European occupational therapists’ attitudes toward the dark side occupations: an in-depth E-survey in 32 countries

BACKGROUND: The concept of "dark side occupations" remains ethically and culturally sensitive within occupational therapy practice. While the topic has been explored conceptually, less is known about how therapists across European regions address such occupations in clinical dialogue. This study examined regional differences in the perception of ethically sensitive or socially contested occupations and explored how professionals see the term itself. METHODS: A cross-sectional survey was conducted among occupational therapy professionals across four European regions: Central and Eastern, Southern, Western, and Northern Europe. The questionnaire combined closed-ended items assessing the frequency with which specific topics (e.g., sexuality, addictions, politically or socially sensitive activities) are addressed in practice, with open-ended questions exploring avoided topics and perceptions of the term "dark side occupations." Quantitative data are presented descriptively with comparison across regions. Qualitative responses were subjected to thematic content analysis. RESULTS: Marked regional differences were identified. Topics such as sexuality, addictions, and other socially sensitive activities were addressed significantly less frequently in Central and Eastern Europe and, to a lesser extent, Southern Europe compared to Western/Northern Europe. In several regions, a pattern of pre-emptive topic avoidance was evident rather than explicit therapeutic refusal. Open-text responses suggested that contextual factors, including cultural norms, institutional climate, and perceived professional boundaries, shape clinical decision-making. Perceptions of the term "dark side occupations" were varied, with some respondents considering it a useful analytical framework and others viewing it as potentially normatively loaded or stigmatizing. CONCLUSIONS: The perception of ethically sensitive or socially contested occupations and topics in occupational therapy practice appears to be context-dependent and regionally patterned. Avoidance of certain topics may have implications for client autonomy and therapeutic dialogue. These findings highlight the need for culturally informed ethical reflection and clearer professional guidance in addressing complex socially sensitive or socially contested occupations within European occupational therapy practice.