworthy’ of it. In other words, occupational therapy aimed to return inactive patients to ‘life’ in the community. Ranked on a scale of difficulty, five stages of activity were used to establish social worth [30]. The first stage included “carrying things or pushing wheelbarrows under close supervision, or simple mechanical activities such as weaving matting”, while the second stage comprised “spreading compost on the gardens, housework, or sealing envelopes” [p. 32]. Patients would perform “sewing, vegetable peeling, ironing” in the third stage, followed by “more advanced gardening (planting, work in the greenhouses), mowing, or office work” in the fourth stage [30, p. 32]. The fifth and final stage was equivalent to employment outside the asylum and consisted of “running errands, answering the telephone, supervising patient work parties, or pottering” [p. 32].

The imperative of activity in occupational therapy worked as a normalisation process that produced independent individuals who conformed with societal norms valuing a set of acceptable behaviours that provided employment. When patients improved their productive capacities, they would be rewarded using “confectionery, tobacco or enhanced freedom of movement under relaxed supervision”, which fostered “calm and order” in the asylum [30, p. 31]. Instrumental in managing ‘disturbing behaviours’ in the asylums [25], occupations replaced force with a sort of “aggressive reasonableness” [30, p. 32], where the only weapon left for medical personnel was their moral superiority established by controlling any manifestation of insanity. While occupational therapy was successful with some of the most acute cases, those who did not benefit from the set activities were classified as ‘refractory’, ‘therapy-resistant’ and ‘incurable’ and cast aside to live a slow, vegetative existence [30]. Paradoxically, occupational therapy ‘successes’ produced another category of ‘unsuccessful’ patients for whom nothing could be done. In the cost-cutting environment that characterised post-war Germany, such ‘purposeless’ patients were a burden as occupational therapy had no impact on them, yet they were still costly [30].

Through occupational therapy, asylums came close to being ‘work colonies’ in which ‘worthless lives’ could “repay the money spent on them” [43, p. 22]. In 1934, exiled doctors voiced concerns about the co-opting of occupational therapy by members of the Nazi party in ways that were inhumane: “Occupational therapy has been supplanted by community work which is not geared to the needs of the individual, but to the priorities of the works leadership” [42, p. 378]. While these practices appear abhorrent today, they were not confined to Germany; they also appeared in other regions such as the UK [46,47], USA [45], Canada [48], Romania [49] and Japan [50]. Even more paradoxical was the fact that these so-called ‘unproductive’ patients were not paid for their work in the asylums or were remunerated at a nominal rate [25]. They provided a labour force for various sectors in agriculture and manufacturing, in addition to saving on costly psychiatric treatments [30].

While each asylum administration was required to submit a Registration Form 1 for every patient under its watch, the T4 operation expected that some of them would not be reported due to a form of ‘plea-bargaining’ [42]. In truth, the obligation to report patients to the T4 operation encountered challenges, which at times involved the falsification of medical records. This was done to save patients with whom doctors had developed an emotional bond or whose work in the asylum proved beneficial [42]. Under war conscription laws, the choice to underestimate certain patients’ capacities was presented as a strategy to preserve their contribution to the asylum’s economy, rather than dispatching them to the battlefield [42]. In spite of this, the logic was installed that these unproductive and incurable bodies were not only unworthy of basic maintenance, they had a ‘negative value’ as they were responsible for the degeneration of the Volk [43] and had to be eradicated using the most radical means. Although occupational therapy did not have the most direct role in the T4 operation, it was part of a chain of crimes, an “emerging therapeutic strategy”, in which the idea of killing the ‘incurable’ began to be internalised [30, p. 83].

Occupational therapy in France’s colonisation of Algeria

The violence of concentration camps did not emerge during WWII; according to Mbembe (2019), it existed in every colonial project. Occupational therapy’s complicity in colonial projects was exposed in the imperialism that dictated the development of the discipline [13,15,51,52]. Threads of colonialism were reported in theoretical models [53], concepts [17,54] and teaching [12,55,56]. Despite often being disregarded, historical records have underlined occupational therapy’s tangible contribution to colonial medicine [27,28,57–60]. In the field of postcolonial theory, Frantz Fanon was widely recognised for his contribution to the idea of radical decolonisation. Less attention was paid to Fanon’s clinical background as a psychiatrist, which largely informed his philosophical perspectives. Interestingly, occupational therapy played a central role in shedding insight into the violence of French colonial medicine in which Fanon was involved at the mental hospital in Blida near Algiers [61]. Because of their explicit depiction of occupational therapy’s involvement in these systems, we focus on Fanon’s accounts and complement them with other descriptions gleaned from the literature (e.g. Hocking [62], Ernst [24]).

Both of Fanon’s most famous works, Black Skins, White Masks [63] and The Wretched of the Earth [9], drew on his experience as a psychiatrist using ‘institutional psychotherapy’. Fanon first interacted with institutional psychotherapy during a residency at the Saint-Alban hospital in France, under the supervision of François Tosquelles who developed the approach [64]. At the crossroads between Marxism and psychoanalysis, this French approach was developed in the 1940s after the horrific events that took place in asylums during the Vichy regime in WWII. While the Vichy regime did not have explicit extermination policies, 40,000 patients died in French psychiatric institutions over the period of WWII [65]. Institutional psychotherapy did not aim to treat patients individually [4]. Rather, the aim was to “treat the institutions producing madness through alienating and oppressive practices” [62, p. 314]. Core components of institutional psychotherapy included ergotherapy (occupational therapy) group sessions (painting, woodwork, pottery, gardening), a Club (self-organised patient groups), a journal (printed in the ergotherapy stations) and other cultural activities, like movies, concerts and theatre.

As Fanon [66] wrote: “In most French hospitals the practice of what is called ‘ergotherapy’ is much closer to an ‘unconscious’ institutional therapy on the part of the doctor than to some genuine Anglo-Saxon ergotherapy” [p. 297]. Mirroring the French term (ergothérapie), a similar etymology has been utilised in various other languages to refer to professions also known as occupational therapy, such as Norwegian (ergoterapie), Dutch (ergotherapie), Danish (ergoterapi) and Greek (ergotherapeía). Fanon [66] added: “Ergotherapy has an important place in the life of the clinic, and we seek to integrate it harmoniously with the other activities” [p. 356]. Institutional psychotherapy challenged the common idea that mental illness had exclusively biophysiological origins; rather it was viewed as a socio-political phenomenon [4]. Rejecting the totalising approaches that marked WWII under fascism, the new approach spurned the use of specific intervention models and rigid frameworks. Instead, it provided general principles around which theory and practice formed a ‘therapeutic constellation’ [64]. Instead of abolishing psychiatric institutions, the idea was to reinvent them so that they foster social relations that ‘dis-alienate’ not only patients, but also the therapists themselves. Each activity aimed to create a therapeutic collective through mechanisms that resisted every shift towards a centralising institutional structure [4].

Fanon was so impressed with the use of institutional psychotherapy that, when he went to work at Blida, the largest psychiatric hospital in North Africa, he wanted to replicate what he had learned. However, Fanon did not manage to repeat in Algeria under French occupation the success he had observed in France. Rather, he found that the approach failed with Algerian men, particularly during ergotherapy workshops [61]. In the Algerian colonial context, patients were distributed in gender-segregated divisions, with units for Europeans and Algerians. The division in which Fanon practised included one unit with European women and three with Muslim men. While the approach was immediately successful in the unit for European women, Fanon noticed that Muslim men, contrary to European patients, did not engage in the occupational therapy activities. Beyond Algeria, comparable mismatches were noted in reaction to craft activities proposed by occupational therapists in colonial regimes, including in India [27,28,58], Canada [57], Israel [59] and Angola [60]. Whether due to gender, class, or religious inadequacies [62], these circumstances pushed some occupational therapists to concede that the suggested activities were, in fact, “not particularly therapeutic” [61, p. 22].

When reflecting on what he called a “total failure”, Fanon [66] noted that a considerable number of patients remained “unoccupied, completely indifferent to the accomplishment of shared work” [p. 360]. Furthermore, the atmosphere in the unit was “oppressive” and “stifling” [67, p. 361]. Fanon [66] became critical of what he called the “ergotherapy-factory” (ergothérapie-usine) and “gymnastic-motor ergotherapy” (ergothérapie gymnastique-motrice), which were characterised by the repetitive, stereotypical work done in Western ergotherapy workshops [p. 294]. According to him, occupational therapy could not blindly replicate the Western approach and should reflect local culture, which served as a basis for his theory of decolonisation. As Fanon [66] maintained, “such approaches must be preceded by a tenacious, real and concrete interrogation into the organic bases of indigenous society” [p. 362]. Fanon [66] realised that the activities used in France were culturally inappropriate:

If we had wanted to have daily evening meetings, it would have been necessary to base them on reality: after work, Muslims gather with other men at the Moorish café. They sit around a table playing cards or dominos or lie down on a mat to discuss the day’s events or listen to music for hours while drinking a cup of coffee or a glass of tea. [p. 369]

Instead of the Club he had observed in Saint-Alban, Fanon [66] opened a ‘welcome’ café, Le Café Bon Accueil, where patients would play cards and dominos as a “space to re-learn the actions of outside” and “institute social life” [62, p. 317]. Ergotherapy workshops were also questioned as they replicated the norms of a heavily industrialised Western country (France). One element that explained their failure, according to Fanon [66], was that most Algerian men were unable to produce baskets or do any rudimentary handicrafts. The weaving and pottery offered in ergotherapy sessions were seen as ‘feminine’ work [61] and Fanon [66] assumed that “it would be better to entrust this work to women patients” [p. 371]. As most of them had a peasant background and were close to the land, it was easier to attract Algerian men to farming activities. Embedded in a specific social activity, the ergotherapy sessions consisted of giving patients shovels and axes and a patch of land to start digging the earth [66]. Even the most delusional and catatonic patients would be interested and there would not be “the slightest need to push them” [67, p. 371].

In the previous failed initiative, Fanon [66] recognised the psychic effects of alienation. For Fanon, to be alienated (aliéné) had a double meaning: first, the feeling of being both estranged and foreign, even in their own land, and second, being mentally unstable, crazy or insane [61]. The play on this word enabled him to see how feeling estranged is a source of mental instability. As Fanon [67] wrote in his essay The North African Syndrome:

… threatened in his belonging to the community—the North African combines all the conditions that make a human sick. Without a family, without love, without human relations, without communion with the group, the first encounter with himself will occur in a neurotic mode, in a pathological mode; he will feel emptied, without life, in a bodily struggle with death, a death on this side of death, a death in life. [p. 13]

For Fanon, because Algerians were alienated through colonisation, they were kept in a state of absolute depersonalisation, a “death-in-life”. To explain the effects of alienation on the bodies of the colonised, Fanon [9] described a form of ‘atmospheric violence’ or violence “in the atmosphere” [p. 70], one that “infiltrates into the pores and veins of society and into the air one breathes” [16, p. 59], making life unliveable. To Fanon, it became clear that it was impossible to practice colonial medicine without breaking the Hippocratic oath to “first do no harm”. This absurd contradiction compelled him to defy the colonial medicine he was perpetuating. In addition to ordinary, biological forms of racism that characterised the Nazi regime, Fanon introduced another type, a cultural racism, that instead destroys ways of living, existing and being [16]. For Mbembe [16], these two forms of racism are connected through a bioeconomy that subjugates life to the power of death, that is, biocapitalism, which must be resisted in every possible way.

Occupational therapy and the rise of biocapitalism

Progressing from biopower to necropower, contemporary knowledge surrounding occupational therapy was shaped materially and discursively along with the economic practices of capitalism [68]. Linking Foucault’s biopolitics to a Marxist critique of political economy, Rajan [69] termed this relationship ‘biocapitalism’, that is, the development of biotechnology and science according to shifts in global capitalist production, consumption and exploitation [68]. As the basic science informing the recent evolution of the occupational therapy profession [70], occupational science took firm root in liberal capitalism [71]. As Emery-Whittington and Te Maro [72] recalled, John Locke, the British philosopher considered the father of liberalism, was also credited with being the father of occupational science [73]. Drawing from liberal principles essential for the growth of colonial capitalism [74], occupational therapy ardently committed to enabling individuals’ freedom to ‘choose’ their own occupations and become self-reliant as universally valued goals [75]. However, the ableism intrinsic to this view began to be criticised nearly 30 years ago [76].

Before that, critical disability perspectives exposed the political nature of disability as an identity oppressed by structural ableism ingrained in the neoliberal dismantling of welfare states in the 1960-70s [68]. Drawing on disability rights and independent living movements, disability theorists criticised normative biomedical discourses that sought to correct, cure and rehabilitate ‘abnormal’ bodies that lacked sufficient ‘capacities’ to function socially [77,78]. According to Puar [79], however, ‘normalising’ the disabled body is no longer the ultimate goal of biomedical interventions. In fact, biocapitalism affects every embodied subject, challenging the binary division into ‘disabled’ and ‘non-disabled’. Within a biocapitalist framework, everybody is “evaluated in relation to their success or failure in terms of health, wealth, progressive productivity, upward mobility [and] enhanced capacity” [80, p. 155]. Thus, able-bodied norms are no longer an achievable frame of reference because humans may all embody gradations of capacity and debility [68]. Encompassing the impairment, lack or loss of certain abilities, ‘debility’ may be understood as the slow wearing down of populations through a profound disruption of bodily norms and personhood itself [80].

Ramugondo [13] exposed how colonial medicine introduced debility in many parts of the conquered world, where colonised people were automatically ‘debilitated’ by capitalist imperialism. Propagated by colonialism, binary viewpoints about disability fostered the notion that Indigenous peoples were actually ‘disabled’ in Western institutions [81]. As a form of alienation, debility can be assimilated with the notion of ‘slow death’ [82], meaning that in biocapitalism life is subjugated to the power of death insofar as the experience of debility confronts humans with their own finitude and the limits of life itself [68]. Being debilitated, for Kristeva [83], “… is perceived as a deficit, which (although repairable in certain cases and within certain limits) lets me die if I am alone [me fait mourir si je suis seul], without a prosthesis, without human help” [p. 225]. In this sense, the fear of death consistently accompanies the experience of debility, imposing a thread of risk and vulnerability over the lives of disabled persons, who are seen as vulnerable, yet disposable and not grief-worthy [84]. Kristeva [83] added:

Disabled persons live with the work of mortality in them, it is the companion of their solitude, as Baudelaire says of his pain: “My pain, give me your hand; come this way.” The so-called solitude of the disabled person inevitably has an absolute companion, a permanent body-double: the pain of mortality. [p. 225]

While instilling a fear of death in those experiencing it, debility can paradoxically become a source of profit in biocapitalism [79]. In fact, ‘curative’ medical approaches cannot be profitable insofar as they can be used only once, preventing any accumulation of capital. For debility to be profitable, anyone must be able to be considered ‘possibly disabled’ or ‘at-risk’ of impairment, ‘fragile’ or ‘vulnerable’, and to potentially benefit from preventive or rehabilitative measures that address these risks [85]. Instead of normative able-bodiedness, the focus is now on the differential ‘capacitation’ of all bodies, regardless of disability status [86]. Capacitation strategies focus on remediating and maximising capacities using, for example, prosthetic enhancements, assistive devices, environmental modifications and technological tools [68], like motivational interviewing, cognitive behavioural therapies and individualised resilience strategies [87]. As Hammell [88] showed, implicit in these strategies are ableist discourses that seek to ‘normalise’ and ‘classify’ disabled bodies with reference to able-bodied norms using standardised assessment tools and the compulsory promotion of independence, performance and productivity. Also reflected in practices [89] and pedagogical tools [90], these discourses induce a reductive, procedural reasoning that leaves the door open to ableism [91]. During the COVID-19 pandemic, the same reasoning supported the use of functional assessments, including those carried out by occupational therapists [92], to differentiate between patients admitted to Intensive Care Units and those excluded [84, 93]. An analogous set of norms is applied to establish eligibility for assisted suicide in Canada, where the so-called ‘Medical Assistance In Dying’ programme has now been expanded to include disabled people [94].

Under necropower, deinstitutionalisation provided occupational therapy with a new form of power that determines who is exposed to the risk of death and who is not [95]. Rigid institutions are no longer necessary for power is extended to and penetrates every aspect of daily living [96], facilitated by surveillance mechanisms that occupational therapy becomes entwined with [92]. Rather than replacing Foucault’s disciplinary societies, these societies of control proceed unbeknownst to the individual, at a molecular level, to control who is exposed to the risk of death and who is not, in ways that “compete with the harshest confinement conditions” [97, p. 1]. Risk management tools have proliferated in clinical settings including: fall prevention [97], ergonomics [98], forensic mental health [99], childhood development [100] and suicide prevention [101]. As with other health and rehabilitation professions, occupational therapy is dominated by individualistic, biomedical conceptions of risk that reinforce a focus on impairment and alienate disabled persons from the socio-political factors that produce debility [102,103]. Increasingly privatised under neoliberal policies, occupational therapy may thus become a profitable market insofar as debility requires permanent support to live outside the risk of death, a process that can never end in a society designed to minimise any exposure to risk [103,104].

Based on dominant norms that value healthy and productive living, occupational therapy becomes complicit in controlling the risks to which disabled bodies are exposed by ‘conducting the conduct’ of occupations [21]. Understood as activities that make a social or economic contribution, or that provide for economic sustenance [105], productivity has been one of the three main purposes of occupations as defined within occupational therapy for over 25 years [106] and continues to be a significant focus of interventions [107]. While the inclusion of disabled persons in the labour market is a desirable outcome of some disability activism, the flip side of this inclusion is the creation of a category of disabled persons for whom working is too ‘risky’ or impossible without sufficient investment in human or technological support [108]. Under neoliberal policies, the devaluation of disabled bodies is reflected in the privatisation of social care that renders their lives/bodies ‘unworthy of funding and employing’ [68]. This is achieved through deliberate exclusion from benefit systems that fail to allocate funds for essential aspects of life, such as housing adaptations or support for communal living spaces within the community [86]. Rather than being a sentence of death, these mechanisms demonstrate how biocapitalism is debilitating for anyone who is unable to join the labour market by transforming life into a form of ‘slow death’ [82]. As a consequence, more radical alternatives may suddenly become appealing, such as the idea of expanding assisted suicide to include disabled people, which could potentially be presented even before attempting to address and nurture what actually gives their life value [94, 109].

Conclusion

The involvement of occupational therapy in institutionalised violence has cast an inevitable shadow side that must not only be revealed, but also reckoned with. Being exposed to the shadow side of occupational therapy is certainly disturbing as this challenges its intrinsic ‘goodness’. For a profession used to showing itself under its best light, this may feel uncomfortable as it could make this discipline look ‘bad’. As with ‘Truth and Reconciliation’ processes [110], the intention behind questioning this intrinsic goodness is not to oppose it with a tragic and pessimistic conclusion, an intrinsic ‘badness’. Like Plato’s pharmakon, we maintain that violence and care cohabit in the work that occupational therapists do on a daily basis. Thus, this paper is a call to recognise that the unconscious desire to annihilate also exists within this discipline. Using extreme examples from the Nazi Euthanasia Programme and France’s colonisation of Algeria, we exposed the role of occupational therapy in institutionalised forms of violence. Within emerging forms of colonialism [110,111] and a (bio)economy that designates a category of ‘unproductive’ and expendable individuals [84,94], it is quite likely that occupational therapy will be called upon to reproduce violence. What may make this discipline look ‘bad’ is not that occupational therapy may be associated with violence, even involuntarily. Our greatest concern is the potential refusal to admit this and the resulting failure to work to prevent it from happening again. We firmly believe that a mature profession would squarely confront its past crimes, understanding that this violence is not exclusive to the profession, but is deeply entrenched in the larger system that gave rise to it. Recognising that humans cannot simply disengage from this system and unilaterally choose to be ‘good’: as proposed by Machado de Oliveira [112], the most viable approach would be to directly confront what surfaces when occupational therapists genuinely begin to scrutinise the profession’s practices and embrace the inherent uncertainty of where this endeavour might lead them.

Acknowledgements

Pier-Luc Turcotte and Dave Holmes would like to thank the Canadian Institutes of Health Research and the Social Sciences and Humanities Research Council of Canada for funding.

Conflict of interest

The authors have no conflict of interest to disclose.

Notes

1 The Phaedrus is a Socratic dialogue written by the ancient Greek philosopher Plato around 370 BC.