Facing My Privilege: The End of a Journey

Anyone who has left behind the comfort of privilege and thrust themselves into a situation that we might call "unjust" or in "poverty" understands the wave of emotions that rolls over as you are faced with the realities of our world. Stepping into a homeless camp, a "third world" country,  or even a prison, as part of the privileged class, I was taught first to feel pity and sadness for the unfortunate situation before my eyes and gratitude for the situation I left behind at home.

As you dive deeper into the injustice, you realize that this pity and gratitude you have been taught to feel can be detrimental and hurtful to many people and therefore begin to leave behind these first reactions to excavate new truths that inspire new emotions. Learning of the connections between my own country and the civil war and poverty that occurred and is still occurring in Guatemala, seeing the connection between health and poverty in the United States, understanding the relationship between politics, business, and the provision of medical technology, understanding the economic control exerted over countries or communities in order to exploit and use the poor, crime connected to prejudice, prejudice connected to history, cultural norms that disregard some humans while affording advantage to others for arbitrary characteristics, accepted realities of competition, profit mongering, selfishness, ignorance, hatred and finally the realization that our world functions on systems that are so complex, so intricate, so compounding, that it is impossible to articulate or even imagine what a world might look like in which each human was treated with love, value, and joy, all come together to create an overwhelming, distressing, and frustrating gauntlet between us and the realization of a loving world.

Anger, frustration, pain, and guilt emerge each time I find myself in these situations, as I sit in realization that even in my attempts to approach poverty, human rights violations, and injustice in a way that breaks the norm of dependency and subverts control over the poor, I, a white cis-male US citizen, from a middle class family, many times simply reinforce and sometimes further the oppressive system in place. I cannot separate myself completely from the world in which I was formed, from the unchanging "truths" of western culture and the culture of the United States. It seems that I cannot step back from myself and sift through these truths and find which ones are valuable and which are not. It feels almost impossible to discover which ideals hurt and harm the people around me and know then that I should leave those behind. When you pull on one string of injustice, three more appear, when you try to pull the choking vine from the tree, branches fall on your head.

We become overwhelmed and saturated with the complexity, jaded by the constant uphill battle, and frustrated when people simply choose to be selfish, greedy, and deceitful. We feel like single droplets making no difference in the ocean of injustice. As we turn home, we feel broken, incomplete, and sorrowful as we face the privileged situation before our eyes and feel longing, shame, and discomfort for what we leave behind. We recognize that no matter what, we can always return to our safe havens, our comfortable homes, and our distracted lives. We know that we will never be able to feel the full extent of the pain and hardship of those people who are suffering at the behest of our lifestyle of imprisoned consumerism and forced individualism. We always have an escape. We always have a plane ticket out of poverty. We always have a ride waiting for us at the airport when we get home. We throw ourselves onto our soft beds in our warm houses and cry because our privilege permeates even our very blood.

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But then, as you lift your face from your tear-stained feather pillow, as you feel the wounds from standing next to the oppressed, the broken pieces of yourself laying around you, and the voids in your soul calling for fulfillment, the faces of the many people you met along the way emerge, little by little tending to your wounds, aiding your recovery, sorting the pieces of yourself into piles to keep and piles to throw away.

You allow the smile of a young shoe shiner to leave its mark on your soul through compassion, reminding you of his passion for learning, his dedication to his family, and his ability to simply sit in peace even at 10 years old.

You feel the care and guidance of the powerful spirit of your mentor, an occupational therapist with a heart for true solidarity and mind for true understanding, helping pick up the pieces of yourself that were broken, putting them back together, maybe in new places with new purposes.

You feel the embrace of a new friendship emerge from an unexpected relationship, holding your hand as you drive along the hard road of analysis, understanding, and true recognition of the complexity of oppression, pain, and anger.

You feel the energy of humans colliding together from all sides of the planet to learn, grow, and change with one another, opening up themselves to the souls of others.

You hear the laughter of new friends echoing off the cobblestones of an old colonial city, sending vibrations of hope through the hardest of stones.







You see light peek over the mountain of pain and injustice before you, reminding you that there is hope, there is joy, and there is a possibility for a better future.

You touch the scars from your past wounds, reminders that the wounds of the oppressed don't often have the time or privilege of healing into scars. You are reminded that the work is never done, and you have been forever changed. You hear the call to return to solidarity, to leave your privileged life, give back what has been stolen from the deprivileged people of our world. As you look in the mirror to see who you have become and what you might provide to our world, your ears are forever tuned to the cries for human dignity and human rights.

You bring your past experiences with you as tools for the future, filling you with the fuel of passion, driving you to stand up, open your windows and your heart, and scream to the world that you are ready for change, ready to be a small part of a body, walking toward justice, taking on the challenge of imagining the potential for a better world alongside your fellow humans. You are ready to listen with your whole being, to be moved by the poor and shaped by the suffering. You realize as you turn to face your privilege that, although it affects your life so much,  it does not have the final word.





You are ready to reclaim what it means to be human,  what it means to be a part of the human community. You are ready to make the final word something much more powerful than privilege: love.

Speaking Without Words

Over the past 4 years, I have traveled to Central American many times, each time with a particular purpose: to explore, understand, and support the resolution of the injustices that are present here in the world between the United States and Colombia.  Each journey dove deeper into the structural, cultural, and political causes of the hunger, violence, and injustice prevalent throughout this land of lakes and volcanoes. Each time I set foot in these places my agenda was "analyze", "ask questions", and "find answers", however in the past few weeks, it seems my agenda has included a more diverse schedule.

In some moments, as I step across the familiar cobblestone streets of Antigua, walking to the print shop or passing by Central Park on my way to buy some bread, as I sit at the bow of a boat skimming across the silky water of Lake Atitlán, feeling just a sprinkle of rain hit my skin, as I feel the warm sun on the back of my neck as I talk with a young Guatemalan with the soul much older than mine, or as I sit at dinner with friends discussing fears and personalities, I feel myself forget to analyze. I forget to connect all the social and political factors together into a map leading me directly to my place in society at that moment.

Instead, I feel the pressure of each stone through my shoes on the balls of my feet, the sharp and the dull, the angled and the flat, the rough and the smooth. I hear the music of flutes and drums in Central Park as a band plays for onlookers. I let the wind of the lake whip across my face, holding my attention with its gentle touch yet roaring sound.

I feel the droplets of rain touch my skin as small reminders that I am alive. I sit and do nothing, creating space to see the people around me as humans rather than sociological pawns. I hear the laughter of a friend as I feel the same sound escape from my own chest.

As we drive home from a National Hospital, the smell of the truck exhaust in front of us pinches my nose with its unnatural stench. The spiciness of jalapeño pupusas sits on my tongue for just a moment longer than usual, breaking from my usual hasty eating to experience the food. I walk lightly through ancient ruins, imagining the people who 500 years ago walked the same path.

I feel the soft touch of a friend's hand as we dance together, laughing and smiling as the only ones brave enough to let the music move us. I see the reflection of people in a puddle as they walk by, a portal into another world. I feel the bump and rattle of the camionetas we ride to class each Monday and Wednesday, noticing the detail and intricacy of the designs on each one.

In these moments I am pulled from my demanding mind and find peace in the sensory experiences of the world around me. There is no analysis, there is no larger contextual connection, there is only feeling, tasting, hearing, seeing, smell, and moving. The details of the world around me light up through my senses, reaching deep into my muscles, telling me each stone's texture through my toes, each droplet's weight through my skin, each human's emotion through my eyes, and each taste of life through my tongue. Without words, the world describes itself to me.


I am not sure why these experiences have been so prevalent lately. Maybe because my purpose on this trip is not really to analyze or process, maybe because the person who taught me the value of these experience has been on my mind quite frequently of late, maybe it is because I am not engulfed in searching for an answer because I have not asked a question... there could be many reasons. It really doesn't matter why.

Sometimes the only thing that matters is that I am here, in this complex and diverse world, filled with experiences, people, tastes, sounds, sensations, and emotions. I am one living organism speaking with the world through my life, a dance of soul and sense, a moment in time to be felt to its fullest extent.

Identity, Occupation, and Environment

In many ways, I think my generation in the United States has become obsessed with the idea of authenticity, identity, and the true self. I am not sure exactly why this preoccupation has emerged within my age group, and one could speculate reasons regarding many things, both negative and positive like narcissism, historical context, or even a reaction to a consumerist and wasteful culture. Whichever may be the cause, we have seen the emergence of identity seekers shape the environment and occupations of our society into a young generation that values local beers, "alternative" lifestyles, nuanced or sometimes new aged religious beliefs, and diversity. Our identities, our true selfs, emerge from the interaction between our agency and the environment around us, occupation. Our occupations become integral to the expression of our identity, acting as the means through which we create our persona in this world.

I am laying on a blanket in a park in Cincinnati with my shirt off, reading Pedagogy of the Oppressed with a friend playing Arcade Fire songs on her guitar next to me. These activities relate to and facilitate an identity for myself both in my mind and the minds of others, a university educated, urban living, male in the United States.

I sit in a coffee shop with another student discussing our shared experience in Nicaragua and the merits of fair trade products and the potential pitfalls of genetically modified organisms. An identity emerges through this engagement, a traveled, cultured, socially aware global citizen.

These occupations, the ways that we live our lives, create an identity that our generation believes is deeply rooted in the authenticity of the soul, the true human essence.

As I spent the past week and a half here in Guatemala, I have realized that there is both a lasting truth and deceitful lie intertwined with this true self concept. As I have walked through the streets of Antigua, spoke with locals, and simply sat in the park, I have found a forced identity shift because of the changes in what I am doing and environment in which I am doing it.

I sit modestly dressed, with a backpack sitting next to me, camera hidden within, taking notes on a bench in Central Park. In that moment, no matter what, my white skin, height, clothing, and my lack of a native routine will always connect me to my identity as a visitor, a foreigner. This identity is forced to the surface of every unclear interaction, unfamiliar exchange, or even passing glance. In the United States, I may have thought of myself as alternative or slightly outside the mainstream, yet here I am far from the most alternative gringo who walks barefoot in the street with Aladdin-like pants, a tie die tank top, dreadlocks, and a guitar slung around his back. I am foreign, white, and most usually expected to not speak Spanish and never expected to speak any of the 23 native languages.

Here in Guatemala, my environment has had a profound impact on what I do and how I do it which therefore has had a noticeable impact on my perception of my own identity. But is this such a bad thing, to be forced to reform and reassess my identity within this new context, new environment. Some in my generation might claim travesty that the Guatemalan context simplifies me to a white foreigner, most likely "helping" poor Guatemalans through a mission trip.  People my age might say I am being unfairly pigeonholed into an identity that isn't "truly" me.

Is it not? Is this white, middle class, man, taking notes and pictures here in Guatemala not who I "truly" am. Well, like I said, this is both a truth and a lie. As much as my generation might want it to be, I have come to realize, our identity is not like a stone sitting in a river, being moved or thrown about, chipped our smoothed on the surface but with an unchanging, unbending core. We are not the same in every environment with which we interact.

We are much more like a toy box, filled with many different identities, both small and large, some of which have drifted toward the bottom. The identities that lie on the surface, just as you open our lid, depend on what the person who you are engaging with most usually plays with and toys you make most easily found. Your environment through your occupations within it, often pulls to the surface the part of your identity that it most wants, sometimes taking just what is on top, and sometimes digging deep into the parts of ourselves with which we have never engaged. We are always changing, reorganizing, and reinventing the identities within our selfs to interact with the world. We might be able to maintain a static identity if we did not do anything, however to be human is to occupy our time, to do, to be, and to be alive. Our identity is something richer, deeper, and more fluid than a simple label or a single story.

So yes, I am a university educated, urban living, male as well as a somewhat traveled, generally socially aware person. However, part of my identity is also simply a white person from the United States who is visiting Guatemala for a short time. This is no more or less authentically part of who I am and becoming aware of that fact may inform and enrich how I go about engaging with this new context. Understanding what that newly emerging identity means for my place here in Guatemala challenges me to understand how I fit into this contextual puzzle, if I am, as Frank Kronenberg would say, "doing well with" the Guatemalan people.

Recognizing the many parts of my identity through the things that I do every day, being aware of them, and understanding their relationship to the world around me will help me to better understand how I can use the many toys in my toy box to support change toward justice in our world. Being aware the many facets of my being will better equip me to relate, engage, and be open to the people and experiences waiting for me in the world. Our generation has clung to the idea that we each have an single unchanging truth that runs in the core of our being, and that may be true in some ways, however our identity and the occupations associated with it are malleable, changing, things that allow us to disconnect and connect with our world.

We are part of the world around us, shaping and being shaped by it. We exist with our world, not in spite of it and our occupations help us discover what that existence looks like and means.

Back in Guatemala: Thinking about Productivity and "doing nothing"

I am back in the wonderful country of Guatemala this week, preparing for the National Association for the Practice of Anthropology - Occupational Therapy Field School. I was lucky enough to return to Antigua as the coordinator for this fantastic fieldwork experience for both anthropology and occupational therapy students. We will be going on a whirlwind adventure of four weeks exploring and researching various topics including Pediatric Development, Sustainable Technology, and NGO Networks in Health.

Before that adventure begins, I have had some time this week, as we prepare for the fast paced weeks to come, to explore and spend some time simply being in Antigua. Today, I found myself sitting on a bench in the middle of the city. In the center of this small colonial town sits Parque Central, a hive of activity, events, and interactions. People, both Guatemalan and foreign, walk, talk, and move throughout the green plants, cobblestone streets, and small stores. Venders selling ice cream, bracelets, table centerpieces, and shoe shines meander through the park gently and sometimes more aggressively engaging with those passing by or seated on the benches. Tour guides and instant photographers linger around the fountain in the middle of the square, waiting for someone who needs their services. Young children play around the fountain and old men smoke cigars, commenting on scantily clad gringas walking by. Pairs of police officers wearing intimidating military-like uniforms stroll through the area eyeing the people with a heightened awareness.

Guatemalan teenage school girls sit in a circle around one of the benches in the park surrounding a laptop computer looking at something that periodically makes them shriek like... well... school girls. They giggle and glance at the older boys who walk passed them, all of them dressed in the typical white and blue uniforms of Guatemalan public schools. A young mother and her child sit near the edge of the fountain. The little boy chases the pigeons as she texts on her cell phone, taking a moment to stop and give her child a peck on the lips when he approaches. Today, there is an event for a local gym in which children from all the local schools came out and did something akin to Zumba with the gym's instructors. There was music and microphones echoing throughout the square, but one could always still hear the constant flow and splash of the center fountain over it all.

As I sat on that bench I pulled out my old Spanish class notes to review some vocabulary. After a few pages, I realized there was no way I would remember any of it with everything happening around me so I opened my notebook and began journaling some thoughts. As I looked around, the majority of other park-goers who were sitting on benches had no notebooks, books to read, crosswords to fill out, or even cameras to take pictures. They were doing nothing. I realized I had pulled out my notebooks to provide some impression that I was not just sitting there watching everyone; I was being productive and had a reason for sitting down and being in the park. However everyone else had no intention of creating an image of productivity, they were doing nothing. Doing nothing, what an interesting idea. Is it even possible?

I guess in reality, these people were doing. They were talking with each other, they were simply being present in the community, and they were watching, breathing, seeing, itching, smoking, hearing, touching, simply existing for a moment to experience the world around them. Such a foreign concept to my mind, marinaded in the protestant work ethic and the fast paced productive culture of the US. How often do you see people at the park in the US simply sitting and watching the other people at the park? They are reading a book, doing homework, exercising, or doing a variety of other things, but few are simply existing in the space, experiencing the world around them without being productive. We march through life with productivity as our goal.


As I sat staring into my world of occupation and analysis, I had stopped writing and was simply glancing around. In that moment, the Guatemalan man who was sitting near me on the bench began a conversation with me. We talked about his teacher in Guatemala City and about some sicknesses he had. He asked about why I was in Guatemala and how long. Then we stopped talking as he told me "I didn't mean to interrupt your work, you can continue working now." He went back to staring and I returned to my notebook.

My apparent productivity had stifled an opportunity to engage the people around me. Holding still in my productive timeline allowed someone else to catch up to me and connect. When I opened up to the world around me and allowed an empty space to emerge in my productive life, it was quickly filled with community. I wonder what else could fill up in those spaces if we just allowed them to happen? Maybe "doing nothing", something so countercultural, is actually an opportunity for the world to fill in the vacant corners of your life, allowing the nuances of people, the smells of the air, the sounds of a fountain, and the sights of a community to enter into the dance we call life. Maybe in spending some time "doing nothing" sometimes we learn to exist together and taste the diverse flavors of this world.

Final Presentation

Crossing Borders, Culture Blindness, and Understanding the Client

As with most journeys like this one, I set out with a specific trajectory in mind, however I arrived at a very different destination than what I would have expected. My goal in the beginning of this project was to understand how Occupational Therapy was being provided to Guatemalans and Nicaraguans based in their own culture and from native therapists in hopes of informing and developing the approach therapists take when working with these specific populations. My question was originally, "How does occupational therapy change and adapt to the cultural differences of Guatemalans, indigenous and ladino, and Nicaraguans?" When looking deeper into the current situation of these countries, along with the current status of Occupational Therapy in them, I realized this question was not so simply answered.

We believe that Occupational Therapy is a client-based profession, one in which therapists must understand their patients' goals and meaningful activities to truly provide effective therapy. However, naturally we, as therapists, employ our own cultural framework to expedite this process. We function from assumptions about our patients that are inherent to our own culture, using  presumed and simply understood cultural paradigms to approach therapeutic intervention. When crossing cultures and even sub-cultures this becomes an obstacle to effective therapy delivery. To provide effective therapy to individuals from diverse socioeconomic and cultural backgrounds, therapists must step outside of what occupational therapy scholars have called "culture blindness", being immersed in one's own culture so comprehensively that the therapist does not recognize their own cultural influences in the therapeutic relationship.

From my experiences in Guatemala and Nicaragua, I have come to realize that for culture blindness to subside and culturally competent occupational therapy to be delivered, therapists must take a step back from their traditional and assumed interventions and approaches and begin to look first at the theoretical foundations of occupational therapy. Therapists must first shave off the culturally biased flavors in which occupational therapy has developed and discover the raw underlying philosophy of the profession. From there we can allow this raw philosophical seed to grow in the natural culture of our patients, bearing the appropriate interventions and approaches rooted in the patients' own cultures and experiences.

This process requires a variety of factors to be in place. The first and foremost is rich soil into which the occupational perspective can be placed. Resources, time, and support are all necessary for the occupational perspective to be cultivated within a population in a way that connects theory to the patient in an authentic and effective manner. Unfortunately, just as Guatemalan campesinos have little land to cultivate their own crops, Guatemala and Nicaragua have little room to develop the occupational perspective. In Guatemala, the healthcare system is overburdened, disjointed, plagued with ethnic tension, overrun with NGOs, and has little room for prioritizing occupational therapy. In Nicaragua, what little occupational therapy is present is restricted by economic and political limitations, having neither the time nor the resources to effective emerge through the Nicaraguan culture.

Secondly, for the occupational perspective to take root and emerge through a new culture it must be interpreted effectively. Because of the huge presence of NGOs, service organizations, and foreign aid in Guatemala, much of the therapy is provided by non-Guatemalans who, although with good intentions, may not be providing the most effective or appropriate interventions for Guatemalan people. On many occasions, therapists provide interventions and techniques that come directly from their experiences in their respective countries instead of providing the reasoning and underlying philosophy behind those interventions to native therapists or caregivers. This creates a situation where patients, family members, or caregivers are performing interventions that may not make sense, are not effective, and maybe even create more of a burden rather than alleviating a problem.

As caregivers or therapists begin to realize that these transplanted interventions are not effective with their population, for example in Nicaragua, they resort to simplified non-occupation based techniques that do not resemble true occupational therapy. The occupational perspective, which was cultivated in Western/Developed cultures, has not been effectively interpreted for cultural differences outside that paradigm. Occupational therapy, because it is such a client based approach, must be acculturated before it can be sustainably effective. For this to occur, occupational therapists must step outside their own cultural paradigms and begin to understand the many structural and contextual factors that influence the efficacy of the therapy.

Understanding that in Nicaragua, the idea of independence may not be the most meaningful concept for a 75 year old woman because culturally she expects her children to care for her. Understanding that the routine of an indigenous woman in Guatemala may not have the flexibility to provide extra exercises to her child with special needs. Understanding that the standard approaches and solutions for assistive equipment, adaptive solutions, or even safety procedures may not be accessible, affordable, available, or of high quality. Understanding that therapists are viewed with less authority and less respect in some cultures. Understanding that sickness, disability, poverty, and independence are all viewed very differently within these cultural contexts.

For therapists crossing borders, it is integral to first understand these factors that affect their clients' in order to be creative, innovative, and revolutionary practitioners and effectively facilitate rehabilitation and/or change. Therapists crossing borders, whether that be across national borders or stepping into a homeless camp, work with tools that both hinder and facilitate potential success in their practice, having to take the time and effort to understand the full context of their patients while also bringing a new and diverse perspective on ways to resolve obstacles for their clients. It is the responsibility of therapists to find a balance between these two, uncovering a manner in which they foster occupational justice while preventing the imposition of their own culture.

Translation: "I want to be happy: To study and to play"

As a global community and a global profession, we must learn to share ideas across cultures effectively and dialogue between therapists, professions, and nations. As occupational therapists, the adaptive thinkers that we are, we approach obstacles from a new and exciting way, thinking of new and sustainable ways to overcome occupational injustice using innovative minds and passionate communities. When we hone the ability to apply the theory, values, and principles of our profession across cultures, socioeconomic statuses, gender, sexual orientation, religion, and countless other diverse contexts, we will make a new step in becoming a globalized profession seeking to support occupational justice for all people both locally and on an international scale.

Nicaraguan Occupational Therapy: Seeing the Whole Picture

Craft Materials

As I began my observation and participation in occupational therapy in Nicaragua, I was planning on providing a reflection on each of my days at the hospital where I am working. It quickly became apparent that this was not going to be an effective manner of conveying my experience because to truly
display and understand the complexities of what is happening in Nicaragua with OT would take much more time to understand or even reflect on. Therefore I altered my approach and attempted to dive deeper into what I was seeing in the therapy room, what I was hearing from the therapists, and connect that to what I already knew about Nicaragua.

Block Pusher

This week has been an interesting and fulfilling experience to say the least. I have been fully immersed in one of two or three locations (still uncertain) that officially provide occupational therapy in Nicaragua, a rehabilitation hospital called Aldo Chavarria (Aldo for short). However, the occupational therapist who I am observing noted that she was unsure that the other places still gave OT. When it comes to receiving OT, Aldo is the place to go in Nicaragua.

Aldo has many departments including physical and occupational therapy, prostheses, aqua-therapy, and others I am sure I have not seen. I have focused all my time in the Occupational Therapy room working with a Nicaraguan occupational therapist and a physical therapist who has taken some courses in occupational therapy. I arrive at 7:30am every morning and begin observation from 7:30am to 10:00am. I have performed two different types of observations: 1) Patient observations - noting every exercise or action the patient performs during their time in therapy and 2) OT observation - noting every interaction, activity given, and other activities performed by the OT. These hours are the most populated by patients. After these hours I begin lending my time as a student by treating patients and actively observing treatment of other patients.

Rheumatism Gym - Excercises for neck

From my observations I have come up with a typical session within this OT room: 1) Patient enters and greets therapist 2) Therapist takes appointment card and sends patient to an exercise for a specific amount of time (usually between 5-15 minutes) 3) Patient performs exercise while therapist is giving activities to other patients (sometimes up to 10 patients), doing paperwork, or standing watching the room 4) Patient alerts therapist when time has been completed or therapist stops patient 5) Therapist directs patient toward a different exercise 6)This continues until end of 30 minute session. The OT occasionally will provide further explanation or instruction to the patient and observe them perform the activity for a few seconds, however the majority of the time she does not have one-to-one interaction with the patients for more than the time it takes to set them up with a new exercise. On some occasions, the OT will stand back and watch the room of patients without interacting with anyone. On a few occasions, I have seen the OT have increased interaction with more severely involved patients with stroke or spinal cord injury. Some patients come with a family member or helper who provides one on one interactions with the patient during their session, sometimes even taking the patient through a set of routine exercises they have

Large Peg Board

learned, without consulting the therapist. In many ways, these helpers and family members are actually providing therapy to the patients, however they may not always be providing the most effective or most beneficial techniques.

Some of the typical activities used are: large peg board (placing pegs in and out of holes), small pegs or blocks, standing while sliding objects across wires, wiping a slide board, removing and placing small velcroed squares or large tic tac toe pieces on a board, lifting rings from one pole to another, general shoulder exercises, wrist machines, squeezing hand strengtheners, screwing nuts on and off bolts, weaving shoe laces through small holes, finger ladder, and making circles and arcs on the table with an ace bandage. (See pictures of some of these activities throughout post). In the fact that I am able to even attempt to list most all the activities I have seen in one week, one can seen their repetitive and unvarying nature.

Sensory integration, autism, adapted technology, occupation based interventions, therapeutic use of self, mental health approaches, and environmental approaches, all of which are huge focuses today in OT, are rarely if at all present in the occupational therapy I am seeing in this Nicaraguan rehab hospital. Physical rehabilitation exercises and the bio-medical model prevail over any specifically occupation based theories or approaches. The PT told me that in the 80s, occupational therapy was provided to the psychiatric hospital near the rehabilitation hospital, but it no longer offers that to their patients. In my

Ring Poles

observations in the past week, I noted 4 patients in the OT room of probably around 100 who received ADL training (wheelchair to bed transfer and functional mobility). The physical therapist performs many of the ADLs in the inpatient rooms. She travels throughout the hospital working with referred patients, maybe 5-7 per day. Otherwise patients, especially out-patients are performing usually one of the repetition based exercises above for sometimes up to 20 minutes. Entering the room, and after a little searching, one can find many materials that could be used to do crafts, games, or creative activities. When speaking to the OT, she recognizes that they have these materials, but she does not use them.

As I sat on my first few days, observing and noting all that I saw, I felt a pinch of condescension and authority believing that I already could see ways therapy at this hospital could be improved. As a student accustomed to the fast paced, function based, productivity oriented, and necessary one-to-one therapy of the United States, my first few days of observation left me frustrated, irritated, and asking

Finger Ladder

the question, "Why won't they do more?" From an outside and foreign perspective, especially one educated in the contemporary OT theory emerging in the US, Europe, and other "developed" countries, I was tempted to harshly judge this OT's methodology for being non-occupation based, simply medically oriented, and far from holistic. Sometimes we are even be tempted to patronize the therapists we seek to serve when we travel abroad and volunteer our time because, "they just don't understand or know". We may believe they don't have a good answer to the question, "Why won't they do more?'

After a few days of internal self-touting, the OT actually asked me directly, "What are you seeing? What do you think about me?" with the attitude that she already knew what my answers would be, and she did. I provided my observations just as I did above. She then proceeded to explain to me her reasons why she had to provide therapy the way she did, recognizing very blatantly that she knew about occupation and occupational therapy and that she knew what she was doing wasn't the best therapy possible. As she continued, each of her reasons sharply poked holes in every view and recommendation I had. I slowly began to realize I had been roped into superficially looking at a situation, allowing myself to forget what this whole project has been about. By the end of the conversation, I realized instead of asking the question "Why won't they do more?" I should have been asking "Why can't they do more?". I needed to step back, understand the context, and see the whole picture.

In the next few paragraphs I will attempt to present my thoughts as to what the answer to this question might be, based in and informed by my observations, quite frank conversations with both therapists, and my current knowledge of Nicaragua and its structures.

When OT is Emphasized

Exercises for the elbow and wrist

According to the PT, in the 80s occupational therapy was focused on in Nicaragua. This was a time directly after the victory of the Sandinista Revolution and during the Counterrevolutionary war which I assume would require from occupational therapy a much more medically focused approach to meet the needs of the physically injured soldiers. However, as stated in this paper by West (1984) published in the American Journal of Occupational Therapy, seated crafts were still considered the standard for OT intervention and only just then were beginning to be critiqued. Imagine a Nicaraguan soldier returning from guerrilla war in the jungle after losing a leg and being asked to make a basket or sew a design in cloth. OT's craft focus at this time may not have helped its proliferation within the Nicaraguan culture especially since many of the crafts, ideas, theories, and methods were based in other cultures not experiencing the social and economic obstacles Nicaragua faced then and still faces today. This may have left OT to be misunderstood and not respected within the rehabilitation world.

Materials in the Closet

How OT is Viewed
As OT has grown its authority, prestige, scope of practice and scientific base as well as broadened its interventions through a deeper understanding of its philosophy and purpose, Nicaraguan occupational therapy has been left behind in a resource scarce context. As therapists become more respected in the developed world, the OT here notes that she feels least respected of all the therapists and that no one thinks OT is important. In the developed world, therapist have the ability to evaluate their patients and plan their treatments, here in Nicaragua the doctors decide the amount of time a patient will be in therapy, how often they will go, and sometimes even what specific activities they will be doing. She stated that patients often refuse to do what she asks and treat her poorly. Unfortunately, she also notes that her job is at risk if patients complain about things like her being too hard on them. For this reason she feels she cannot have more in depth and challenging relationships with the patients and therefore stands back and keeps her distance during therapy. With the patients who she can tell want to work and be challenged, she says she does build rapport and works with more closely. She does not enjoy the job security and support of an administration like many therapists do in the States when it comes to therapist respect, patient interaction, and complaints.

How OT Comes

Tactile Materials

Most commonly occupational therapy arrives in Nicaragua through the hands of foreigners. US citizens, Japanese, Canadians, and others who come to Nicaragua and provide activities they have learned in their own cultures.  In essence, occupational therapy has not bee translated for Nicaragua, it has been transplanted from other cultures. The local university, Universidad Nacional Autónoma de Nicaragua (UNAN), had an OT program that apparently chronically lacked resources and has since been closed. I cannot find any information about this program, how long it was open, how many students graduated from it, or who the professors were. However, the OT at Aldo is one of those graduates. She stated that she had classes for three years on activities, medical conditions, and some psychology to receive her degree. It is clear however, that this program neither had the time nor the resources to truly begin teaching what I might call "Nicaraguan" occupational therapy.

Craft Materials

From my observations and conversations with the OT it seems the activities that Nicaraguan OTs were taught to use are not meaningful or desirable for the Nicaraguans. She says she has tried to use crafts and the patients think they are silly and prefer to come in and do repetitive exercises and leave. The patients do not enjoy nor understand how making a craft like origami, which has no cultural significance, will benefit their progress after a stroke even if the therapist attempts to explain it to them. According to the OT, these crafts do not speak to Nicaraguan patients. The occupations the OT was taught to use do not find meaning in the hearts of Nicaraguans so she stopped attempting to use them.

How OT has Adapted
It hasn't. Occupational therapy has not had the opportunity, resources, or personnel necessary in Nicaragua to flavor the profession to the needs of the Nicaraguan people. The occupational therapist has outdated and, due to the culture, ineffective techniques for providing therapy.  She therefore resorts to non-function based repetitive exercises that lack the attributes that characterize occupational therapy. She understands the value of the diversion activities for mental health and the physical benefits of specific movements during those activities. However, I do not think the underlying philosophy of using meaningful occupations of the patient as a means and ends (which has more recently been more deeply developed in the profession) was emphasized greatly in her education due to context and time in which she received it. The other therapist who is by profession a physical therapist, commented that she had received one class from a professor from Philadelphia that did focus on this perspective. The professor supported the idea of using occupations relevant to Nicaraguan culture and the Nicaraguan people (e.g. planting a garden for the those patients who come from the countryside). The therapist said this could not continue after the professor left because the hospital did not have the resources to provide it. The lack of emphasis on this philosophy as well as the many other structural factors facing occupational therapists have hindered at least this Nicaraguan OT (one of the only ones giving occupational therapy) from applying it to her own culture and social systems, preventing her from developing applicable activities and occupations for her patients to perform. This leads to a stagnant and irrelevant existence for occupational therapy in Nicaragua as nothing more than physical exercise for the upper body.

Continued Conditions of OT
The word that I can use to best describe the OT I work with is burnt out. She is sometimes required to

Small Pegs

treat all the 30-60 patients that come through her door each day. On Tuesdays, Wednesdays, and Fridays she is virtually alone due to the responsibilities of her partner who is the department head. When her partner is there she is not alone, but she is still treating 20-40 patients. Most of these patients come in the morning because they refuse to come later in the day. According to her, if she tries to schedule them later, they tell her no and to schedule them earlier or they just won't come. She cannot use activities that require too much one-on-one attention due to the patient caseload or non-reusable materials due too lack of physical resources that she cannot replenish.  She cannot prescribe adaptive technology because there is no way for the patient to get it. I am also not sure how much education she has had with assistive or adaptive equipment in general, let alone classes or workshops on using local resources to create the equipment. Wheelchairs are often donated and therefore she does teach patients wheelchair mobility and transfers. In my first few days, I was constantly wanting to use a slide board for spinal cord injury patients, a walker for stroke patients, and gait belts for everything else because that is the safety measures I have been taught. However, it would be impractical and actually not function-based to offer a slide board or a 

Wrist Machines

walker to a patient who will not be able to acquire one outside the hospital. With all of these obstacles and demands placed on the OT, I can see why the OT is not the happy fluttering butterfly full of energy and new ideas that we often envision ourselves needing to be as occupational therapists. Therefore she is demotivated and overworked with little resources, leading to therapy that does the job, but is the bare minimum.

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I began my week in the mind set of an occupational therapy student from the United States. As my week comes to an end, I find myself adapting and changing to the needs of the patients here, learning and understanding how to function within this setting. In my short time here, I won't be able to truly understand the complex situation that occupational therapy is existing within in Nicaragua, but I can at least gain a taste of the structural factors and circumstantial obstacles that face the occupational therapists working here. In the upcoming week, I hope to reflect more on how my own treatment, approaches, and presence changed as I begin working with more patients.