Witnessing the Power of Occupation Working With the Unhoused

I had the pleasure of being one of the first occupational therapy (OT) students to complete their Level II fieldwork at the Rescue Mission of Utica. This Central New York facility is a local nonprofit that supports individuals who are unhoused. Myself, my service dog, one other OT student, and our facility lead supervisor started at this facility with the hopes of exploring and laying the groundwork for OT’s role when working with the unhoused.

During our time there, my team and I focused on developing our professional role within the facility’s Emergency Men’s Shelter (EMS) and Drop in Center (DIC). Each setting served unique populations in need of different services related to housing and community integration. Our professional goal within this setting is to help each individual gain the highest possible degree of functional independence in daily life in order to thrive in their community with a sense of dignity and belonging.

The EMS is a temporary residential setting that serves males aged 18 and older. Clients are provided with lodging, clothing, and meals. They are also connected to services related to counseling, addiction recovery, mental illness, and housing. The DIC is a nonresidential setting that serves all unhoused individuals within the community who do not qualify for services at the EMS. Our clientele within this setting consisted of both men and women; individuals identifying as LGBTQIA+; and those experiencing severe mental illness, physical disability, and chronic homelessness.

According to the National Alliance on Mental Illness (2023), 21.1% of unhoused individuals in the U.S. have a serious mental health condition. Almost every client within this facility had a mental health diagnosis. The most common diagnoses that we worked with were schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, generalized anxiety disorder, post-traumatic stress disorder, and substance use disorder.

The prevalence of serious mental health conditions within this population makes utilizing a trauma-informed approach imperative. My team and I focused on providing a trauma-informed approach that emphasized safety, trustworthiness, peer support, collaboration, empowerment, and inclusion through the understanding of unique barriers. We also utilized therapeutic use of self and occupational participation to remind our clients of their strengths and to to establish a sense of purpose.

Our time there was full of implementing occupation-promoting changes. To our surprise, the facility’s residential settings are not accessible to individuals with physical disabilities due to the fact that many of the buildings were built more than 100 years ago and were not renovated to meet the Americans with Disabilities Act of 1990 guidelines. While interviewing the employees, my team and I learned that they do not have the background or training to provide services to such individuals. As OT practitioners, we are experts in accessibility and would be able to address this facility’s accessibility gap in the future. OT is a special profession that can meet the unique needs of people with both mental and physical health conditions. We can also provide employee education on the unique barriers and needs of different populations.

To measure outcomes within our programming, we primarily used the Canadian Occupational Performance Measure (COPM; Law et al., 2019). My team and I found that the COPM can be used as a trauma-informed assessment that empowers unhoused clients through discussing the important occupations that bring them a sense of life purpose. The majority of clients initially scored valued “performance” and “satisfaction” scores as no greater than 5 (out of 10). The most common scores were a 1 for both, indicating that clients were unable to perform the occupations that were most meaningful to them due to deprivation and were therefore not satisfied at all with their performance.

As OT practitioners, we can assist our clients in navigating occupational injustices such as occupational deprivation. It was essential that my team empowered our clients and worked with them to build self-advocacy skills by understanding and addressing their contexts. In order to best understand their contexts, my team and I took field trips to many of the community resources that our clients utilized every day.

Sessions with individuals focused on developing and strengthening the skills necessary to perform and participate in various occupations. Common interventions focused on community navigation, education, self-care, assistive device management, health care management, medication management, sleep hygiene, safety awareness, and sobriety attainment and maintenance. Each intervention was tailored to the unique needs of each client.

Group sessions were the most popular of our interventions within this facility. All groups had a therapeutic discussion, purpose, and expert therapeutic responses that could only be provided by an OT practitioner. Therapeutic groups focused on health management, spiritual wellness, leisure participation, meditation, sleep hygiene, emotional regulation, sensory processing, and intellectual wellness.

I am honored to have been one of the first individuals to lay the groundwork for OT within this Central New York facility. I would highly recommend a nontraditional fieldwork setting for those who enjoy leading and are passionate advocates for the OT profession. This experience encouraged me to express my understanding of the profession in nontraditional and new ways.

Advice for nontraditional Level II fieldwork students

• Be sure to understand the Occupational Therapy Practice Framework: Domain & Process (4^th ed.; American Occupational Therapy Association, 2020) in order to be a confident advocate for our profession.
• It is important to have a strong understanding of diversity, equity, and inclusion. This will help you be a strong advocate for clients experiencing occupational injustices.
• The employers at your setting may also benefit from participating in OT groups to see the breadth of our interventions. Always welcome them to join the group whenever possible.
• Your teammates are the key to a successful fieldwork experience. Be sure to delegate tasks, respect each other's ideas, and utilize each other's strengths.
• Stay organized and document everything you do as best as you can.
• Be aware of compassion fatigue and your own wellness.
• When hosting OT groups, make sure that they contain a therapeutic purpose that is special to our profession. Consider asking discussion/reflection questions involving personal habits, routines, everyday life, and occupation.

References

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Americans with Disabilities Act of 1990, Pub. L. 101-336, 42 U.S.C. §§ 12101–12213 (2000).

Law, M., Baptiste, S., Carswell, A., McColl, M., Polatajko, H. & Pollock, N. (2019). Canadian Occupational Performance Measure (5th ed., rev.). COPM, Inc.

National Alliance on Mental Illness. (2023). Mental Health by the Numbers. https://www.nami.org/mhstats

Anna Owens, OTS, is an occupational therapy student at Utica University. She is a pediatric brain tumor survivor and active member of the Pediatric Brain Tumor Foundation. Anna enjoys completing her occupational therapy education alongside her service dog, Penelope, and she plans to practice with her in the future.

Cicily Talerico, OTD, MS, OTR/L, is a Professor of Practice of Occupational Therapy at Utica University. Her teaching and scholarship focus on mental health across the lifespan, health and wellness, and OTPs for social justice.