Occupational therapists working on the front lines of acute mental health care often enter the profession with a powerful conviction: that meaningful everyday activity—occupation, in the language of the discipline—is one of the most effective tools for healing. Yet a new study published in the Scandinavian Journal of Occupational Therapy suggests that the systems in which these clinicians work frequently crush that conviction, pressuring therapists to abandon the very practices that define their profession. The research, led by MaryBeth Gallagher of Duke University and Nancy Bagatell of the University of North Carolina at Chapel Hill, offers a rare, intimate look at how a group of nine therapists experienced and confronted what the researchers call hegemony—the quiet dominance of biomedical and business interests that renders other ways of knowing invisible.
The concept of hegemony, drawn from the Italian philosopher Antonio Gramsci, describes a situation in which a dominant group’s worldview becomes accepted as simple common sense, even by those it disadvantages. Crucially, hegemony does not depend on coercion. It operates through persuasion and passive acceptance, through the accumulated weight of policies, productivity targets, billing rules, and professional hierarchies that make one way of doing things feel inevitable. In healthcare settings, researchers have long described how medical discourse dominates decision-making, sidelining nursing and allied professions. For occupational therapy, whose entire identity rests on the therapeutic power of occupation rather than the treatment of impairment alone, this dominance creates a profound professional dilemma.
Earlier studies have documented the problem. In Australia, researcher Clare Wilding used action research to show that occupational therapists unconsciously complied with others’ expectations, focusing on medical diagnoses rather than occupational concerns and on productivity rather than client-centered care. She concluded that such hegemonic practices rendered occupational therapy an invisible and subservient profession. In Malaysia, investigators identified hegemony as a suppressor of the profession’s growth, producing occupational injustices. But until now, little attention had been paid to how therapists in the United States—particularly those working in acute mental health settings governed by risk-averse and biomedical ideologies—experience and respond to these forces in their daily work.
To answer that question, the researchers turned to practice-based enquiry, an action-oriented methodology in which clinicians become co-researchers of their own practice. In 2020, Gallagher, then practicing in a university-affiliated acute mental health facility in the southeastern United States, invited all of the occupational therapists at the hospital to join what the team called a community of practice scholars. All nine agreed. The group included therapists with one to sixteen years of mental health experience, spanning entry-level and advanced practitioners, some with international experience, and a diversity of gender and ethnicity. Following a structured three-stage facilitation model, the scholars met biweekly from May 2020 to June 2021, documenting their thoughts, emotions, and actions in written or audio reflections posted to a secure shared platform while collectively discussing their experiences of practice.
The analytic process was deliberately rigorous. Each reflection was read by at least two members of the analysis team, and the data were coded using three complementary schemes: in-vivo codes that preserved the therapists’ own words, process codes that captured their actions, and emotion codes that recorded their feelings. The team then assigned each reflection a descriptive title—names like ‘Good Trouble’ and ‘Staying the Course’—and through repeated discussion distilled the material into themes. Because the co-researchers themselves had generated the data and ultimately confirmed that the final analysis accurately reflected their experiences, the researchers argue the findings carry strong internal trustworthiness, even though a study of a single small community is not intended to be generalizable.
What emerged was a strikingly maritime metaphor for professional survival. The therapists’ shifting narratives resolved into three themes: making waves, staying afloat, and sailing away. Responses to hegemony varied by person, by moment, and by circumstance, and the overall story, the authors write, was one of challenge and survival, much like navigating difficult waters in the face of strong prevailing winds. For some clinicians, growing awareness of how the system constrained occupation and dulled their professional values ignited what one therapist called being ‘fired up’—a decision to make waves and, in a phrase borrowed from civil rights leader John Lewis, to make good trouble.
The acts of resistance were often small, subversive, and deeply humane. One therapist deliberately broke a unit policy by leaving a patient with her own hairbrush, reasoning that the woman needed some agency and self-care at a time when nothing in her life was within her control. Another took a patient to a courtyard coffee shop, following protocol but not waiting for permission, and described the moment as one of embodying her own values rather than adopting values that rang hollow. Others asserted themselves within the interdisciplinary hierarchy: one practitioner recounted telling a doctor to come back later so she could finish an evaluation, and described feeling empowered by it. Beyond individual defiance, some therapists pursued structural change, with one successfully advocating for a seat on the clinical leadership team to help redesign unit schedules and improve quality of care. These acts of counter-hegemony, the study found, left therapists feeling hopeful that change was possible, though sustained transformation would demand a long-haul approach.
Not everyone had the bandwidth for battle. The second theme, staying afloat, captured therapists who, worn down by the COVID-19 pandemic, personal circumstances, conflict avoidance, or relentless productivity demands, chose to work within the system rather than against it. One practitioner admitted feeling guilty for avoiding her unit because it was so physically and mentally taxing. Another spoke of prioritizing productivity over change, acknowledging she had little capacity for reform. Some gave up on educating colleagues or improving programming when staff would not follow through, retreating into a narrowly defined scope of practice. Yet staying afloat was not framed as failure. The researchers describe it as a valid protective state, and some therapists preserved their commitment by modeling small moments of occupational connection—organizing coffee and music on the unit so patients could pour for one another, share interests, and experience belonging—which they knew had the capacity to heal even if fleeting.
The third theme, sailing away, was the most sobering. Feelings of being undervalued, frustrated, and trapped by context pushed several therapists toward detachment, including literal departure from the setting—the first author among them. Others sought influence elsewhere, such as a state-level role in occupational therapy, or withdrew emotionally, with one noting that she wanted change at both individual and macro levels but was simply tired. As one reflection poignantly summarized, some colleagues traveled hundreds of miles to find fulfilling practice aligned with their values, others bided their time searching for jobs with less moral distress, and those unable to leave were left to work around whatever stood in their way.
The findings resonate with broader evidence of occupational alienation and burnout in healthcare. A Swedish national survey found that occupational therapists considering leaving the profession struggled for recognition, felt less valued than physical therapists, and reported working in constant headwinds when trying to justify occupation. The authors argue that practice-based enquiry itself can serve as a counter-hegemonic tool, fostering the critical reflexivity needed to see that feelings of isolation and discontent may stem from an oppressive biomedical and fiscal culture rather than personal inadequacy. They call for professional socialization and curricula that teach therapists how to advocate, ruffle feathers, and make good trouble—skills they believe could produce a healthier workforce and, amid a national mental health crisis, better care. The stakes, they conclude, could not be higher: if occupational therapy’s unique ways of knowing are to survive within hegemonic systems, therapists must be empowered not merely to stay afloat, but to change the course of the ship.
Subject of Research: Occupational therapists’ experiences of hegemony in acute mental health practice
Article Title: Occupational therapists’ experiences of hegemony in a mental health setting: A practice-based enquiry
Article References: Gallagher, M., & Bagatell, N. (2025). Occupational therapists’ experiences of hegemony in a mental health setting: A practice-based enquiry. Scandinavian Journal of Occupational Therapy, 32(1), Article 2456462. https://doi.org/10.1080/11038128.2025.2456462
Image Credits: AI Generated
DOI: 10.1080/11038128.2025.2456462
Keywords: hegemony, occupational therapy, mental health, occupation-based practice, practice-based enquiry, occupational alienation, occupational justice, biomedical dominance, community of practice, burnout, professional identity, advocacy
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Glenn Wilkins. (September 11, 2026). Therapists Push Back Against Medical Hegemony in Mental Health Care. Scienmag. https://scienmag.com/therapists-push-back-against-medical-hegemony-in-mental-health-care/
Glenn Wilkins. “Therapists Push Back Against Medical Hegemony in Mental Health Care.” Scienmag, 11 September 2026, https://scienmag.com/therapists-push-back-against-medical-hegemony-in-mental-health-care/. Accessed 11 September 2026.
Glenn Wilkins. “Therapists Push Back Against Medical Hegemony in Mental Health Care.” Scienmag. September 11, 2026. https://scienmag.com/therapists-push-back-against-medical-hegemony-in-mental-health-care/
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Tags: advocacyalternative approaches to mental health treatmentbiomedical dominancebiomedical dominance in healthcareburnoutchallenges to traditional mental health practicescommunity of practicehegemonyimpact of policies and billing rulesinfluence of business interests on therapy practicesinterdisciplinary perspectives in mental healthmedical hegemony in mental healthMental healthmental health care systemsoccupation-based practiceoccupational alienationoccupational justiceoccupational therapypatient-centered occupational therapypractice-based enquiryprofessional hierarchies in healthcareprofessional identityrole of occupational therapists
