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.