Working with underserved populations is incredibly rewarding, according to OTs who have taken up practice within these communities. “It is incredibly fulfilling work. You get to use all of your OT training,” says Emily I. Raphael, MA, MS, OTR, instructor, programs in occupational therapy, Columbia University, New York. Raphael works with the homeless in Manhattan.

There are plenty of opportunities to work with the underserved, including refugees, according to Yda J. Smith, MOT, OTR/L, assistant clinical professor, division of occupational therapy, University of Utah, Salt Lake City.

“Volunteer opportunities are endless. All of the agencies are happy to take volunteers.” For jobs, she says, “OTs can come in as case workers or positions that help with health issues.” Smith supervises projects with refugee-based reciprocal learning principles in Salt Lake City, one of a number of designated resettlement communities for refugees.

OT Advantage

OTs have an advantage working with the underserved. “We understand that small changes and small gains are really tremendous changes and gains,” says Janet Falk-Kessler, EdD, OTR, FAOTA, director, programs in occupational therapy,
Columbia University.

Falk-Kessler has been working in homeless shelters for 15 years. Initially she looked at the relationship between cognitive deficiencies and difficulty with activities of daily living.

“I found that there was certainly a very strong connection between the two, which wasn’t a surprise to me or occupational therapists, but it was a surprise to non-occupational therapists working with this population. They don’t use the same lens that we use when we look at how well somebody functions,” she notes. “In shelters, there are people who work really hard to provide opportunities for their residents to learn various skills. They teach basic skills like money management and cooking skills, but they do not approach it in the same systematic way an occupational therapist would approach it. Then they wonder why these individuals are not learning or retaining the skills they are trying to teach.”

Prior to teaching and working with refugees, Smith worked with people with head injuries. “There are a lot of similarities in the training that you can easily transfer over,” she notes. Through a joint city and university grant, Falk-Kessler and Raphael are working to show that promoting skills through OT helps the homeless move out of the shelter and into a community environment sooner.

Basic Housing Skills

Both Smith and Raphael work with clients on basic housing skills. Whether it is unfamiliarity of a new environment or a physical or cognitive deficit, the same OT training and tools apply. According to Smith, “A lot of the people we work with had dirt floors and no electricity or plumbing before. So now they have an apartment and an apartment manager who can get upset with how they are maintaining their apartment, and then they are at risk for eviction. So we teach them how to clean and what products to use in what situations.” Refugees also may need help understanding how to work appliances such as garbage disposals and ovens, how to use public transportation, how to enroll kids in school, and how to pay bills.

The homeless may need help adapting to independent living, Raphael explains: “Housing readiness is a very important issue with these clients, who have often not maintained their own apartments. Many of these clients have schizophrenia, substance use disorders, as well as traumatic brain injury. All of these conditions lead to
cognitive impairments, especially in the [areas] of decision-making, organization and sequencing, judgment and safety, as well as planning and problem solving.

“Many people who are homeless and move into apartments become very fearful if something breaks in the apartment. Rather than talk to a super or try to fix it themselves, they move back out on to the street. Their ability to deal with new information or executive function is compromised.”

With help from colleagues, Raphael was able to convert an old smoking room at the shelter into an OT clinic. “We have created a model apartment so that clients can learn and practice the skills they will need to maintain their own apartments and a healthy lifestyle,” she says.

The Happiness Factor

Smith and her group started a weaving project with women from Korea to help them work on their traditional weaving. “So many people come here as refugees and then aren’t participating in things they cared about; they are struggling financially … and depression is really common. So if you can have people do things that bring them happiness, then you can help to avoid depression or other mental health issues,” she says.

A gardening project also was implemented. “The joy that it brought to be able to garden was so evident, and they viewed it as an economic advantage that they could spend less money on food and therefore have that money to spend on other things,” Smith notes.

Raphael’s work with the homeless also incorporates creative projects, such as a photography and walking group, co-led by an OT student and a recreational specialist, that resulted in photos and poems for display at the shelter. Two men who enthusiastically helped navigate the group through their favorite places — a park and boat marina — have since moved into their own apartments in the city.

Resources

Migration Policy Institute: www.migrationpolicy.org

National Coalition for the Homeless: www.nationalhomeless.org

Helfrich CA, Fogg LF. Outcomes of a life skills intervention for homeless adults with mental illness. J Prim Prev. 2007;28(3-4):313-326.

Miller KS, Herzberg GL, Ray SA, eds. Homelessness in America: Perspectives, Characterizations, and Considerations for Occupational Therapy. Binghamton, NY: The Hawthorne Press Inc.; 2006.

Pollard N., Sakellariou D, Kronenberg F, eds. The Political Practice of Occupational Therapy. Edinburgh, Scotland: Elsevier; 2008.

Townsend E, Wilcock AA. Occupational justice and client-centred practice: a dialogue in progress. Can J Occup Therapy. 2004;71(2):75-87.