The Power of the Imagination

As we explore and learn about the educational system of Guatemala, read articles about the educational modalities often used, and see first hand classes being given, we have come to realize, as mentioned in my previous post, that imaginative play and practice of creative thinking skills may not often be seen within the school system or even within the home. Bear in mind this is simply a perceived generalization rather than something we have discovered through our research, nevertheless it is worth contemplating.

This idea of the lack of opportunities to practice using the imagination, creative play, or critical thinking inspired a bit of reflection on my part in ideas of the imagination and its importance.

Take a moment and imagine if using the imagination were not revered or encouraged, and looking past reality to pretend were an unfamiliar exercise. Imagine if you were not taught to practice using creative skills to believe in a better tomorrow, to believe that you could be unique and anything you wanted to be, but rather you were taught to simply memorize the reality of the present given to you by those around you. Imagine if your innate human ability were to be suppressed by a hostile fatalism. Imagine if your future were determined by options defined by others, potentially others who do not want you to succeed, rather than your own dreams and ingenuity. Imagine if you were told that your fate was to be poor, and then you were never even given the practice, let alone the opportunity, to believe in the possibility of an alternative. Imagine not being able to experience even this simple exercise because you had never learned to suspend perceived reality for a moment.

The power of the imagination lies in its ability to look beyond the perceived present, liberate the

Kids Restaurant

mind from perceived restrictions, and allow a view of the world from a different angle. From childhood we pretend. We create worlds without rules or at least only with the rules we want. We create friends who are purple and tall with five eyes and tiny feet. We apply only the limits we define for ourselves.

"Freedom of choice does not constitute the basis of real power; rather it is the faculty of defining possible social choices that is the main source of power in any society." (Mulot, 2004)

Macadamia Nuts

It is in learning to define our own limits that we experience the freedom to imagine our future in whatever light we see fit. Our belief in a malleable future pulls us toward achievement, creativity, progress, and social change. Imagination allows us to live in a mentality where the answer to "What do you want to be?" and "What can you be?" are the same.

Imagination is what allows us to create organizations with radical ideas of changing the world, protecting the earth, or simply providing macadamia nuts to undernourished Guatemalan children. It allows us to believe in ourselves and our ability to design our own future.

Imagination allowed young activists to believe in civil rights and the potential for their realization within the United States using creative, imaginative, and non-violent stands against injustice. It is the imagination that allows someone to have the silly idea of making a bathroom into a garden. Young entrepreneurs, today, seeking new, sustainable, and beneficial services to provide the world are using their imaginations to believe in and work toward a better tomorrow for themselves and their community.

With the power of the imagination, we gain the countercultural idea that we can step outside the individualism, selfishness, prejudice, and stereotypes perceived as normal today in order to believe that we can care for someone, who maybe we never expected, more than ourselves. In all of this I came to realize, that it is from our innate ability to imagine that we also gain the experience of love.

Reference
Mulot , E. 2004. A historical analysis of the educational modalities of inequalities management in Costa Rica, Cuba and Guatemala. Compare: A Journal of Comparative and International Education, 34(1), 73-85.

Occupational Imprisonment

The NAPA-OT Group

The idea of occupational imprisonment emerged from a discussion of the daily lives of those we are observing here in Guatemala as well as the impoverished in general. Occupational Imprisonment arises when an individual's occupational "need-to-dos", those tasks that we all must participate in to survive (e.g. finding/growing/earning and consuming food and drink, maintaining shelter, sufficient clothing), overburden all other occupational opportunity.

In a sense naming this phenomenon occupational imprisonment is a bit ironic in that many who are currently imprisoned within the penal system are in fact experiencing occupationally deprivation, having little opportunity to participate in meaningful activities, the exact opposite problem I am attempting to describe.

If someone is experiencing this occupational imprisonment, there is little opportunity to diversify the occupations performed by that individual, little room for Miss Frizzle's favorite advice, "Take chances, make mistakes, get messy." For example, an indigenous woman in Guatemala who is responsible for cooking tortillas, cleaning the home, caring for children including getting them to healthcare, weaving to earn an income, pleasing her husband, and abiding by social requirements for community ceremonies has little space or "occupational opportunity" to make progress toward something like women's equality or organizing communities to prevent land loss.

In the same way, a poor ladino man who wakes early to collect firewood for the breakfast fire, works all day in a construction site, returns to his own small rented plot of land to tend his own garden, and works to maintain their small casita has little opportunity to further his education so that he can acquire higher paying and more stable job opportunities. This also occurs in the United States. A homeless man who wakes at 4:00am under a thunderous overpass from a sleep only coaxed into existence through exhaustion works a day labor job all day to pay for his dinner, walking 6 miles to and from the labor office, has neither the energy nor the time to lend toward properly advocating for affordable housing in the urban center.

Because the systems are built in such a way that leaves no room to explore adaptations to these occupations without severe sacrifice and risk, it is nearly impossible for the impoverished to explore potential new methods or technology to increase resources or time. A woman making tortillas will not attempt a new method or a different meal because failure means her family does not eat that day when they need to, so she maintains the routine and never tries to innovate or imagine something different.

Those with the privilege of already having a surplus of technology and resources attempt to step in with NGOs or Non-profits and insert a solution that did not emerge from the people, that was not born of the native culture and customs. Therefore this new synthetic solution doesn't work or at least work well because it did not organically grow from the imaginations and hearts of those who need it. 

The oppressed become imprisoned in an impoverishing routine of their own necessary occupations, leaving no opportunity for imagination and innovation.

Then we, as the privileged, are able to step back, watch the systems and impoverishing routines, and say, "Work harder and you will make it. Pull yourself up by your bootstraps and you can be successful. You are poor because you are lazy and not working enough." When in reality they are poor because they can do nothing else but work.

Week 2 - Guatemala

After two weeks here in GA, I am absolutely loving this field school. We have performed over 25 observations of social work visits and educational promoter observations. Our research is based in a small town called San Miguel Milpas Altas, a mostly sustenance farming village further into the mountains. We visit for approximately 4-5 hours a day and I and my partner follow an educational promoter around within the classrooms she is working or hike up and down the very steep streets to visit different homes and check on families and children with a social worker.

We have visited multiple levels of the tiered Guatemalan Health System and I believe I am beginning to understand some of the many barriers to health care delivery. The complex system of State organizations and NGOs create a healthcare system that is often inefficient and not client centered. However, on paper, the healthcare system and educational system look fantastic with multiculturalism, equality, and equal opportunity built right in. The caveat to this paper paradise is the actual enforcement and implementation of the laws that have been put in place. Based on different sources, somewhere between 2-5% of homicides are investigated, let alone convicted. This statistic parallels the implementation and resources allocated to the education and health care system by a largely corrupt government.

We began the process of Qualitative Data Analysis this week by forming the beginning ideas for a code book. We still have some data collection to finish up next week but because we have little time we are beginning early. We will be producing a 60 page written report from our findings hopefully at the end of the 4 weeks.

This week we spoke with the dean of the college of social sciences at a large university in Guatemala City concerning the history of structural violence in Nicaragua and the niece of a former president of Guatemala who is doing anthropological (and in my opinion occupational) research into safety perceptions and environmental risks for young girls. Her project is actually very interesting in that it first has multiple levels. She has a complex process of finding and working with women and young girls who have experienced domestic or sexual violence. Using the occupation of not only documenting the issues facing these girls but also allowing the girls to tell their story on a larger scale through videos this anthropologist is empowering and rehabilitating. 

The second level of her project is something they have named Safe Scaping. The young girls take GPSs throughout their town and mark down coordinates of where they feel safe, mildly safe, and unsafe. Using this activity the researchers have been able to pin point locations that are problematic for young girls and are now taking steps to alleviate those problems.

Ashley and Ryan

Also this week, I was indigenously married, for the second time. This is what I get for always being one of the only boys in this profession.

My best moment this week probably was discussing within our smaller group  a seeming cultural norm that may be impeding huge amounts of progress for Guatemalans. In reviewing and  discussing our observations within the classroom, we have realized that critical thinking and imaginative play are severely lacking within the education system as well as in general. Granted a generalization at this point, but it seems that ingenuity and imaginative thinking are simply not taught or at least not taught often. The main technique is rote memorization. For this reason, Common Hope has made it a particular goal to increase critical thinking within the school setting. 

The most exciting realization then was that the educational promoters, after looking back on our notes, were actively working to resolve this problem. For example a teacher asked questions about a book, "What color was the lion?", "Where did the mouse like to run?", whereas the promoter stepped in and began asking questions like, "If you were the mouse what would you have done?", "If you were a hunter and saw the mouse eating the rope, what would you have done?". The promoter then praised those students who were able to think outside the box and create answers that weren't based on pure memory of the story.

Worst moment... definitely tripping in the street and straining a tendon in my knee. It definitely reminded me of the many physical accessibility barriers that are still very present within Guatemala. But before we make Guatemala wheelchair accessible, we may want to also focus on decreasing barriers to actually receiving a legitimate wheelchair through the Guatemalan health system.

This is a very typical dilemma of a socially or otherwise oppressed group. The sufficient provision of resources is being prevented not only because resources are scarce, but also because the systems (international and domestic) are built in such a way that removes the power from the oppressed, effectively creating a web created to keep them trapped. 

We have learned that this can be referred to as the "core" and the "periphery". For example, countries who are part of the "core" hold the power to manipulate and form structures that then affect the periphery. An example of this might be CAFTA. Much of Central America currently could not function without the aid and economic interaction from the US. Therefore they have no ability to refuse or bargain for a more appropriate agreement that does not tip the scales in favor of the core. Because the oppressed countries are functioning on a baseline of survivorship, they have no room to take risks or make bargains. Literally, one day of bargaining or community organizing for some members of the community we are working in would mean no food for the family sometime later.

We are exploring and attempting to understand how the complex systems of economies, politics, healthcare, and education negatively affect the ability of everyday Guatemalans to perform in meaningful and sometimes even necessary areas of occupations.

Week 1 - Guatemala

After a hectic trip of 18 hours due to delays and then the airline delaying my bag, I finally arrived in GA Saturday morning July 13th at 7:00am. I spent the weekend with a friend visiting a variety of groups of people affiliated with different organizations here in GA. I also made a connection that I hope to use to go into La Limonada one of the most impoverished portions of Guatemala city.

I arrived at my home stay on Sunday night and met my family which consists of two parents and two young boys as well as another OT student in the field school. They are in GA terms around middle class and the mother loves to cook and explain her cooking for us. We began the fieldschool on Monday and I don't know that I have ever been more excited for 4 weeks before in my life. We are a group of OTs, anthropologists, a biomedical engineer, and a doctor who are first and foremost attempting to understand Guatemala from a holistic and structural perspective.So far we have had lectures looking at its history and health systems from a birds eye view. I am learning a lot of big picture systemic reasons why occupational therapy meets barriers in its delivery as well as the cultural differences that face potential therapists or other healthcare workers.

An interesting factor is the historical memory of the recent civil war and the desire to remember what happened has created a distrust in medical workers because many who reach out to the rural communities are employed by the government, a government, supported by the rich, that committed genocide during the civil war. Many indigenous are fearful of any interaction with government workers therefore they choose not to receive medical care.

Another interesting cultural difference is that, in many ways, humoral medical beliefs still permeate the populations, both indigenous and ladino. This can sometimes cause confusion or distrust of certain medical interventions because from this perspective they may seem counter productive

Our fieldschool is divided into three groups researching a different topic. One group is researching infant nutrition and cultural norms relevant to it. Another is researching the systemic barriers present to surgical referrals and reception. And finally my group is partnered with a pretty great organization called Common Hope and we are researching how social workers are supporting the progress of children's education within the program by visiting their families and how educational promoters (pretty much teachers teaching teachers better classroom management techniques) are being received by teachers. We talk a lot about the occupations these two groups (Social workers and educational promoters) use to create effective results and change within each of their respective settings.

 It is a wonderful exercise in using occupation to create social and structural change on an individual level as well as within the classroom as a whole. My job within this group is to do qualitative observations of educational promoters interacting with the teachers and students and social workers interacting with students and their families. I am responsible for taking notes on every single conversation that occurs within the class and between the teacher and the promoter.

I have 3 hours of one on one Spanish class/ 3 times a week with a Guatemalan Spanish professor. That can be pretty tiring but I have found my professor to be a rich resource for understanding structures and norms relevant to medical service delivery.

I have been surprised at how well my Spanish has held up, I have also been wonderfully surprised to find a great group of OTs who are really ready to think outside the box from the occupational perspective. I was pretty tired after the first week for sure and slept for most of Saturday morning.

I am ready for the next week.

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.