Occupational Therapy: A Profession Born from Liberation and Empowerment

 Asclepiades

As discussed earlier, the American Dream was an influential factor in the formation of the United States Culture we know today. A focus on working as a moral obligation shaped the way US citizens viewed their everyday lives and activities. Occupational therapy however, or at least the founding concepts, have been used for ages in places like Greece and Rome. In 100BCE activities like "therapeutic baths, massage, exercises, and music" were prescribed by the Greek physician Asclepiades to treat human patients considered to be "insane" while 100 years later, Roman Celsus prescribed music, travel, conversation, light, and exhausting exercise for those he treated (Quiroga). Regardless of historic examples, humans have been engaging in everyday activities to fulfill their lives and enrich their lived experience for much longer than documented history. It is a natural instinct for humans to seek out activities that provide them with pleasure and fulfillment. It was only in the beginning of the 20th century that therapists professionally began to use this instinct to influence health and wellness. The origins of the occupational therapy profession are deeply shaped by three national and global occurrences that very much encapsulate the ideology that fuels the occupational therapist's perspective: 1) the Arts and Crafts movement in reaction to the industrial revolution, 2) the return of veterans  from World War I, and 3) the women's rights and suffrage movement

In the early part of the 1900s, two very important changes within our world were occurring that would ultimately affect the development and formation of occupational therapy. First, the industrial revolution was in full swing, increasing factory jobs but at the same time drastically altering what "work" looked like. Assembly line factories quickly overtook the job market and countless citizens found themselves completing only a portion of the work to create a product, sometimes never actually seeing the finished product. The creativity had been removed from craftsmanship, effectively degrading the individual to a single repetitive tool in a long line of tools to create interchangeable products. The Arts and Crafts movement, present in both Europe and the United States and usually only participated in by middle- and upper-class citizens, sought to counteract this distancing of the hand from creative work by studying and continuing various craft forms. Hand-made textiles, woodworking, metalworking, basketry, weaving, and sewing all became more than simple hobbies, but methods of liberation from the "tyranny of the machine" and grasping a more "productive and meaningful" lifestyle by working in the traditional manner.  They sought to maintain a moral work ethic that did not demoralize the human into the tool of the machine, but rather abide by the cultural norms that had already been deeply rooted in the Protestant Work Ethic. From this movement occupational therapists, or reconstruction aides as they were called at that time, usually middle- and upper-class,  found inspiration in how to provide treatment for their patients. By providing their patients with the opportunity to successfully complete the entire process of a craft, the therapists were able to provide a moral experience of satisfaction, self-worth, accomplishment, and learning while also possibly improving other aspects of the patient's quality of life in the same moment. This flavor can still be tasted in therapy sessions today, as craftsmanship are still used to evaluate, remediate, and support participation.

WWI Amputees 1919

Secondly, the United States entered World War II in 1917, creating an influx of veterans suffering from physical disabilities, mental disabilities, and what WWI veterans called "combat neurosis" or "shell shock" (what we call today Post Traumatic Stress Disorder). The combination of this population as well as the already present needs for Mental Health services sparked an increased awareness of the need for "mental hygiene" services throughout the United States. Psychology, psychiatry, nursing, and doctors began to seek out methods to facilitate the rehabilitation or "reconstruction" of veterans with both mental and physical disabilities. Many men returned home, unable to work in the traditional manner, unable to provide financial resources to their family. There was a desperate need for a treatment that could effectively improve the mental status of these veterans and return them to their roles as breadwinner as quickly as possible. In a culture where idle hands were immoral and dependency on others was pitiful, these individuals needed to discover a way to regain their independence. Occupational therapy seemed to fill that need. After therapists formed their first professional association in 1917 called the National Society for the Promotion of Occupational Therapy (NSPOT), one of the first tasks they undertook "was to convince the U.S. Army and the commander of the Allied Expeditionary Force in World War I, General John Pershing, to order the hiring of 5,000 reconstruction aides to provide occupational therapy to the war’s wounded."[Source] In fact, one of the founders of NSPOT had seen occupational therapy as the solution to the difficulty of unemployment and disabled veterans previously and had already created a workshop for the chronically unemployed.

Slagle

Addams

 Eleanor Clark Slagle was one of the most influential founders of the occupational therapy profession. She set the stage for the growth and development of a new profession for young women in a time when the movement for women's suffrage was slowly emerging within US culture. Born into a family of abolitionists, she was surrounded by the ideas of liberation and advocacy from an early age. When Slagle traveled to Chicago in 1911, while most women were ascribing to the traditional ideologies of domesticity, purity, piety, and submissiveness, Slagle was surrounded by the women of the Hull House, notably Jane Addams and Ellen Gates Starr,  who were actively involved in politics, pushing for the rights of women, and crossing social barriers not yet crossed by women in the US. Through her interaction with many who experienced social oppression and deprivation as well as the women of the Hull house, Slagle recognized her interest in the "unfair social attitude toward the dependency of the mentally and physically handicapped" by realizing the parallel between this social marginalization and that of the women of the time. Her experience working with people with mental illness specifically led her, in 1914, to found a workshop for the chronically unemployed called the Experimental Station. Once the high demand for this type of workshop for more individuals than simply those with mental illness was realized, Slagle began to accept individuals who were being limited by disabilities of all sorts. Because therapists had begun to use arts and crafts as a therapeutic method, she was able to work with both veterans and others who could no longer participate in the jobs they once had, to support themselves financially. They were able to sell their products and thereby at least somewhat reconstruct their roles within their everyday lives as a breadwinner and independent individual. She believed that not only could occupations provide effective rehabilitation for some illnesses, but it could also provide job training for those who might otherwise not have access, an ideology later employed by Herbert James Hall to support the Devereux Workshops.

But Eleanor Clark Slagle was not the only one concerned with liberation and empowerment; in the early 1900s, William Rush Dunton, Jr., the "father of occupational therapy" was forming the Sheppard-Pratt Hospital, a hospital that encouraged patients to take active roles in their own care. After being influenced by William Tuke of the York Retreat, a Quaker-run home in England for those who experience mental illness, Dunton sought to incorporate a "judicious regimen of activities" into the care within his hospital. This "moral therapy" was meant to provide "habit training" for the patients, a method of replacing unhealthy habits by practicing new ones repeatedly, also allowing a more engaged participation in their own rehabilitation. At this point various institutions, mostly mental health facilities, were incorporating the idea of "occupations" into their everyday treatment by using crafts such as weaving, woodworking, metalworking, basketry, leather craft, and bookbinding. Patients were beginning to take an active role in their health and wellness instead of simply being the subject of treatments and surgeries by hospital staff. "Occupational therapy" began to be seen as a norm rather than an experiment and was largely recognized as an integral part in the betterment of patients' well-being, especially those within the mental health setting. Therapists and hospital staff were now able to provide services that surpassed mere "custodialism" and moved more towards a team effort between the doctor, nurse, therapist, and patient.

First Meeting of NSPOT

And so began the germination of the profession we know today as occupational therapy. From its roots, occupational therapy is a profession that seeks liberation and independence. It seeks methods to empower the human person to achieve meaningful participation. From liberating ourselves from the tyranny of the machine, to reconstructing our roles after combat experiences, to claiming the rights of all humans, male, female, physically disabled, mentally disabled, doctor, or patient, occupational therapy has worked to empower men and women to claim their right to participation through the work of their hands. Today, we continue to teach, support, and encourage all those who are deemed atypical to rebel and liberate themselves from the idea of normal by walking with them as they take an active role in working toward accomplishing meaningful occupations.

______   ______

But has occupational therapy ceased growing; has it become all that it can be? No. As a profession we are still learning and continue to reevaluate our perspectives and assumptions. Through globalization and cross-cultural interaction, we have begun to realize that many of the assumptions that stem from our roots in US culture may not apply in all situations.


Quiroga, V. A. M. (1995). Occupational therapy: The first 30 years 1900 to 1930. Bethesda, MD: The American Occupational Therapy Association.

www.aota.org

Jeremy and the American Dream

What are some of the founding beliefs of the United States? Or at least the current ideas that we purport as the foundations of this nation?

The two most prevalent words in the "American" language would most assuredly be freedom and equality, concepts built upon a foundation of the Puritan work ethic¹. If we are free we can work, if we are equal we all have the same opportunity to work, and stemming from the Puritan work ethic we seek to work to assure ourselves we are one of the "blessed." The maturation of these two concepts throughout our history and culture along with the Puritan work ethic birthed the "American Dream."

What is the American Dream? Here at Xavier we have an entire center, The Center for the Study of the American Dream, dedicated to studying and understanding this cultural phenomenon. Although the various forms and methods to achieve the American Dream have changed over the years, astoundingly, it does not seem to have ideologically changed much at all.

Today, most people would describe a picture of a husband, wife, 2.5 children, and dog named Spot standing next to a medium sized house with a white picket fence to encapsulate the ideology behind the American Dream. What does that picture represent? Does it represent the better life that countless immigrants are searching for as they walk, climb, and swim toward the United States? Is it the idea that some US citizens hold in their minds to push them through another day of an excruciatingly meaningless job? Is it the picture of what the poor and poverty-stricken have failed to achieve in their lives? Is it even what the majority of Americans really want?

 John Steinbeck

One of the most influential and ingrained beliefs within this nation is that each citizen will move up the socioeconomic ladder proportionally to his or her own volition. This belief facilitates the existence and encouragement of the American Dream. In fact John Steinbeck brought attention to this idea when he said,

“Socialism never took root in America because the poor see themselves not as an exploited proletariat but as temporarily embarrassed millionaires.”

He explains that the poor within this country are taught and told that it is solely their fault that they did not achieve the American Dream. It was the poor who put themselves in poverty and it is up to them to pull themselves up by their bootstraps. When they fail to do this, it is their burden to bear and their failure to endure. The poor are poor by choice - past choices, current choices, and nothing else.

Is this true? Whether it is true or not can be debated on another day, what is important is that Jeremy (see posts 1, 2, and 3) is living within this belief system and living his life by the bible of the American Dream. This is specifically relevant on several fronts within his occupational performance.

On several occasions Jeremy has expressed severe self-deprecation by making statements such as, "I am not worth anythin' anyway, I am just here rotting on the side o' this big ol' city" or "I belong out here. I am a screw up, that's pretty obvious don't you think." Jeremy describes his experience of panhandling in Cincinnati,

"I keep my head down and they do the same. They walk by without paying much attention to the bum sittin' on the side of the street. If I have a good sign or something then maybe one will throw a couple coins my way, but most the time I think that is more for them than it is for me. Feels good to give a lil' charity to the less blessed you know."

 Here in the US, homeless people are beaten, taunted, and left to die on the side of the street.  A homeless person is first homeless, then a person, dehumanized and forgotten as a failure within our society. We tell our children not to make eye contact, as we ourselves avert our glance. We try to ignore as long as possible as a homeless individual approaches us on the streets asking for money. We are afraid of the possible "crazies" out there, because only a crazy person would allow themselves to remain on the streets for years, months, or even days.
But interestingly, the first sort of community service most often suggested is "serving at a soup kitchen". What is it about this activity that is so appealing to those who have privilege? How is it that a society that casts out its poverty-stricken will so readily pass food across the counter to a homeless person for a night? The answer to this question, personally, comes from my own experiences in soup kitchens and visiting the people on the streets of Cincinnati: fear.

The fear within us towards the homeless is planted from the very first time our parents hold our hand a bit tighter as we walk past a man stooped on the corner of a city square. Fear germinates as we watch cartoons and television shows that depict homeless people as dangerous and psychologically unstable. Fear branches into indignation as we watch homeless men and women walk into rehabilitation programs and human service agencies while we work jobs and go to college to earn our dreams. Fear blossoms into hatred and sometimes violence as we pull ourselves far away from the idea that those people could possibly be the same as us. Finally, the fruit of fear is plucked as we stand behind the protective barrier of a soup counter and hesitantly pass a plate of food to the homeless. We neither have to speak nor touch, both of which will remind us of their humanity. If they are not human, a person just like me, then there is no chance that I, who have worked so hard, could lose my precious American Dream. This is why we, or at least I, glanced away from our brothers and sisters on the streets but scurried to a soup kitchen to provide them with food. Standing behind a plentiful counter of food, serving those who had less without actually interacting with them solidified my belief that they need not be treated like humans.

Non-human. This is what the culture Jeremy is surrounded by tells him that he is: anything but success and anything but human. He feels he is not capable nor worth being anything but homeless. He fought for a country that now is afraid of him.

______ ______

It is this culture and these factors that you, as an occupational therapist, must take into account when working with Jeremy. You must understand that although your goal for him may be to adequately provide a roof and living for himself, there are more obstacles than simply motivation to overcome.  Is there a place for him to go in Cincinnati? Will his mental condition allow him to work in any setting, let alone a traditional one? Can he overcome the culture that surrounds him on a national level without the support of a community that rejects that culture? These are the questions occupational therapists must discover through analyzing the context and specific situation of their clients. We are a holistic profession which means we not only look at the whole person, rather it means we also look at the whole picture.

¹ Cullen, Jim. The American Dream: A Short History of an Idea That Shaped a Nation. New York: Oxford University Press, 2003. Print. 

Final two photos are from Robin Cheers's Everyday People Series

Jeremy and Post Traumatic Stress Disorder

Today there are countless veterans living with PTSD who have returned from wartime situations and are attempting to acclimate to the civilian lifestyle. Many of these also populate the streets of the cities of our nation. Veterans represent 23% of the homeless population in the United States. 96% of homeless veterans are male. There were reported 192 sheltered and unsheltered veterans in Cincinnati/Hamilton area in January of 2011.

What do veterans with PTSD face when coming back to the United States, let alone when they are homeless?

First, the direct symptoms of PTSD are burdensome and affect an individual immensely. The Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition- Text Revision) provides descriptions of the symptoms one must present with to be diagnosed with PTSD:

There is persistent reexperiencing of the traumatic event in memories, images, emotions, thoughts (Criterion B1), dreams (Criterion B2), acting or feeling as if the event is actually happening again (Criterion B3), intense psychological distress at exposure to cues that may be relevant to the experience (Criterion B4), or physiological distress to the same cues (Criterion B5).

The individual must also persistently avoid those stimuli associated with the trauma and they will experience numbing of general responsiveness that had not appeared before the traumatic event. This symptom can manifest as efforts to avoid mental processed associated with the trauma as in thoughts, feelings, and conversations (Criterion C1), efforts to avoid concrete items like people, places, or activities that remind the individual of the trauma (Criterion C2), an inability to remember or recollect a significant portion of the trauma (Criterion C3), disinterest or less interest in common activities enjoyed before the trauma (Criterion C4), antisocial behavior or feelings of detachment or estrangement from others (Criterion C5), a general restriction of emotions (Criterion C6), or a belief that they will not have a full lifespan or will not complete major life goals (Criterion C7) (DSM–IV–TR).

Often times, flashbacks are caused by this intense aversion to threat or danger, and can play a significant role in maintaining this symptom by constantly reminding the survivor of the danger or threat. This creates a vicious cycle, from which it is difficult for the survivor to remove him or herself (Brewin, p. 185).

Finally, there must be a state of increased arousal which can emerge as difficulty falling or staying asleep (Criterion D1), angry outbursts or general irritability (Criterion D2), difficulty focusing or concentrating (Criterion D3), hypervigilance (Criterion D4), or an exaggerated startle response. These symptoms, after the traumatic event, must be present in the individual for over a month to be considered PTSD (Criterion E); acute PTSD is diagnosed when the symptoms are present less than three months, while chronic PTSD lasts longer than the three month period. These symptoms must also cause significant distress and disorder within the normal functioning of the individual through any important aspect of their life (Criterion F) (DSM—IV—TR).

These though, are simply the fundamentals of the disorder; the dynamic condition of PTSD can influence varying people in varying manners, creating large varieties of manifestations that could be considered within the PTSD spectrum. Many soldiers, returning from and with a war torn experience who show symptoms of PTSD, seem to have some trends in their reentry experience.

These symptoms create many obstacles for returning veterans and often lead to outcomes that severely affect their everyday lives.  Jeremy's experiences with these obstacles ultimately had a strong influence in facilitating his current situation.

If you have not already, I would recommend reading these two (1) (2) posts so that you know who the fictional character Jeremy is and why I am talking about him.

When Jeremy returned from war, his parents used to tell him that he seemed "changed". He was less enthusiastic about the activities he once enjoyed: motorbikes, fast cars, and ATVs. He often avoided driving in general and refused to drive on highways or other long stretches of road without exits because this was a factor that had caused the tragedy that occurred overseas. He had told his parents that he wanted to stay in Cincinnati for the job opportunities and cheaper rent, but he alluded to being uncomfortable with driving the distance to return home as well.

He became distant and irritable with his family first and then generally everyone around him, he began to calm his anxiety and penetrating headaches with copious amounts of alcohol. His personal relationships disintegrated along with his perception of his personal worth. He was conflicted in his identity because his personal worldview and moral system did not coordinate well with the things that had occurred during combat. His most overwhelming guilt came from surviving the tragedy that killed the three other members in the vehicle, because he had been the one driving. He felt like he had no control over his life anymore and that he was not capable of functioning properly. The combination of these factors led him to, as was described before, lose his job and ultimately facilitate his chronic homelessness.

Once Jeremy first became homeless, his PTSD was in many ways exacerbated by the environment in which he was living. His already hyper-vigilant mind and frequent bouts of paranoia preventing him from sleeping. With each attack from other homeless people or simply inhumane citizens, more experiences began to fill the memory banks to which his mind would flashback. His temper was uncontrollable and his emotions were even more sporadic. With every honk of a horn or screech of tires, Jeremy would be thrown into a panic attack or flood of anger. This continued until he found his camp near the river, where he was able to leave the populated areas of the city.

Over the next few years, Jeremy was able to remedy some of the severity of the PTSD symptoms by creating some structure in his life. He has specific places within his camp for certain activities, while not always enforced they are still considered important. He continuously works to construct a more elaborate and luxurious structure for his cats to live in, while only sometimes improving his own. He is mostly consistent in waking up early in the morning and walking to find work in downtown.

At this point Jeremy refuses to drive, is very skeptical of anyone who enters his camp, avoids large social situation unless absolutely necessary, and spends most of his time alone. When he is social he says little and listens less, only freely interacting with Will and Terry. He often reports that he is awoken from sleeping by nightmares and flashbacks which leave him in an alerted anxiety preventing him from sleeping well.

He believes the system he has created is the only solution to the way he feels and stubbornly argues with anyone who believes he could live in society in a more traditional manner. He has begun to exhibit a sense of pride in the new life that he lives day by day, with nothing and no one other than himself on which to depend. However, on many occasions he expresses strong self-deprecation and shame due to his homelessness and mental status.

His sentements are well put in his quote "Who would want to help a lazy, crazy bum like me anyway? We're all lookin' out for number one here aren't we. That's what I'm doin'... lookin' out for numero uno."

References:
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
 (4th ed., text rev.). Washington, DC: Author.

Brewin, C. R. (2003). Post traumatic stress disorder: Malady or myth?. New Haven: Yale Unniversity Press.

Paulson, D. S., & Krippner, S. (2007). Haunted by combat: Understanding PTSD in war veterans including women, reservists, and those coming back from Iraq. Westport, Connecticut: Praeger Security International.

Putting Jeremy in Context

I would recommend checking out this post if you have not already read it to catch up on who the fictional character Jeremy is and why I am talking about him.

The amount of factors and influences that are affecting Jeremy are numerous to say the least. Just as any individual is affected by all the various networks within which they find themselves during their everyday life, the homeless individual is affected by factors like the housing and labor market conditions, poverty, social and racial inequality, personal vulnerabilities, and precarious life circumstances.¹  Since this is simply meant to be an example, I will only look at some of the most typically influential interactions between contextual and structural factors that are directly affecting Jeremy's occupational outcomes, meaning how Jeremy's personal attributes (contextual) are functioning within the system of his larger cultural context (structural). Hopefully through this analysis one can begin to uncover the potential for occupational injustice or apartheid as well as begin to understand the individual through his context.

The interactions we will be looking at will be the interaction between 1) Jeremy experiencing homelessness and the affordable housing availability and structures within Cincinnati, 2) his experience of homelessness while living with PTSD, and finally 3) his experience of homelessness within the cultural values and beliefs systems of the United States. It is important to note that these interactions are greatly influenced by other factors, but for the sake of clarity I will attempt to minimize the comprehensive picture I present.

Jeremy and Cincinnati

     As you walk through the streets of Cincinnati, like any other modern urban center, you will encounter individuals living on the streets. Some roam city corners all day panhandling, others are simply on their way home from a day of labor, while still others do a multiple of other miscellaneous tasks throughout the city. Some huddle between the pillars of the courthouse building, ironically a building that is meant to represent justice, while others find homes under overpasses throughout the city. Some simply cover themselves with blankets, while others have built shacks and lean-tos under the cover of wooded areas. This group of individuals is described as the "chronically" homeless because its members experience homelessness on a regular and long-term basis. Of the 1,300 to 1,500 individuals who experience homelessness on any given night in Cincinnati, this population makes up around 3%, according to the 2012 Point-in-Time report performed by Strategies to End Homelessness.

You may be surprised that Jeremy fits into such a small percentage of the homeless population, but many people are unaware that the term homeless includes individuals on the streets, in shelters, in transitional housing units, sleeping on a friends from lack of personal housing, or living in any location not originally intended for human occupation [Source]. Often times, people who are experiencing temporary homelessness are thrown into the cycle of systemic poverty which leads them to chronic homelessness. This was Jeremy's case as well.

The two most frequent causes of temporary homelessness in Cincinnati are lack of affordable housing and loss of income, both of which Jeremy experienced first hand. After his injury and subsequent return to the United States, Jeremy remained in the VA hospital for 6 months, receiving therapy to rehabilitate his injured leg. After 6 months, Jeremy moved into a small apartment in Price Hill due to its cheap rent and its proximity to a mechanic who had agreed to hire Jeremy to work part-time in his garage.  While receiving some compensation from the military combined with the income from his part-time job, Jeremy could regularly pay his necessary bills. Over the course of a year or so, however, it became apparent that Jeremy's PTSD symptoms as well as chronic pain in his thigh and lower back were severely affecting his job performance. For example, if a tool was dropped unexpectedly by a fellow mechanic, the loud noise sent waves of anxiety and adrenaline through Jeremy causing him to need breaks often. Unlike most of the other mechanics, Jeremy needed aid lifting wheels and engine parts as well.

These factors weighed heavily on Jeremy and often caused his mental condition to deteriorate while his self-medication compounded. He felt alone and useless, unable to discern his role within the world around him. He had little social interaction outside of work and refused to see a counselor because he believed it was for "weak girly men" as well as he had no time to spare walking to talk to "a loonie shrink" instead of working.  These habits began to affect his job performance even more severely, causing him to be irritable with customers and smelling of substances on the job. After two years of working in this garage, one morning, after an incident with a reckless driver on his walk to work, Jeremy was anxious, angry, and overwhelmed, so much so that he stopped at a gas station and bought a 40oz beer. He finished the bottle as he walked into the garage. Unfortunately the supervisor was forced to fire him over this incident.

Now without a job and with a severe addiction problem stemming from depression and PTSD, Jeremy could no longer afford to live in his apartment. There were no housing facilities within the area that had low-income residences. Within a month, Jeremy found himself facing his first night on the streets. Out of desperation he called a friend from work and asked to sleep on his couch until he could find a place. For another month, Jeremy slept on his friend's couch searching for work or a cheaper place to live, neither of which he found. He also consumed large amounts of alcohol and returned to his friend's home intoxicated on several occasions. After that month came to an end, his friend could no longer keep him in his house. Again, Jeremy was faced with the prospect of sleeping on the streets.

Instead, he headed to the Drop Inn Center, the only large scale homeless shelter in Cincinnati. As he walked into the building, it became very apparent that he was not going to be able to stay here. It was a crowded and hectic arena of human interaction. There was no privacy and Jeremy's anxiety was exacerbated by often unpredictable events like fights or simply antagonistic individuals. After spending four hours in the common area, he decided to face the streets.

For the first few weeks he roamed downtown Cincinnati searching for quiet hidden places to sleep. He was attacked on multiple occasions both by others experiencing homelessness and by some who were not. Finally, after a month and a half of living from alley to alley, Jeremy found a camp on the east side of Cincinnati, near the river, the camp he resides in three and half years later as you, an occupational therapist, interview him.

He states that he searched for housing for another seven or eight months after he found the camp, but soon realized there were no locations he could afford in Cincinnati. He says his only option currently would be to check into a rehab facility, which he attempted to do then, but he did not have enough public intoxication citations to qualify for the program. He also had attempted to find employment, but without a residence or a phone number he was unable to apply for many low-level positions.

Today, Jeremy has given up on trying to find affordable housing in Cincinnati or any method through which he may leave the streets. He believes, perhaps justifiably, that there is little opportunity for him, and as gentrification and displacement continue to have significant impacts in the city, his opportunity is only decreasing further. He enjoys the the quiet camp in which only he and his camp-mates reside. Although he often still has fits of anxiety and anger after newcomers attempt to set up camp near their location, it is by far more suitable for his conditions than any other place within his socioeconomic reach at this point. As you discovered before, most of his income comes from his inconsistent day labor job and panhandling. His substance abuse has largely reached terminal velocity at somewhere between functional alcoholism and constant inebriation.

As an occupational therapist, you must take into account the resources available to your clients and focus on goals that are currently possible for them. At this point, based on your understanding of city policy, programs, and resources it is not possible to help him find an affordable living situation indoors that fits his needs, wants, and obligations.

What is important to recognize about the interaction between Jeremy and his context of Cincinnati? The decreased amount of resources available to him, especially relevant to affordable housing and mental healthcare, affect his occupational performance as well as limit the intervention possibilities to you as therapist. Due to his physical location and the time and effort it takes for him to get to work, his energy level and time is significantly limited. Overall, Jeremy's situation calls for a great amount of creativity and smart goal setting to be effective within the constraints set by his context.


While in Nicaragua and Guatemala, I hope to uncover how varied availability of resources on a general scale affects occupational therapy services. Understanding extrinsic barriers like economic policy, healthcare systems, human service delivery, and government subsidies will help to paint the picture of the Nicaraguan and Guatemalan context.


¹ Petrenchik, T. (2006). Homelessness: Perspectives, Misconceptions, and Considerations for Occupational Therapy. Occupational Therapy in Health Care, 20(3), 9-30. 

*Photos are all locations within the city of Cincinnati

Understanding the Whole Picture

As one dives into cultures and societies, especially with hopes of uncovering certain phenomena, it is important to maintain an aerial view of the puzzle that is a cultural system. For an occupational therapist searching to understand how to work most effectively with a specific disability or other obstacle creating difficulty in performing occupations, an understanding of the grand network that influences the individual is necessary. Recognizing the cultural background, societal norms, and typical living styles as well as the possible presence of occupational apartheid and its effects is integral to understanding how one should approach working with each client. Just as how a US citizen must understand what cheese is in Nicaragua, so must an occupational therapist understand who their client is within the client's context. This concept was emphasized by the Ecological Human Performance Framework first purported by Winnie Dunn, Catana Brown, and Ann McGuigan in 1994 in their article titled "The Ecology of Human Performance: A Framework for Considering the Effect of Context" in the American Journal of Occupational Therapy.  This contextual understanding is what I hope to delve into as I experience Nicaragua and Guatemala from an Occupational Therapy student's perspective.

Christiansen and Townsend, in Introduction to Occupation: The Art and Science of Living (2010), describe the context of an individual and their resulting unjust or just occupational outcomes in terms of structural factors and contextual factors. Structural factors are similar to the idea of occupational apartheid; these are the structures of society that create systems, social norms, or values in which the individual is functioning. Contextual factors are specific attributes of the individual that affect the effectiveness or fluidity of function within the systems created by the structural factors.  As an occupational therapist, we can and should only understand our client's occupational performance with these factors, both structural and contextual, in mind.

To provide a clearer explanation of my goals, in the next few posts I hope to exemplify how one might explore an individual here in the United States. One example, that demonstrates this process well, emerges when looking at a specific population within the United States: the chronically homeless veteran living with post traumatic stress disorder (PTSD).

Usually, I would prefer to begin the analysis with a top-down approach, understanding the larger social systems before excavating how the individual fits into them, but I think it would be helpful and a bit more entertaining to tell a story. This story will hopefully, over a series of posts, highlight an example, closer to home than Guatemala or Nicaragua, of when it is important to understand the whole picture. To be clear, the factors here are those that, hypothetically, will be affecting the client's occupational performance. This is a fictional character, but very well could exist today.

So without further adieu, this is Jeremy's story:

You are an occupational therapist who has been hired by a non-profit that seeks to reach out to individuals experiencing chronic homelessness in Cincinnati, OH. Your job is to visit the streets and meet the people who are living there, while providing as much service as possible.

Your first potential client is Jeremy. Jeremy is a 34 year old Caucasian male, living in a camp under an overpass next to the Ohio River. He is originally from southern West Virginia, but has been living in the urban center since his honorable discharge from the army when he was 28 years old. He was discharged after sustaining wounds to his right thigh after an encounter in which 3 of his team members were killed. Stemming from his military service and this final violent experience, he has been exhibiting symptoms of PTSD like violent flashbacks, anxiety in social situations, avoidance of triggers, and severe headaches, since he returned to the United States. Because of his growing addiction to substances as self-medication and his rent being increased Jeremy was unable to afford an apartment and therefore, now, lives on the streets. There is more opportunity for work and resources near the city and therefore, instead of returning to West Virginia, Jeremy decided to remain in Cincinnati.

He currently lives with two other individuals, Will and Terry, a couple who have been camping on the streets for about a year. The three have a good relationship and rely on each other for social interaction as well as caring for the camp, making money, and cooking. They care for two cats, Whiskers and Tigger, who have roamed the area for the past two years. Jeremy often finds comfort in feeding and petting the cats. They calm him and give him a sense of responsibility and structure. He spent 3 months building a small structure in which the cats sleep, live, and play, commenting that the work helped him concentrate and stay calm. Jeremy is mentally capable and can be very proficient with tools and engineering.


He consumes alcohol, cigarettes, and marijuana on a regular basis, usually in the evenings but many times during the day as well. He often justifies the use of these substances as self-medication, tending to anxiety and headaches. Although, he has a limp in his gait due to his past injuries, usually at 4:00am on at least five out of the seven days of the week he walks 30 minutes from his camp to a day labor association downtown.  He usually finds some sort of work two or three days out of the week, usually consisting of construction or manual labor. He gains a small wage from these employment endeavors.

The rest of Jeremy's time is spent either passing hours in the camp talking, drinking, or working around the camp, walking to and from the day labor association and working, or panhandling at various locations throughout the city. The combined income provides enough money to buy some food, beer, cigarettes, and occasionally marijuana. The camp is also sometimes visited by various charity groups who bring canned food and supplies like firewood, water, and tools.

Jeremy does not express desire to get off the streets because he believes even if he tried he could not hold a consistent job due to his symptoms and now seasoned ability to self-medicate. He fears various situations that are related to the accident and many times has severe reactions to them if encountered. Before and during his stay in the army, he loved working on cars, trucks, and tanks. He often expresses the desire to do this type of work again, but is also often frustrated that his symptoms and his socioeconomic situation does not allow it. He often presents as depressed and sometimes angry that he is unable to participate in the work he once enjoyed performing. This anger and depression, which exacerbate his PTSD symptoms, push him to self-medicate more.


Because of his special circumstances and non-typical relationship with you as an OT, it has taken you 3 months to discover all of this information. In the process you have learned much about Jeremy and the contextual factors influencing him, meaning those attributes of him as an individual. So what do you do with it? Are you ready to approach the client with possible interventions? Do you need more information? Are you ready to write Jeremy's goals?

I would say we need more information, but not about him. Rather, we need more information about his context. We need to see how Jeremy and his contextual factors fit into the larger structural factors; we need to broaden our view to a bigger part of the picture.

Some Important Terms

So in hopes of providing more information and knowledge concerning the content of my research project, I found it necessary to provide an explanation of some terms that will be most likely referred to throughout my blog. I will provide the technical definition (also seen to your right on the side bar) and then follow this with elaboration to indulge the idea a bit further.

Occupation: “[A]ctivities…of everyday life, named, organized, and given value and meaning by individuals and a culture. Occupation is everything people do to occupy themselves, including looking after themselves…enjoying life…and contributing to the social and economic fabric of their communities.”

-Cited in American Occupational Therapy Association's Occupational Therapy Practice Framework: Domain and Process (2008)

http://www.xavier.edu/OT/images/OccTherapy061.jpg

To this day there is debate concerning the most correct definition of occupation and all that it entails. In some instances it is used to refer only to those activities in which individuals, communities, or societies find meaningful participation, while in other instances it refers to everything that is done ever. The various types of occupations include anything relevant to Activities of Daily Living, Instrumental Activities of Daily Living, Education, Work, Rest and Sleep, Play, Leisure, and Social Participation. There is not much, if anything at all, that cannot be defined as an occupation. For clarity's sake Activities of Daily Living (ADLs) are those tasks we perform on a regular basis like brushing our teeth, bathing, walking, eating, sexual activity, and using the bathroom. Instrumental Activities of Daily Living (IADLs) are activities that often require more complex participation and cognitive ability like paying bills, caring for another person, child rearing, religious observance, preparing a meal, safety precautions etc. The rest of these areas of occupation are self-explanatory.

Occupational therapy: "Occupational Therapy is a client-centred health profession concerned with promoting health and well being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupation engagement."
-World Federation of Occupational Therapist's Statement on Occupational Therapy

 Occupational Therapy is considered the use of the above defined occupations, along with a relationship between the client and the therapist, to facilitate progress and rehabilitation toward the client's goals. The World Federation of Occupational Therapists elaborates by stating that OTs have many potential roles "with people, individually, in groups, or in communities."   Their Statement on Occupational Therapy also recognizes that OT has a role with "all people, including those who have an impairment of body structure or function owing to a health condition, or who are restricted in their participation or who are socially excluded owing to their membership of social or cultural minority groups." This recognizes that OT is also relevant in places outside hospitals, clinics, nursing homes, and schools like prisons, homeless shelters, and impoverished slums. If occupation is being prevented, OTs have a role.

Occupational injustice: "Occurs when participation in occupation is barred, confined, restricted, segregated, prohibited, underdeveloped, disrupted, alienated, marginalised, exploited, excluded or otherwise restricted."

-Townsend L, Wilcock AA. Occupational justice and client centred practice: a dialogue. Canadian Journal Occupy Therapy 2004; 71(2) 75-87.

http://www.xavier.edu/OT/images/OccTherapy060.jpg

Because OT is comparatively a young profession, many of the terms and ideas within it are still being ideologically debated and defined. Occupational injustice is one of these terms. To attempt to be succinct and possibly oversimplifying, occupational injustice could be defined as when an individual, group, or community is not permitted to participate in meaningful occupations. This term describes specific instances when occupation is prevented. Occupational deprivation, marginalization, and isolation are various types of occupational injustice. When one steps back from our society and looks at the larger picture, these injustices create systems and societal structures. Many of which function as obstacles for the occupationally oppressed. These structures form what some OTs have come to call Occupational Apartheid. 

Occupational apartheid: "Refers to the segregation of groups of people through the restriction or denial of access to dignified and meaningful participation in occupations of daily life on the basis of race, color, disability, national origin, age, gender, sexual preference, religion, political beliefs, status in society, or other characteristics. Occasioned by political forces, its systematic and pervasive social, cultural, and economic consequences jeopardize health and wellbeing as experienced by individuals, communities, and societies."

-Occupational Therapy without Borders: Learning from the Spirit of Survivors - p.67

Some common norms within our, the US, society function to make understanding this idea of Occupational Apartheid a bit more difficult. The American Dream and the idea that we freely move between social and economic classes proportionally to our own volition seems to battle with the idea that our society continues to function with many structures that resemble a rigorous social and economic caste system sans official sanction. From this comes the expectation of those who find themselves born into "less than desirable" situations or minorities to meet the majority. We expect those who use wheelchairs to function within a world made for the walking. We expect those who speak other languages to assimilate to the language spoken by the dominant culture. We expect veterans to return to the everyday US life after being submerged in battle and violence for months and years. We expect ex-convicts to learn the ways of "good" people after spending years in facilities that punish for profit. From the privileged perspective, structural oppression seems like the lazy being lazy, when in reality it is watching people try to swim up Niagra Falls.

Occupational Apartheid is the falls. This idea recognizes that structures and systems are many times in place that do not work on behalf of minorities or oppressed populations and in some instances work against them. There is debate within occupational science as to whether these structures and norms must be officially recognized or codified in policy for "true" occupational apartheid to be present. These structures, according to WFOT, can include restrictions due to "the physical, affective or cognitive abilities of the individual, the characteristics of the occupation, or the physical, social, cultural, attitudinal, and legislative environments." As occupational therapists attempting to provide meaningful occupation through effective therapeutic relationships and methods, we must understand the whole picture, all the factors affecting our clients, and resist the temptation to believe that the populations we work with are solely responsible for overcoming "their" obstacles. It is we, as a society, minority and majority, who have to work to overcome our obstacles.

An Example to Begin

If we were to choose  one attribute (out of many) of United States culture that clearly distinguishes itself from the grand majority of other countries and cultures in the world, it would be our incessant love for cheese. We add cheese to everything, even salads.

So, if a US citizen were to travel to Nicaragua and be a little hesitant toward the food or want to add a little familiarity to the typically served rice, beans, maduros, and ensalada, they may think to order queso (spanish for cheese).

Map of Nicarag

If you are a US citizen and have ordered queso in Nicaragua before, you soon realize that you in fact will receive a spongy, bitter, white, and often fried type of cheese, that largely tastes like nothing commonly served here in the United States. Nicaraguans have told me most foreigners do not enjoy this cheese. Through personal experience, I can confirm this trend.

So cheese in the US and cheese in Nicaragua, are two very different things. Culturally, a simple food is drastically changed by its context. Without contextualization and cultural competency, some pretty unfortunate consequences can take place.

This idea is the basis, as of this moment, for the research I will hopefully be conducting in Nicaragua and Guatemala in relation to, instead of cheese because I am in no way a food connoisseur, Occupational Therapy. The occupations -- Activities of Daily Living, Instrumental Activities of Daily Living, Education, Work, Rest and Sleep, Play, Leisure, and Social Participation -- are drastically different occupations than here in the United States. This begs for investigation.

Map of Guatemala

As a client-centered practice, therapists must function from the context of the client, therefore understanding the context in which the client's daily life takes place is integral to providing effective therapy service.

I hope to observe and discover through interviews the culturally relevant differences that influence Occupational Therapists in providing effective occupational therapy in Nicaragua and Guatemala, searching for occupations, norms, and values typical of an economically underprivileged country and a country with a rich indigenous population.

I expect this experience to be enlightening, intriguing, and hopefully informing to the Occupational Therapy profession.