Abstract
This Eleanor Clarke Slagle lecture describes the author’s work with marginalized populations, including homeless adults with mental illness, premature aging conditions, and poor literacy; women who became homeless as a result of domestic violence; children in impoverished, urban school systems reading below grade level; and adults with severe and chronic mental illness that impeded their ability to secure employment, housing, and independent community living. The author illustrates how and why occupational therapy practitioners should become part of the primary care team that evaluates the impact of multiple disorders on marginalized populations’ daily life activities, provides services to optimize community participation, and provides environmental modifications to enhance safety and function.
This Eleanor Clarke Slagle lecture examines the occupational therapy profession’s work with marginalized populations, particularly adults with mental illness who have experienced homelessness, and calls on practitioners to improve the lives of this population by providing services as well by joining primary care teams to identify the impact of multiple disorders on the daily life skills clients need to leave the shelter system and transition to and maintain supported housing.
In this Eleanor Clarke Slagle lecture, 1 I examine a topic that has not been addressed in the occupational therapy profession by more than a handful of dedicated practitioners, and that is our work with marginalized populations. A marginalized population is a group of people who—because of personal attributes such as clinical diagnosis, socioeconomic status, age, race, ethnicity, religious beliefs, or gender orientation—have been excluded by society from typical community participation.
There are many marginalized groups in our society today, but one of the most ostracized groups is homeless adults with mental illness. The U.S. Department of Housing and Urban Development (2021) has estimated that on any given night in the United States, approximately 580,000 people are homeless. Roughly one-fourth of homeless adults have a severe mental illness that likely contributes to and serves to maintain their homelessness (National Coalition for the Homeless, 2009; U.S. Department of Housing and Urban Development, 2020).
Homelessness among adults with mental illness commonly has roots in unstable childhoods marked by precarious or absent parenting, neglect, and sometimes violence (Tyler & Schmitz, 2018). Children in such situations often experience family homelessness and intermittent foster care placements. Many experience childhood depression, anxiety, and conduct disorders (Narendorf, 2017). They grow up with an innate feeling that the world is an unsafe and unstable place. The depression, anxiety, and anger they experience in childhood often become heightened in adolescence, a developmental period when serious mental illness—such as major depression, bipolar disorder, and schizophrenia—often becomes more apparent (Gewirtz O’Brien et al., 2020).
Approximately one-fourth of homeless adults are estimated to have mental illness (Ayano et al., 2019). This figure is likely underestimated, however, and it is grossly disproportionate to the 1 in 25 adults in the larger U.S. population who have serious mental illness but are not homeless (National Alliance on Mental Illness, 2021). It is likely that the chaotic family home lives, housing instability, poverty, food insecurity, and unsafe living environments experienced in childhood and adolescence foster the mental health conditions that contribute to adult homelessness (Ayano et al., 2019). These life events—unstable childhoods, successive periods of foster care placement, and onset of severe mental illness in adolescence—cause gaps both in education and in the learning of daily life skills.
By the time a child experiencing these events has reached early adulthood, that adult likely possesses significant knowledge gaps with regard to basic life skills, such as self-care; meal preparation and nutritional knowledge; banking, budgeting, and bill paying; clothing care and laundering; cleaning and taking care of a home; obtaining employment; and managing health disorders (Marshall et al., 2021). Many have dropped out of high school or have graduated with substantial academic incompetencies, such as an inability to read fluently or use functional math, which are skills needed for almost all instrumental activities of daily living (Grajo et al., 2020).
If it seems that the cards are stacked against these adults, it’s because they are. According to the U.S. Bureau of Labor Statistics (2019), high school dropouts are 3 times more likely to be unemployed than college graduates. Adults who have only a GED or high school diploma earn about 50% less than those with a college education (Torpey, 2021). Approximately 85% of juveniles in the court system are functionally illiterate (Formby & Paynter, 2020), and 75% of prison inmates never earned a high school diploma (Lockwood et al., 2015; U.S. Department of Justice, 2003). Although marginalized populations in the United States have not traditionally received occupational therapy services, many could greatly benefit from our assistance. Through this Slagle lectureship, I will share my work and that of colleagues to illustrate how and why occupational therapy practitioners should provide services to marginalized populations.
Life Skills for Women Who Experience Domestic Violence
My work with marginalized populations began many years ago, when my colleague Hanna Diamond and I, with a group of occupational therapy students, developed and assessed a life skills program for women who had become homeless as a result of domestic violence and were residing in a protected shelter (Gutman et al., 2004). An estimated 5 million women experience domestic violence annually in the United States (Centers for Disease Control and Prevention, 2020), and some studies have suggested that 85% of women with disabilities experience abuse at some point in their lives (Breiding & Armour, 2015). For women, the link between domestic violence and homelessness is substantial; estimates suggest that 50% of women who are homeless have left abusive home situations (Sullivan & Olsen, 2016; Figure 1).
The link between domestic violence and homelessness is substantial.
At the time we worked with this population, researchers had not yet established the connection between domestic violence and cognitive deficits that impair the daily life skills needed to leave a violent partner and live independently in the community (Gutman & Swarbrick, 1999). Fractures of the midfacial bones, the mandible, and the orbitofrontal bones are the most common head and facial fractures sustained as a result of domestic violence (Loder & Momper, 2020). Many of the women we worked with had sustained injuries to the head and face as a result of partner violence and displayed poor attention and concentration, slowed mental processing, short-term memory deficits, poor problem solving and planning, lack of safety awareness and judgment, impulsivity, and difficulty learning new information. We suspected that such cognitive deficits may have functioned to prevent these women from permanently leaving the abusive situation, obtaining employment for economic independence, managing the financial and physical upkeep of a home for independent living, and executing safety awareness and good judgment in self-care and child care (Gutman et al., 2004).
Our intervention with these women addressed the following topics: Safety planning to promote self-protection and prevent revictimization in the home, shelter, and community Drug and alcohol awareness to promote an understanding of how chemicals can impair judgment and facilitate victimization Money management to attain independent living and remove financial dependence on the abuser Vocational and educational skill training to earn money to live independently and leave the abusive environment or homeless shelter Housing applications to attain a safe home Hygiene, medication, and nutrition routines to promote health maintenance Leisure exploration to replace unhealthy activities with health-promoting ones Safe sex practices to prevent sexually transmitted diseases and pregnancies and to learn to recognize unsafe situations that can lead to revictimization Assertiveness and advocacy skill training Anger management training Stress management training Boundary establishment and limit setting.
To help the women learn these skills, we used techniques traditionally applied in the treatment of mild brain injury: practice in real-life settings, opportunities for repeated practice with feedback, use of compensatory strategies and adaptive techniques, and graded activities that progressively became more challenging.
We assessed the intervention using a one-group pretest–posttest design with 26 participants over 6 mo. We used goal attainment scaling to measure outcomes; 81% of the women achieved their most favorable outcome, and 19% achieved their desired expected outcome. Outcomes included applying for and receiving housing assistance, applying for and attaining employment, and reducing or ceasing substance use (Gutman et al., 2004).
Housing Transition for Homeless Adults With Mental Illness
Much of the work that I’ve been involved with in the past decade has been in the development and assessment of housing transition programs for sheltered adults with mental illness. Again, this is a group who commonly reach adulthood without knowledge of basic activities of daily living and instrumental activities of daily living (IADLs). Even when they learn these skills before young adulthood, the skills often deteriorate as a result of untreated mental illness, chronic substance use, periods of hospitalization or incarceration, and mild head injury resulting from street violence (Raphael-Greenfield & Gutman, 2015).
Homeless adults with mental illness and substance use disorders are more likely to remain homeless and to lose housing than homeless adults without these diagnoses (Stergiopoulos et al., 2019). In the United States, occupational therapy practitioners have not commonly been involved in service provision in either the shelter system or supportive housing once clients attain tenancy (Gutman & Raphael-Greenfield, 2017). Many homeless adults with chronic mental illness and substance use histories proceed through the shelter system and receive supported housing without acquiring the skills needed to manage their physical and mental health disabilities or to safely function in and maintain apartment living (Gutman, Raphael-Greenfield, et al., 2018). Once they obtain supported housing, their lack of home management and health maintenance skills commonly lead to problems such as hoarding, which can cause building leaks and insect and rodent infestation; unsafe use of stoves and appliances, presenting fire safety hazards; failure to take prescribed medications, which often results in illness events and rehospitalizations; and inability to budget with sufficient skill to effectively use subsidy payments for food and self-care (Gutman et al., 2016). There’s a critical need for occupational therapy practitioners to help this population attain the skills they need to leave the shelter system and function optimally in supported housing.
Over a 5-year period, Emily Raphael-Greenfield and I designed, assessed, and refined a housing transition and maintenance program that a shelter employee named the SMART Program—Supporting Many to Achieve Residential Transition (Gutman et al., 2016; Gutman & Raphael-Greenfield, 2017, 2018; Gutman, Raphael-Greenfield, et al., 2018). This program was based on a needs assessment with shelter directors, employees, and residents. Over the years, the SMART Program developed into six modules.
Module 1 addressed the housing interview. Many shelter residents must participate in a housing interview in which they are asked to demonstrate their readiness for transition to supported housing. This module included Using appropriate self-care and hygiene skills before the interview; Arriving to the interview on time and in appropriate clothing; Answering difficult questions about their past, which may include incarceration and substance use; Appropriately using eye contact, facial expressions, body language, and posture; and Avoiding substance use before the interview.
In Module 2, participants learned about and practiced the skills needed to maintain supportive apartment living either independently or with a roommate (Figure 2). This module addressed Using apartment cleaning strategies, appropriate cleaners, and a cleaning schedule; Organizing important documents, medications, and self-care products; Storing and preparing food appropriately; Caring for and laundering clothing; Paying rent and utility bills; Getting along with roommates and neighbors; and Using safety strategies in an apartment.
In Module 2, participants learned about and practiced the skills needed to maintain supportive apartment living.
In the third module, participants learned about and practiced the skills needed to live cooperatively and peacefully with neighbors and interact appropriately with supers and landlords. This module covered Understanding what it means to be a respectful neighbor, Understanding when it’s appropriate to contact supers or landlords for help and how to interact with them, Negotiating conflict with neighbors, and Being able to appropriately introduce oneself to others.
The fourth module addressed community living. Many clients feel isolated once they transition from the shelter to supported housing. Because clients often experience posttraumatic stress disorder from homelessness and frequently have a history of conflicted relationships, many do not reintegrate into the community and instead remain isolated in their apartments (Raphael-Greenfield & Gutman, 2015). Module 4 helped clients Explore their new neighborhood; Identify places of importance in the neighborhood, such as the post office, grocery store, doctor’s office, laundromat, and pharmacy; Identify free community activities, including parks, museums, zoos, and YMCAs; and Learn safety skills to negotiate urban streets and subways.
Module 5 addressed money management. Clients learned to Examine their spending habits, Adhere to a budget, Modify their budget when financial needs change, Pay bills on time, Learn saving strategies, and Learn to protect themselves from identity theft and scams.
Finally, Module 6 addressed health and wellness. Many clients have not had adequate medical care throughout their lives and, as a result of homelessness, have prematurely aged and experience chronic medical conditions that affect daily life. This module helped clients understand How to promote physical health through diet and exercise, How to maintain sleep hygiene, Why regular medical care and screenings are needed to prevent and manage illness, How to manage medications, Why smoking cessation is important, How to manage stress, How to improve their health literacy skills, and How to enact a wellness recovery action plan if and when their mental health symptoms return.
Each module was supported by a video and facilitator manual. Facilitators could pause videos to engage clients in hands-on functional activities that allowed them to practice new skills. The SMART Program has been manualized, and facilitator scripts, interventionist training procedures, fidelity checklists, and intervention guidelines have been developed for all six modules. The videos and facilitator manuals are free to download (Gutman & Raphael-Greenfield, 2018).
Findings from three studies that we conducted with 52 participants to assess the SMART Program showed that intervention participants learned desired housing transition skills and attained housing faster than control group participants who received only customary shelter services (Gutman et al., 2016; Gutman & Raphael-Greenfield, 2017; Gutman, Raphael-Greenfield, et al., 2018). Although our housing transition program was successful with a majority of participants, Emily and I were aware that a critical component was missing, and that component was functional literacy.
Functional Literacy for Homeless Adults
Functional literacy is the ability to interpret common written materials needed to effectively carry out basic daily life skills and participate in meaningful occupations and social roles (Grajo & Gutman, 2019). Functional literacy is an emerging practice area in which occupational therapy practitioners support literacy as it directly affects clients’ performance of and participation in daily occupations. The term functional literacy was first coined by Lenin Grajo and me in 2018. Functional literacy activities include money management, medication and health management, navigation of public transportation systems, shopping and meal preparation, clothing care, and employment seeking. These are all critical skills that homeless adults need to transition from the shelter to supported housing, and they are involved in almost all IADLs.
Although services have been developed to teach homeless adults reading skills (Goodacre & Sumner, 2021), such programs have commonly been divorced from literacy skills embedded within real-life daily activities that homeless adults identify as most personally meaningful. To address this gap in service provision, Lenin and I developed a functional literacy program for sheltered homeless adults having difficulty with the IADLs needed to transition to supported housing. Our functional literacy program was based on five essential elements: Focusing on participation in daily community occupations that clients identify as most important Facilitating literacy within an occupational context instead of teaching reading skills in isolation; participants identified the essential reading materials they encountered in home and community occupations and facilitators of and barriers to access to those reading materials Helping clients generate their own problem-solving strategies for word and symbol decoding Partnering with community organizations, such as local banks, grocery stores, pharmacies, and transportation authorities, to provide participants with opportunities to practice functional literacy skills in meaningful, real-life contexts during therapy sessions Allowing clients to identify the community environments in which barriers to desired participation occur because of poor functional literacy skills and holding therapy sessions in those environments.
We assessed this intervention in a two-group controlled study with a group of 23 sheltered adults with mental illness. The 8-wk, twice-weekly intervention addressed functional literacy skills in six specific areas needed for housing transition: Apartment living: interpreting household product labels, food package directions, nutrition labels, cooking directions, expiration dates, appliance labeling, clothing labels, laundry detergent instructions, community flyers, and weekly store advertisements Community living: interpreting signage in stores, subways, buses, streets, pharmacies, and post offices; writing letters and addressing envelopes; interpreting subway and bus schedules and maps; reading transportation kiosk instructions to purchase subway tickets; and using maps to reach specified destinations Money management: writing checks and paying utility bills; developing monthly budgets, recording weekly expenses, and reconciling receipts; completing direct deposit and electronic fund transfer forms; using ATMs; and reading bank statements Medication management: interpreting medication and prescription labels; understanding dosages, directions, warning labels, and expiration dates; and sorting pills and organizing medications according to package instructions. Health and wellness: learning about healthier food options in the grocery store and purchasing healthier foods by interpreting nutritional labels Leisure participation: exploring leisure activities using the Interest Checklist (Klyczek et al., 1997) and identifying low-cost community resources for leisure pursuits, including parks, museums, zoos, and card games.
Our results demonstrated statistically significant differences between the intervention and control groups—the intervention group made gains in reading participation with regard to performance, satisfaction, frequency, effectiveness, and level of support needed for daily life activities requiring functional literacy (Grajo et al., 2020). Although occupational therapy practitioners are not responsible for developing clients’ reading abilities, we must be responsible for addressing literacy skills that promote occupational participation.
Literacy Support in the School System
Nowhere is the need to address literacy more evident than in the education system. According to 2015 data from the National Assessment of Educational Progress, an estimated 64% of fourth graders and 66% of eighth graders in the United States read below grade level. Low-level readers are disproportionately African-American and Hispanic and largely grow up in neighborhoods of low socioeconomic status (Nitardy et al., 2015). Illiteracy and low-level literacy are often embedded in an intergenerational cycle of poverty and residential instability (Bennett et al., 2013). The children of illiterate and low-literate parents acquire fewer preliteracy skills during their preschool and school years, and many children residing in low socioeconomic areas live in shelters or foster care homes. Such children typically have few opportunities at home to engage in literacy, often lack role modeling for literacy behaviors, and commonly do not internalize self-concepts as readers during their early childhood years (Menheere & Hooge, 2010). Children in underserved communities are at significant risk for growing up with deficiencies in the reading skills required for school completion, employment attainment, and independent community living.
The classroom environment, where low-level readers are required to sit still at desks and focus on worksheets and books for extended periods, is often difficult and foreign to them (Buckingham et al., 2013). Such children are often unable to maintain pace cognitively with grade-level work, and feelings of frustration and stress commonly erupt into disruptive classroom behaviors. The further these children fall behind academically, the more frustrated they may feel when presented with educational activities beyond their comprehension. This dynamic results in a cycle of low self- concept, feelings of frustration and stress, and disruptive behavior (McArthur et al., 2016).
To address this gap in service provision, I worked with an extremely gifted doctoral student (who has since earned her doctorate), Mari Arnaud, to develop a school-based reading participation program for first and second graders attending elementary school in an impoverished New York City area. In a pilot study, we used a two-group randomized controlled design to determine whether 21 students reading below grade level who received the occupational therapy reading intervention in addition to traditional classroom instruction would demonstrate higher reading levels and participation than students receiving only classroom instruction (Arnaud & Gutman, 2020). We provided the intervention over 10 weeks beginning in the 6th month of the school year. Each participant received two weekly sessions consisting of a 30-min individual session and a 30-min small-group session with a peer. Sessions provided the opportunity for participants to practice basic reading skills through activities supporting nine principles (Arnaud & Gutman, 2021): Children can learn to associate reading with positive experiences to break the cycle of dislike for reading, avoidance, and dysfunctional classroom behavior. Games, play, and rewards are incorporated into the reading instruction process. Children can learn to integrate reading and motor activity, such as vestibular and proprioceptive movement, that alerts the reticular activating system and provides a pleasurable sensory experience. Children are invited to learn while engaged in movement instead of seated at a desk. Children can learn to integrate reading and sensory activity—in other words, learning can be facilitated through the use of sensation to strengthen the association between words and sensory experiences (e.g., touch, smell, sight, taste, sound; Figure 3). Children can make reading personally meaningful by integrating their own interests, choices, and cultural contexts into the learning process. Children can learn reading skills through participation in purposeful, functional activities that are meaningful to them—for example, book making, letter writing, and craft projects. Children’s unique strengths and learning styles can be identified and incorporated into the learning process. For example, we encouraged children with artistic talent to write and illustrate books and children with musical talent to write and sing songs. Children can learn emotional regulation and frustration tolerance skills to better deal with reading challenges. Children can create and rehearse habits and routines that support reading activities in the classroom and at home. Children can be helped to internalize images of themselves as readers.
Children can learn to integrate reading and sensory activity.
We found statistically significant differences with large effect sizes between the intervention and control groups’ scores on postintervention reading assessments (Arnaud & Gutman, 2020). We also found that intervention group participants displayed greater reading enjoyment, increased home reading participation, improved home literacy routines, and greater agency as readers compared with the control group.
Parent–Child Literacy Support for Children Reading Below Grade Level
The pediatric literacy support study showed us that school-based occupational therapy practitioners can and should support literacy skills in underserved and at-risk populations using familiar sensorimotor activities. But we realized that intervention must also take place in the home, with the children’s parents or guardians, if literacy activities are to be embraced and promoted by these children’s caregivers. Mari and I are currently carrying out a second study in which we are assessing a parent–child reading participation program that we’ve developed. The purpose of this pilot study is to assess the reading participation program in a low-income community targeting the parents of elementary schoolchildren who are reading below grade level.
The program equips parents with strategies to incorporate reading participation with their children into their home routines to increase their children’s exposure to print, reinforce academic skills at home, and provide opportunities for positive associations with literacy. Participants learn to establish times in their daily schedules for reading, identify locations in their homes to organize and store reading materials, and experience a variety of pleasurable ways to engage in reading, including playing games, following recipes, taking walks in the neighborhood, and going to the library. Preliminary data indicate that parents are learning to interact with their children in literacy activities in ways that parents did not understand or address previously.
Supported Education for Adults With Mental Illness
The preliminary results of this parent–child literacy program support an idea that was presented to me many years ago by one of my doctoral professors at New York University, Judy Grossman: One of the best ways to help children succeed is to help their parents succeed. As I mentioned, many adults with mental illness experience gaps in their education because of illness onset in adolescence, and they are twice as likely as peers to drop out of high school (National Alliance on Mental Illness, 2021). In the United States, educational attainment is directly linked to employment success. Adults who have only a GED or high school education earn approximately 50% less than those with a college degree. Adults without a GED or high school education have a higher unemployment rate than all other categories of workers by approximately 50% (U.S. Bureau of Labor Statistics, 2019). The ability to succeed in the worker role is directly related to one’s ability to secure basic needs—appropriate health care; food, clothing, and housing; and social participation. Success in the worker role is also related to one’s ability to live independently, secure an acceptable quality of life, and engage in activities and roles that are personally meaningful.
In 2004, Vicky Schindler and I developed a supported education program to help adults with mental illness newly enter or return to school to complete a GED, vocational training, or community college courses (Gutman et al., 2007). This work was later continued in New York City with Irene Zombek and Jennifer Dulek, who were practicing at St. Luke’s Roosevelt Hospital at the time. Many of our participants had histories of homelessness and were living in temporary or supported housing.
The supported education program consisted of 12 classroom modules that focused on the skills needed to succeed in school or work: (1) exploration of training programs, certification, and work options; (2) study skills; (3) time management skills; (4) effective reading skills; (5) basic writing skills; (6) basic computer skills; (7) introductory Internet skills; (8) functional daily life math skills; (9) use of library resources; (10) public speaking strategies; (11) professional behaviors and social skills; and (12) stress management skills. The modules provided opportunities for participants to enhance their basic educational knowledge and practice the skills needed to succeed in postsecondary settings and job training programs. The program allowed participants to practice professional behaviors and social skills such as coming to class on time, comfortably interacting with instructors and peers, having the confidence to speak in front of others, and independently completing homework assignments. Additionally, each participant was paired with a mentor who was an occupational therapy student, who helped their mentee maintain their motivation to remain in and complete the program, apply skills learned in each module to their personal educational goals, explore available educational and job training programs, complete applications for specific schools or training programs, complete financial aid forms, study for the GED or for school or job placement tests, and use customized compensatory strategies to enhance their performance at school or work (Figure 4).
The supported education program consisted of 12 classroom modules that focused on the skills needed to succeed in school or work.
The supported education program was assessed in two separate studies. In a randomized controlled trial with 38 participants, we found a statistically significant difference between the intervention and control groups in scores on the five instruments used to measure the program’s effectiveness (Gutman et al., 2009). Of the 21 intervention group participants, 76% completed the program. At 6-mo follow-up, 63% had enrolled in an educational program, obtained employment, or applied to a specific vocational program; only 1 control group participant had enrolled in an educational program.
Fall Prevention and Environmental Modification for Prematurely Aged Sheltered Homeless Adults
After years of working with the homeless population, it became clear to me that chronic homelessness severely prematurely ages people and increases their risk of major systemic organ disease. Adults with a history of chronic homelessness have a mortality rate 3–4 times greater than an average adult in the United States and a life expectancy of approximately 50 years (Roncarati et al., 2020). Premature aging and disability in sheltered homeless people likely result from poor conditions they encountered while living on the street, including unsanitary bathing and toileting; little to no physical, mental, and dental health care; substandard nutrition and lack of a consistent food supply; and exposure to physical assault and victimization (Pope et al., 2020).
Very little is understood about the impact of disability on the sheltered homeless population’s ability to stay safe in and maintain temporary or permanent supported housing. For example, cognitive problems resulting from head injury and chronic substance use may increase the risk of fire hazards in communal kitchens. Physical disabilities resulting from orthopedic injury and systemic organ disease may place them at risk for falls when rising from the toilet or getting in and out of a tub. Visual–perceptual problems and low vision resulting from diabetic neuropathy or stroke can heighten fall risk by decreasing their ability to see items on the floor, recognize changes in surface levels, and identify wet or slippery surfaces (Gutman, Amarantos, et al., 2018). Unfortunately, the shelter system rarely identifies the problem of premature aging and the impact it may have on housing placement (Figure 5).
The shelter system rarely identifies the problem of premature aging and the impact this may have on housing placement.
In 2016, a group of occupational therapy students and I conducted a study in which we examined the safety risk of 25 formerly homeless adults then residing in temporary supported housing; we sought to better understand the impact of their chronic health conditions on their home safety (Gutman, Amarantos, et al., 2018). The participants, who had a mean age of 58, possessed severe and debilitating health conditions that closely resembled a normative reference group of 563 adults age 75 and older (Chiu et al., 2001). Participants’ physical, cognitive, and mental health problems significantly interfered with their ability to safely function in supported housing apartments and engage in desired daily life activities such as self-care, meal preparation, and home management. Most supported housing environments lacked essential home safety modifications and equipment, such as shower and toilet grab bars, nonskid flooring, and ramps. Participants reported high rates of falls, near falls, and emergency department (ED) visits.
In the following year, we implemented a home safety modification program with a small group of 11 sheltered homeless adults residing in temporary housing who were identified as prematurely aged or chronically ill. Participants had experienced one or more falls in the previous year, and we sought to determine whether we could reduce falls, near falls, ED visits, and hospitalizations in this group (Gutman, Douglas, et al., 2018). The intervention consisted of two components: (1) providing environmental modifications and (2) training participants in home safety strategies. Environmental modifications included the provision of grab bars in shower areas and around toilet frames, safety treads in tubs and shower areas, shower benches and chairs, raised toilet seats, nonskid shower mats outside the tub area, bed rails, adjustable standing aids, memory foam mattresses for participants with chronic pain, reachers, long-handled sponges and shoehorns, sock aids, nonskid socks, shower caddy totes to prevent soap from falling to the shower floor, automatically lighting nightlights, and clear shower curtains to increase light in shower areas.
To further reduce fall risk, we installed wall-mounted storage and drawer systems to create clear walking paths and reduce floor clutter, and we secured all electrical wiring to the wall. We also repaired brakes on rollators, replaced worn-out rubber feet on walkers and canes, and readjusted mobility device length as appropriate. Training encompassed instruction in and opportunities to practice safety techniques such as getting in and out of a tub; using a shower bench and handheld shower head; and rising from the bed, toilet, and couch. At the end of the year, participants had experienced statistically significant reductions in falls, near falls, ED visits, and hospitalizations compared with the previous year (Gutman, Douglas, et al., 2018).
Stress Management Training for Sheltered Homeless Adults
Shelter life is stressful, and homeless adults in temporary shelters have a unique set of stressors that can exacerbate mental illness. Although shelters typically provide three meals a day, a bed, and medical and psychiatric care, shelter life is often harsh, and residents may be exposed to violence, drug use, and theft. Stress also frequently emerges from conflict with roommates and other residents, insufficient food and medication, lack of transportation resources, and fear of becoming homeless again. Many shelters are located in areas characterized by crime and drug use that can trigger residents’ relapse after periods of abstinence. Many homeless adults are estranged from their families and have no or highly dysfunctional support systems. People who are chronically homeless typically have posttraumatic stress disorder resulting from a chronic lack of basic resources including food, shelter, toileting and bathing facilities, and protection from assault (de Vet et al., 2019; Pope et al., 2020).
Many homeless adults—even after they receive housing—are severely malnourished and sleep deprived and have imbalances in neurochemical hormones needed to maintain basic mental health function. High stress levels that go untreated or are inadequately treated over time are highly correlated with decompensation, ED visits, and hospitalizations (de Vet et al., 2019; Pope et al., 2020). Although the shelter system typically provides psychiatric care and medication, such services usually do not address the stressors commonly experienced in the shelter system, and most shelters do not teach stress-reduction strategies that residents can use over time and once housed (Gutman et al., 2019).
To address this gap in service provision, a group of occupational therapy students and I developed and assessed a stress management program using a two-group controlled design with 24 participants. Intervention and control group participants were matched on the demographic variables of diagnosis, age, race, and gender. The intervention consisted of a 6-wk psychoeducation group with six modules (Gutman et al., 2019): Anger management and conflict negotiation: Shelter residents often experience anger and conflict; uncertainty about their future; and exposure to theft, violence, and crowded living conditions. Diet and nutrition: Although residents typically receive three meals per day in the shelter, we designed the diet and nutrition module to help residents understand which foods and beverages increase agitation and which promote stable blood sugar levels and emotional equilibrium. Exercise, leisure, and recreation: Many shelter residents do not participate in healthy leisure and recreational activities, often because they either never learned such activities or relinquished them when they became homeless. Consequently, residents commonly spend large amounts of time participating in no occupations or in dysfunctional ones such as substance use and excessive television viewing. Sleep hygiene: Dysfunctional sleep patterns are common in shelter residents and often unaddressed, adversely affecting resident stress levels. Wellness recovery action plan (WRAP): WRAPs are written documents in which participants identify stress response strategies consisting of appropriate activities; intervention; and contact with counselors, family, and friends. WRAP documents also allow participants to identify which specific types of intervention, service providers, and family members should and should not be involved in their care if they are no longer able to make self-determining decisions. Meditation and breathing techniques: Many residents have a history of dysfunctional stress management strategies such as substance use and cigarette smoking. Most have never been exposed to meditation and breathing techniques. A large body of evidence supports the effectiveness of these techniques when performed regularly (Rose et al., 2020).
All modules were manualized with written scripts, PowerPoint slides, an appendix of practice activities, and facilitator fidelity checklists. Each session ended with a 20-min meditation in which the facilitator provided guided instruction on breathing and visualization techniques against background music. At postintervention, we found statistically significant differences with large effect sizes between intervention and control group scores on a stress scale.
Conclusion
This body of work demonstrates that occupational therapy practitioners can substantially improve the lives of adults with mental illness who have experienced homelessness not only by providing services to this population, but also by joining primary care teams to identify how cognitive, musculoskeletal, sensorimotor, visual–perceptual, and psychosocial disorders affect the daily life skills these clients need to leave the shelter system and transition to and maintain supported housing. Colleagues have asked me why I’ve carried out this work when occupational therapy practitioners in the United States are not typically reimbursed for service provision to this population. My answer has two parts.
First, as good citizens who care about our fellow human beings, occupational therapy practitioners should use our unique skill set to help this population. They so desperately need help, and our skill set is entirely congruent with their specific constellation of needs. It has become clear from events in the past several years that in our society, homelessness is part of the larger problem of systemic racism. The majority of homeless people in our country are Black, African-American, and/or Hispanic (Montgomery et al., 2020). As occupational therapy practitioners, we should use our skills and knowledge to help solve this societal problem.
The second part of the answer is that as a profession, we need to advocate for occupational therapy’s role with populations beyond those we are currently serving (Figure 6). We should not forget that the founders of the profession intended occupational therapy services to be provided in the community with ill and marginalized populations needing help (Loomis, 1992). Our profession’s history is replete with practitioners who worked with impoverished and socially marginalized groups to better their physical and mental health and to help them integrate into American society and social roles (Harley & Schwartz, 2013). We should remember, too, that our fellow Canadian, Australian, and British occupational therapy professionals are extensively involved in community mental health service provision, including services for homeless populations (Marshall et al., 2021). The work that Emily Raphael-Greenfield and I implemented with sheltered homeless people in New York City created multiple job opportunities for occupational therapy practitioners in area shelters. Several of our most talented students were hired in shelters that had not previously employed occupational therapy practitioners. And all of the research I have described has provided opportunities for occupational therapy student participation.
The founders of the profession intended occupational therapy services to be provided in the community with ill and marginalized populations needing help.
It’s a wonderful experience to go abroad and engage in service learning with underserved populations. But spending thousands of dollars on airfare is truly unnecessary when our own country is filled with people desperately needing help. So I implore students who read this lecture to consider what I’ve said and to step up to this challenge. Use your education, your intelligence, and your heart to help the thousands of sheltered adults and children in our country attain better lives. Use the skills that you were fortunate enough to learn through your occupational therapy education to make a difference in the lives of those among us who are most marginalized by our society. I also challenge faculty members to consider developing student service learning opportunities in your local cities with people who have been left out of the American dream and forgotten by our government officials. Do not stand by witnessing this occupational injustice perpetuated by unresponsive politicians, federal officials who would like to sweep this population under the rug, and a society that wants to maintain closed eyes. Be the ones who see the need for help, and rise to serve.
As I close this lecture, I’m completing the last years of my career. I encourage those who are in the beginning or middle stages of their career to answer this call. Develop and engage in service learning opportunities, provide volunteer services on weekends or evenings, and apply for jobs that have non–occupational therapy titles but in which you can demonstrate how occupational therapy practitioners can improve the lives of this population. Whatever you do, be part of making a positive difference. In closing, I’d like to leave you with two quotes by author and humanitarian Pearl S. Buck: The test of a civilization is in the way that it cares for its helpless members. (My Several Worlds, 1954) Exclusion is always dangerous. Inclusion is the only safety if we are to have a peaceful world. (A Bridge for Passing, 1962)
Footnotes
1
This article is an adaptation of the Eleanor Clarke Slagle Lecture presented at the October 2021 AOTA Education Summit, St. Louis, Missouri.
Note. Photographs in this article are for illustrative purposes only and are not images of the author's clients.