Enacting Cultural Humility

Abstract

Background. Cultural humility is increasingly embraced as a theoretical lens that occupational therapists, educators, and researchers can use to promote justice and inclusion in diverse contexts. Cultural humility differs from cultural competence in its recognition of power and bias and its invitation to embrace advocacy and lifelong learning. Key Issues. Occupational therapy scholarship on cultural humility neither confronts the profound challenges of putting cultural humility into practice nor articulates strategies to integrate cultural humility into daily life and work. These challenges, including perceived objectivity, difficulty identifying power structures, and emotional responses to difference, are particularly salient when belief systems are in clear opposition. In such situations enacting cultural humility requires intellectual, emotional, relational, and community building strategy and skill. Implications. To support development of such skills, conceptual practices are outlined here with a focus on uprooting biases, building self-compassion, identifying multiple, co-occurring dimensions of power, and supporting development of collaborative advocacy vision and strategy. This work offers both theoretical and practical knowledge to advance cultural humility praxis in occupational therapy.

Introduction

Cultural humility was originally articulated by physicians Tervalon and Murray-García (1998) who recognized the essential role providers play in creating dignified and inclusive healthcare encounters. It is defined by a life-long approach to learning, recognition of power in healthcare encounters, and community-based advocacy in pursuit of better health (Tervalon & Murray-García, 1998). Cultural humility recognizes that all knowledge is partial and that our perspectives are shaped by the various cultures and communities with whom we identify (Agner et al., 2025; Hammell, 2013). The goal of cultural humility is not to attain an encyclopaedic knowledge of various cultures, or to perfectly intuit and accommodate individual needs, perspectives, realities and desires (Agner, 2020; Beagan, 2015). Rather, cultural humility requires an openness to dialogue and change, a willingness to allow emergent perspectives to shift our worldviews, beliefs, and objectives, and a commitment to advocacy (Agner et al., 2025).

A systematic review of conceptual and empirical rehabilitation literature on cultural humility by Kokorelias et al. (2025) identified six core elements of the concept: supportive interaction, self-reflection and critique, self-awareness and egolessness, lifelong learning and commitment, recognizing and addressing power dynamics, and openness. While cultural humility scholarship in occupational therapy has yet to be studied empirically (Kokorelias et al., 2025), research in psychotherapy, counselling, social work and play therapy has demonstrated association between cultural humility and numerous positive outcomes (see review by Zhang et al., 2022). This includes stronger therapeutic alliance between provider and client (Hook et al., 2013; Orlowski et al., 2025), fewer perceived racial micro-aggressions (Davis et al., 2016; Hook et al., 2016), greater social justice advocacy efforts, and improved psychotherapy and counselling outcomes (DeBlaere et al., 2023; Orlowski et al., 2025). Furthermore, research has shown that Black, Indigenous and People of Colour (BIPOC) trainees in psychology reported higher training satisfaction, greater comfort disclosing challenges, and stronger working alliance with race discordant training supervisors who they perceived as culturally humble (Wilcox et al., 2023). Thus, while empirical research on cultural humility in occupational therapy is currently lacking, evidence from related fields is compelling, and multiple occupational therapy scholars have made strong theoretical arguments for the application of cultural humility in occupational therapy practice, education, and research (Agner, 2020; Agner et al., 2025; Beagan, 2015; Hammell, 2013). However, occupational therapists have yet to examine challenges to enacting cultural humility, or strategies to address those challenges. This literature gap limits potential for cultural humility praxis (the marriage of theory and action) (Wallerstein & Sanchez-Merki, 1994), and thereby limits the potential for cultural humility to advance occupational justice or social transformation through occupation (Rudman, 2021).

Challenges Enacting Cultural Humility

There are several challenges to enacting cultural humility. First, humans tend to falsely view themselves as objective and others as subjective or impartial (Pronin et al., 2002). It is easy for us to learn and apply the core concepts of cultural humility to others, and harder to examine the ways in which our own perspectives and beliefs are fundamentally partial and biased (Kelly, 2024). Furthermore, individuals tend to perceive others’ perspectives as more objective when they align with their own, and more subjective or partial when others’ views are discordant from their own beliefs (Cheek et al., 2021). This illustrates that perceived individual beliefs are challenged interpersonally, and that humans are prone to believing that they are objectively correct when facing interpersonal confrontations (Kelly, 2024). Furthermore, culture, which is formed collectively, inherently shapes our perspectives although humans often falsely consider our beliefs to be objective and individual (White et al., 2021). Culture determines our assumptions of what is natural, right and good, our visions for the future, our judgements of what is wrong (and who is more likely to be wrong) and thus it also forms the foundation for our biases (Greenfield et al., 2000).

Another challenge is that practicing cultural humility requires attention to power in healthcare situations; however, identifying multiple dimensions of power in real time is complex and requires practice (Pillen et al., 2020). Like culture, power is multifaceted and encompasses both concrete and ideological elements ¹ (Freire, 1970). The ability to recognize power is distinct from the acknowledgement that power exists; furthermore, privilege can cause a lack of awareness to situations where power is at play. Here, privilege is defined by situations where power is not acting upon groups equally and thus power is not visible to all (Minarik, 2017). For example, a colleague, client, or student may experience power constraints or dynamics that I am not subject to as a professor or occupational therapist (or vice versa) and this privilege makes it harder to recognize the ways in which power differences exist and constrain or prompt choices, thoughts and behaviours. Another example of how privilege shapes recognition of power involves the occupation of navigating daily occupations. As a person who does not use a wheelchair, I experience the privilege of navigating daily occupations without having to consider where the wheelchair accessible entrances are. Physical accessibility and built environment design is one form of concrete structural power, that my privilege as a non-wheelchair user does not require me to see, confront, or acknowledge. Privilege is both the opportunity to act without considerations of such power constraints, and the opportunity to engage in a wide variety of occupations without encountering external threats or barriers (Minarik, 2017).

Thus, increased privilege requires conscious attention to make physical and ideological power constraints visible (Pillen et al., 2020; Walgenbach & Reher, 2016). For example, while working with a non-profit organization to develop an occupation-centred intervention in a transitional housing site I have encountered multiple situations that elucidate power constraints that were not in my immediate awareness. When I initially engaged the group in cooking interventions, I interpreted their reactions to the activity (elation, trepidation, and caution) as individually motivated. It was only after learning about how their ability to cook had been constrained by institutional regulations over the long-term that I began to understand their individual reactions within a larger framework of how power and oppression had been enacted within that setting, and how it shaped our interactions related to cooking. Like cultural humility, the process of identifying new dimensions of power in distinct settings is an iterative, life-long process. While skill in this area can grow, the process is always re-occurring.

In addition to the difficulty of recognizing power constraints that are initially unknown to us, another challenge inherent to cultural humility is navigating emotional reactions and personal beliefs (Gallardo, 2021; Gottlieb & Shibusawa, 2020). Conversations across differences may trigger individual wounds or histories, and embracing new perspectives may prompt awareness that we may have unintentionally perpetuated racism, classism, ableism, patriarchy or another iteration of entrenched cultural bias. These realizations often clash with our perspectives of ourselves, prompting defensive attempts to maintain our individual or collective identities. Simply put, enacting cultural humility requires us to entertain perspectives that shake the foundation of what we believe is real, true, and good. Rarely do we discuss how to do that.

Positionality. My perspectives on enacting cultural humility are inherently partial (as all scholarship is) and are shaped by my own experiences, learning, privilege, aspirations, my teachers, through scholarship, and in community. In terms of scholarship, I support a critical constructivist philosophy of science, and I have been particularly influenced by theory and research on reduction of racial prejudice, post-war reconciliation processes, and perspectives of Brazilian theorist Paulo Freire, indigenous activist Lila Watson, post-conflict reconciliation and bias expert Ervin Staub, and Black feminist theorist bell hooks. Here, I offer concepts and strategies to support the enactment of cultural humility by reducing bias, identifying dimensions of power, developing self-compassion and engaging in advocacy from a humanistic lens.

Individual and Relational Practices to Move Towards Cultural Humility

Practices to uproot bias. Culture, and cultural differences, are enacted relationally. We develop culture, learn about our own culture, and discover cultural differences through our interactions with others. Thus, cultural humility requires a dialogical approach, based in curiosity and an earnest desire to understand other's vantage points. Biases prevent curiosity. Biases are grounded in unspoken knowing and unnamed certainty about what, how, or why, a group will do something. Thus, uprooting biases requires a desire to make the invisible visible and a baseline recognition that all humans carry prejudice (Cheek et al., 2021; Devine et al., 2012a). Prejudice is both collective and individual as it is often culturally motivated and is defined by negative cognitive and affective positions towards a group (Dovidio et al., 2010). None of us are exempt from prejudice, and at times, we may even perpetuate prejudices and biases towards groups we are a part of or unintentionally reproduce beliefs that we explicitly disagree with due to internalized oppression. Internalized oppression, as articulated by Freire (1970a), relates to oppressive ideas or biases that we are subjected to from external sources, but then integrate into our own belief system, even if they are directly harmful to us. Uprooting these biases requires us to look inward and outward (Cheek et al., 2021). We must reflect, listen, ask questions, and then imagine an alternative reality as it is shared with us (Kelly, 2024). It is an active process. This does not mean that we immediately agree with other's perspectives, but that we legitimize them by honestly and fully trying to understand alternate realities (Agner et al., 2025).

Imagining realities distinct from our own can help reduce unconscious bias (Devine et al., 2012a; Gonzalez et al., 2017). Perspective taking practices have been fundamental in reconciliatory efforts in entrenched conflicts and can be employed in a wide diversity of settings (Bruneau & Saxe, 2012; Staub, 2006). In my own experience in healthcare contexts, where clients were regularly labelled “non-compliant” or “difficult” for not engaging in therapy, simply asking, “why don’t you want to participate in therapy?” with a true desire to learn and understand dramatically shifted the encounter. Their responses also shifted my approach to therapy. I had to be willing to relinquish my goals or plans for the session, or to dialogue with the client about how my views aligned with theirs or not. Perspective-taking fostered trust.

In addition to perspective-taking, research shows that mindfulness can be an important tool to uproot biases (Fisher, 2020). Strong emotional reactions can block us from being able to imagine and respect the views of a client, student, or colleague, often causing us to instinctively defend our own perspectives rather than engaging in open, reflective dialogue. Particularly when differences are triggering to us in some way, gut-level responses make it challenging to embrace a meta-cognitive, reflective perspective needed to promote empathy and reduce bias. Mindfulness can help us identify and manage our own emotions; practicing awareness of our own sensations helps make visible the ways in which emotional triggers are shaping our responses (Conversano et al., 2020). This may involve asking first, “What am I feeling?” Then allowing those feelings to occur without judgment, but also without channelling them into avoidance, dismissal, aggression, or persuasion. Importantly, the goal of mindfulness is not to stop emotions, or to delegitimize your own perspectives by exclusively attributing them to emotions. Rather, mindfulness practices can support recognition of how emotions are shaping interactions and biases. This can help diffuse feelings of self-righteousness that may block perspective taking (Edwards et al., 2017). By seeing how our own perspectives and biases are shaped by our experiences, cultural background, and emotions, we make space to hold other views simultaneously.

Additionally, hands-on collaborative work towards a shared goal can reduce both explicit (self-reported) and implicit biases (Henry & Hardin, 2006). Stereotypes are often dismantled as we build more complex cultural scripts, and that occurs through individual stories and emergence of skills made visual through co-creation. For example, in my work at the transitional housing site mentioned above, I have gained new perspectives working side-by-side with residents that confront or contradict my preconceived notions. It is both by seeing individual skills emerge through action, and through the natural storytelling that has occurred while we are working together, that my perspectives have been altered, expanded, and transformed. Furthermore, personal narratives—stories shared by individuals about their lived experiences—can also serve as powerful tools for dismantling our prejudices and biases (Devine et al., 2012b). These narratives provide firsthand perspectives on marginalization, resilience, and cultural identity, offering insights that can challenge dominant stereotypes and assumptions. While in-person relationship building is most effective, first-person narratives from film, audio and text can also be very powerful tools to uproot biases and dismantle prejudices (Thornicroft et al., 2007). For instance, a documentary highlighting the experiences of refugee communities can evoke empathy and reshape perceptions of migration, while a memoir detailing racial discrimination in healthcare can express systematic injustices that might otherwise remain abstract.

Growing compassion for self and others. Engaging in cultural humility work collectively and individually requires a balance of accountability and forgiveness. Biases are often entrenched over multiple generations and upending them involves forgiveness for others as well as forgiveness for current and past selves. A lack of self-compassion for perpetuating collective or interpersonal harms may result in self-deprecation, shame or guilt (Conversano et al., 2020). These psychological states result often in disengagement and demoralization, creating a vicious cycle of non-action (Gottlieb & Shibusawa, 2020). A lack of self-compassion may also lead to defensiveness, resistance to recognizing mistakes, or avoidance of unfamiliar cross-cultural situations (Gottlieb & Shibusawa, 2020), all of which limit the enactment of cultural humility, which requires continuous self-reflection and a willingness to confront biases (Tervalon & Murray-García, 1998).

Growth requires acceptance that we may have committed harm, but we recognize our inherent ability, and that of others, to learn and to change. Greater self-compassion is correlated with proficiency and comfort working in diverse cultural settings, indicating the importance of extending kindness to oneself in the face of the unknown (Neff, 2003). Recognizing that cultural humility is a practice that takes time, and that undergoes constant, iterative development fosters self-compassion because it reminds occupational therapists engaging in this work that they are not failing if they encounter difficulties, but rather that they are being offered opportunities to learn and improve their skills. Offer this same compassion to others, while still embracing the responsibility, and taking accountability for outcomes of our actions (intended or unintended). As the Black feminist writer bell hooks stated in an interview with Maya Angelou, “Forgiveness and compassion are always linked: how do we hold people accountable for wrongdoing and yet at the same time remain in touch with their humanity enough to believe in their capacity to be transformed?” (hooks & Angelou, 1998, para 61).

Identifying dimensions of power: Developing critical consciousness. Practicing self-compassion can assist us in the difficult process of identifying and acknowledging multiple dimensions of power. This practice, of identifying power and how it influences everyday situations is referred to as critical consciousness (Freire, 1970). It is important to note that cultural humility does not suggest we put power aside, but rather that we recognize how power shapes interactions between ourselves and others, and that we make efforts to intentionally share power with marginalized groups or individuals. Power can be made visible by identifying concrete situations that limit or constrain action, and then examining the ways in which abstract structural factors (beliefs, assumptions, constructs, and relationships) may shape those situations (Freire, 1970). For example, in rehabilitation settings, occupational therapists can examine how power can operate ideologically by impressing norms or expectations on others, physically through restraint or medication, or structurally via healthcare access, insurance coverage, and institutional policies (Agner, 2017). Power can also be operationalized socially—as social capital or access to support networks can be considered forms of social power, or materially—via financial security, access to higher quality adaptive equipment, or ability to afford needed caregiving support (Hagan & Smail, 1997; Mortenson & Dyck, 2006; Neal, 2014).

Recognizing power requires resisting the ideological tendency of thinking of power and oppression in clearly delineated binaries—where one group holds power and another is entirely powerless (Freire, 1970). This thinking follows our natural tendency to identify in-groups and out-groups, which can further perpetuate existing biases rather than dismantling them (Dovidio et al., 2010). While recognizing power imbalances, also consider the ways in which individuals can both be oppressed and simultaneously oppress others (Freire, 1970).

For instance, occupational therapists have been critiqued for over-emphasizing individual-level factors during therapy (Solaru & Mendonca, 2023). Albeit true, these critiques rarely discuss or acknowledge systemic constraints that are imposed on occupational therapists, that is, the ways that occupational therapists may simultaneously experience and enact oppression within the same context. In the United States, medical reimbursement structures are highly individual-focused, generally fee-for-service, and operate within a capitalist framework that also limits occupational therapists’ ability to promote occupational justice through innovative, context-focused, occupation-centred care. This example provides one perspective on how external forces (such as a capitalist oriented medical system) acts on both occupational therapists and clients. As occupational therapists act within these social constraints they may overemphasize individual factors, in part, because the time and productivity constraints of their workplace do not allow another option (such as seeing clients in community or home settings for example). While the occupational therapists in this context become a vehicle for a constrained, individualized healthcare, they may also experience an inability to provide care that aligns with their ideals of best practice and experience burnout, disenfranchisement, or moral distress as a result (Gupta et al., 2012; Rivard & Brown, 2019). The process of learning to identify multiple dimensions of power acting in a given situation takes time, courage, practice, and ideally a critically minded, open-hearted community of colleagues to engage in discussion and clarification. Over time, honest identification of power can shift how we relate to others, and encourage engagement in advocacy, as recognizing power structures clarifies institutional, political, or systemic factors that constrain occupational choice (Hammell, 2020).

Developing advocacy vision and strategy. Developing critical consciousness, identifying the ways that power impacts health and occupational choice, and unveiling some of our biases, may feel overwhelming, as if society is stacked against occupational justice. However, these emotions can also fuel advocacy work, as occupational therapists move beyond a focus on interpersonal encounters to influence the contexts where they live and work. It is not always clear where to begin when moving from individual therapy to community or population-level advocacy. Further, large paradigmatic shifts, such as policy change, can feel impossible and out of the realm of our influence. In the face of these challenges, I offer the belief that seemingly intractable problems, such as entrenched discrimination, do change over time, through thousands of efforts of committed individuals with a shared purpose working in diverse ways over the long-term. Small, individual and interpersonal steps to ameliorate an entrenched problem are the building blocks of collective gains. Although those efforts can feel solitary, disconnected, or not “big enough,” studies of social change have found that diverse, collective efforts result in paradigmatic changes over the long-term (Hawken, 2008). Practicing this humble but active stance, knowing that we alone will not shift the external factors we see impacting occupational choices (such as healthcare policy, or abusive workplace practices, or land or water rights) can sustain and fuel our internal sense of power and motivation to continue this work.

While engaging in advocacy work I often remember the famous quote from aboriginal activist and leader Lilla Watson: “If you have come here to help me, you are wasting your time, but if your liberation is bound up with mine, then let us work together” (Watson, 2004, para 43). Paulo Freire made a similar critical distinction in his articulation of humanism versus humanitarianism. Often, those of us in the helping professions fall into humanitarianism. He defines humanitarianism by a posture of benevolent paternalism, knowing what is best for communities and then offering up time and services to put visions into action. Freire (1970) argues this approach can reproduce oppression, as many harmful acts have been carried out by well-meaning, charitable individuals lacking context, humility, and community buy-in. Humanism, as opposed to humanitarianism, begins with the baseline assumption that all people (particularly those experiencing marginalization or who are making choices that differ from our own) have the right and inherent ability to participate in decision-making. This does not mean that all actions or perspectives are equally ameliorative. However, close partnerships with community members, built over time, and based on shared goals and trust, have the greatest potential to promote shared humanity.

Conclusion

Cultural humility is a lifelong process that requires individual, interpersonal, and community building skills that interact dialectically. It involves a brave, iterative attempt to look at ourselves from an outside perspective and to identify the factors that shape how we relate to others who are different from us in terms of class, race, gender, nationality, and other dimensions of experience and diversity. It requires curiosity about things we thought we already knew or had no desire to understand. It requires a decoupling of unintentional harms from our definitions of ourselves, forgiveness, and accountability to change course as learning occurs. This individual and interpersonal cultural humility work is crucial if we aspire to occupational justice (Townsend & Wilcock, 2004) and wish to engage in processes of social transformation via collective advocacy (Rudman, 2021).

We cannot have an inclusive multicultural society if we lack the desire or skills to have a conversation with someone we disagree with, whose perspective is unknown to us, or someone whose perspective we erroneously assume we understand already. We cannot sustain social transformation without listening to those who are disenfranchised and oppressed, realizing that all forms of oppression are inter-linking. We cannot promote policy change without a multifaceted strategy that incorporates diverse skills, perspectives, and grounding in lived realities. We cannot educate empathic occupational therapists in educational settings that are not informed by commitment to understanding and addressing student concerns. Learning, debating, and practicing skills to enact cultural humility in our relationships, workplaces, and communities are essential if we hope to advance occupational justice on both micro and macro scales.

Key Messages

• Enacting cultural humility in occupational therapy is often emotionally and intellectually challenging, particularly when ethical or cultural clashes arise that confront long-held, deep-seated beliefs.

• The practice of cultural humility requires commitment to uproot biases, consistent reflection and attention to power, active imagination, perspective taking, and courage.

• Self-compassion, compassion for others, mindfulness, and collective reflection can support the challenging emotional and intellectual processes cultural humility and of negotiating core differences.