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.