Advancing occupational justice through street-based intervention: A case study examining strategies for increasing meaningful engagement in the face of homelessness and incarceration

1 Introduction

The implementation of two sociopolitical strategies of the 1980’s helped set the stage in the United States for the current crises of mass incarceration and scarcity of community-based behavioral health treatment. In 1981, the deinstitutionalization efforts of the Reagan Administration contributed to an increased number of people with mental illness living on the streets. Just one year later, the expansion of the War on Drugs introduced “tough on crime” policing practices which, coupled with draconian sentencing laws, resulted in an unprecedented surge in incarceration rates. By the end of 2016 nearly 2.2 million adults were held in prisons and jails with an additional 6.6 million under correctional supervision [1]. On a global scale this rate of incarceration is unparalleled, reflecting a 500% increase over the last forty years [2].

The rate and impact of incarceration is disproportionately experienced by black and brown communities, those of lower socioeconomic status and the poorly educated. According to Nellis [3], African Americans are incarcerated in state prisons at more than five times the rate of whites, and at least ten times the rate in five states. A report by the National Research Council (2014) found that 64% of jail inmates and 54% of state prisoners report mental health concerns [4]. Growing rates of recidivism indicate that people are released from prisons and jails with unmet behavioral health needs and without adequate access to services (housing, employment, healthcare, etc.) to sustain them in the community. One recent BJS study tracked 404,638 prisoners in 30 states and reflected a 77% recidivism rate for the cohort within five years of release [5].

The devastating and lasting impact of disproportionately incarcerating black and brown individuals, the poor and those with mental illness, coupled with the growing body of research proving its ineffectiveness, has caused some local governments to seek more cost-effective, community-based solutions that not only produce positive health and housing outcomes but also halt the criminalization of these groups.

As Barak and Bohm [6] highlight in their critical analysis of society’s response to homelessness, rarely is the legitimacy of the criminalization process, “administration of justice,” or “the system itself” called into question. In 2013, a county located in a growing metropolis developed an initiative to do just that: call their system into question to shift their crisis-oriented, oft-criminalizing response to issues of homelessness, mental illness, substance use and poverty, to one that focuses on prevention, embraces harm-reduction and eliminates racial disparities.

An initial strategy of this initiative was to deploy a multidisciplinary team of health and human services providers to meet the needs of the individuals who were most frequently incarcerated in the local jails. As is reflective of the national landscape, those most arrested and booked into this county’s jails were disproportionately African American, Hispanic and Native American. Additionally, within this cohort, 94% had a behavioral health condition, 51% had at least one chronic health condition, and nearly all were homeless. It was determined that the complexity of need among this population demanded a team with a diversity of skillsets whose culturally responsive service delivery would be grounded in the evidenced-based frameworks of motivational interviewing (MI), harm reduction, and trauma-informed care (TIC).

In July of 2016 an eleven-person clinical team was formed through a partnership among a level-one trauma hospital, a non-profit with expertise in assertive outreach and case management, and a housing provider specialized in low-barrier, supportive housing. The team is comprised of a program manager, four care managers, a housing case manager, a behavioral health specialist, a registered nurse, a psychiatric nurse practitioner, a primary care nurse practitioner and an occupational therapist. With the permission of the program participants, designated prosecutorial liaisons from the city and county prosecutors’ offices participate in ongoing legal coordination and collaboration with the care team. This unique partnership was envisioned for the shared goal of reducing the participant’s criminal legal involvement through meaningful engagement in treatment and community.

2 Occupational therapy in the face of homelessness

The term occupation is defined as “the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life” [7]. Occupations are broadly described as activities the client wants and needs to do and occupations occur in context and are influenced by the interaction among client factors (values, beliefs, spirituality, body functions and structures), performance skills (motor, process skills and social participation) and performance patterns (habits, routines, and roles) that support or limit occupational performance [8]. Activities of daily living may include those of self-care (hygiene, eating, dressing) as well as instrumental activities that support daily life in the home and community (meal preparation, budgeting, health management, community mobility, home chores) [8]. Other daily occupations include rest and sleep, education, work, leisure and social participation [8]. Interventions of occupational therapy may include building new or enhancing existing skills, creating opportunities for engagement, and modifying or adapting the environment or activity to enable full participation in desired home and community occupations [9]. Individuals experiencing homelessness have limited opportunities for engagement in meaningful occupations. A study by Heuchemer & Josephsson [10] identified perspectives of time as focusing on the here and now with homelessness being perceived as more than a full-time job. Occupations focus on survival and might include protection from the weather, finding shelter, self-care and accessing money or other needed resources. Substance use may also be used as a coping occupation, engaged in to survive highly stressful situations and in times of desperation arising from homelessness [10]. Among other coping and survival strategies, Cunnningham & Slade [11] identified risk-taking occupations such as stealing food/necessities and spending time finding ways to satisfy or curb substance use cravings. Because the coping occupation of substance use is criminalized, the associated consequences can lead to a cycle of arrest and incarceration [10]. Although these occupations were not always seen as meaningful, they helped individuals cope with the trauma and stigma associated with homelessness.

Once daily survival needs were met, individuals who were homeless identified a lack of purpose and overwhelming boredom during their day, looking for activities to pass the time, describing walking up and down the streets, reading, going to the library, spending time in a park, talking to friends, watching TV and sleeping [10, 11]. Even when plans were made for the next day, follow-through was found to be limited by behavioral health conditions, a lack of skills and/or resources needed to accomplish the goal [11]. Individuals staying in shelters or accessing day centers had enhanced opportunities for engagement, however access to such was limited by sobriety-requiring program expectations [10].

Occupational justice, a key concept of occupational therapy, recognizes that all individuals have the right to access and participate in personally meaningful, everyday occupations regardless of age, capability, gender, social class, ethnicity or other differences [8]. This empowering principle confronts the stigmas surrounding homelessness that severely impede a person’s ability to find their place in the community from which they have been ostracized. With the incorporation of OT, the aforementioned care team provided relationship-based, person-centered services to remind clients of their inherent dignity and (re)build their self-determination to improve life skills and reach goals. For most participants homelessness is just one of a multitude of factors impacting quality of life and community connection. However, for the purposes of this case study the impact of homelessness on a program participant will remain the primary focus.

3 Case history

Roger is a 60-year-old, single, African American male who has lived on the streets or in shelters for the past 35 years. His parents are deceased, and he described financial-related conflicts as the cause for lost contact with siblings. When talking about his upbringing, compared to where he is now, Roger stated “I’m just a fuck-up.” Roger began using drugs in his late teens and, amid the onset of the War on Drugs, he experienced multiple drug-related arrests in the early 1980’s. This cycle continued, and throughout his adult life Roger was incarcerated multiple times per year largely due to low-level drug offenses and failures to appear or comply with court expectations.

In July 2016, Roger was identified as being eligible for the program and, after a series of outreach attempts, was visited by the team in April 2017 during an inpatient hospitalization and voluntarily enrolled. At enrollment, he presented with a complex medical history including multiple life-threatening comorbidities such as hypertension (HTN), chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). Medical records dating back to 2014 indicated Roger had been visiting the emergency department 3–4 times per month due to congestive heart failure exacerbated by medication non-adherence and substance use (cocaine, heroin, alcohol). At least 1–2 times per month Roger would require admission to the hospital only to leave against medical advice before any care coordination could take place.

During the initial phase of engagement, Roger was most easily contacted during hospitalizations and was visited several times by the case manager, nurse and occupational therapist who provided support and information on benefits of the program. Given Roger’s general resistance to hospital stays, the occupational therapist would visit regularly to explore his interests and provide resources to help pass time productively and prevent premature discharge. Though initially guarded and resistant, Roger’s motivation for participating in the program increased by the prospect of obtaining permanent housing. Upon discharge from one hospitalization, Roger was referred to a transitional medical respite program only to be denied access during intake due to a 35-year-old felony conviction. The program navigated this barrier by funding a brief motel stay until his health improved enough to return to a local shelter.

During his first few months in the program, staff spent significant time outreaching Roger, bringing services and support to him on the streets, in shelter and bedside when hospitalized. Gradually, on his own terms, Roger’s trust in the program and providers grew, evidenced by his increased willingness to receive medical care. Roger began methadone treatment within weeks of being enrolled, a milestone that not only reduced the harmful effects of heroin use but enhanced his connection to the program as he was frequently accompanied by staff to reduce missed doses. Methadone treatment further improved Roger’s overall medication adherence by establishing a morning routine of taking medications in tandem with his daily methadone dose.

To implement this routine, the program nurse worked closely with shelter staff to provide verbal medication prompts and made weekly visits with a pillbox and, later, a blister pack, which proved to be more effective than taking medications from multiple prescription bottles. This system of close coordination with shelter staff and regular monitoring of blister packs allowed the nurse to observe how consistently Roger was taking medications. Weekly, nurse-coordinated refills reduced instances of medication being lost. To increase trust and connection, staff would take Roger to lunch or to complete errands needed to secure housing (e.g. obtain identification, re-establish and obtain proof of income, and complete applications). The provision of services that were not office-based nor contingent on sobriety is believed to be of critical importance for the trust-building and success achieved with Roger.

Despite having had health insurance, before enrolling in the program Roger did not attend medical appointments due to the complexity of navigating a complicated health care system and the stigma experienced therein. Once connected to the program, the nurse was able to accompany him and re-establish care at the cardiology clinic, secure bi-monthly standing appointments and foster relationship-building with clinic staff. During these visits, Roger received encouragement for the progress he was making, and information was offered without judgement to help increase insight into the impact of substance use on his overall health. These brief but repeated conversations improved Roger’s health literacy regarding the impact of cocaine on his heart and the subsequent triggering of COPD episodes. In addition, the team regularly provided Roger with naloxone and clean syringes as a necessary supplement to frequent conversations regarding overdose prevention. After several months of medication adherence, Roger’s CHF stabilized and a repeat echocardiogram showed an impressive 20% improvement (from 23% to 43%) of his ejection fraction–a measurement of the percentage of blood that leaves the heart each time it contracts.

Despite being denied housing at several locations due to criminal history, with strong advocacy from his care team, Roger was permanently housed within five months of enrollment. Two months later, Roger was considered eligible and agreeable to initiate treatment for Hepatitis C. With extensive outreach, incentives, weekly medication management visits, environmental restructuring and visual cues recommended by the occupational therapist, Roger successfully completed the treatment and continues to maintain an undetectable viral load.

Managing Roger’s COPD proved challenging, but after a year of ongoing support and motivational approaches, he was finally agreeable to visit the pulmonary function lab for testing of his lung capacity. This helped to stage his COPD and gave his medical team a better picture of his respiratory needs. An outreach COPD case manager, in collaboration with the primary care nurse practitioner, nurse and occupational therapist, discussed goals and viable intervention options that Roger might be willing to accept. A home nebulizer was provided to help improve respiratory function and overall pulmonary hygiene. He continues to need considerable skills practice and support to use the in-home medical device correctly and consistently–a goal that is regularly addressed by the team’s nurse and occupational therapist. Although the occupational therapist had semi-regular contact with Roger while he was living in a shelter, it should be noted that occupational therapy services were intensified once independently housed so that interventions and skills practice could be provided in the actual performance environment.

4 Occupational therapy assessments

A primary role of the occupational therapist within the intensive care management team is collaboration with the client to identify meaningful and necessary daily occupations and identify the level of assistance needed for sustained housing while developing skills and routines that enhance well-being. OT assessments were administered to identify the individual factors that contributed to or limited Roger’s occupational performance as well as to assess the complexity of activities he needed to do and existing environmental supports or limitations. Factors assessed included physical, sensory-perceptual, cognitive, emotion regulation, communication and social participation.

Roger was cooperative in completing the occupational profile which provides information on daily routines and an understanding of the client’s occupational needs and desires [8]. Roger’s primary goal was to access and maintain housing. He described his routine prior to housing as sleeping at the shelter, taking transportation to the day center, talking to people, walking around while pulling his rolling luggage, and listening to music. Roger reported having been able to cook and care for home responsibilities but, due to decades on the streets, stated “I might need some assistance remembering how to do things.” He identified meaningful activities as watching TV, listening to music and using a cell phone.

While still in shelter, Roger was agreeable to completing the Allen Cognitive Level Screen-2000 (ACLS) to assess his cognitive abilities and challenges. The ACLS is a performance-based assessment of functional cognition, including the ability to process information and the capacity to learn or relearn skills [12]. This screening consists of three subtests of increasing complexity to predict the level of assistance needed to perform routine tasks in familiar and unfamiliar environments [12]. Roger scored a 4.6 indicating a moderate cognitive functional impairment [13].

Individuals at this level generally have marginal community living skills and should not live alone. Daily checks of the home environment are indicated to monitor safety, remove potential hazards and assist with problem solving. Typically, substantial assistance is needed with instrumental activities of daily living requiring abstract reasoning and pre-planning, such as managing medications and money, organizing time and maintaining health. They may have difficulty understanding abstract consequences and benefit from concrete examples of cause and effect relationships. They often have difficulty generalizing information and when learning new skills, additional time, repetition and visual/auditory cues are most effective when practiced in the actual performance environment. Changes in daily routines are challenging and assistance with problem solving issues is beneficial [13].

During the discussion of results, Roger readily acknowledged difficulty in concentration, complex problem solving, short-term memory, asking for help and following complex directions. As the complexity of the subtests increased, Roger’s performance was increasingly disorganized and he was unable to effectively problem solve. Additional performance-based, functional assessments were made within real life situations in his home and community, such as cooking, grocery shopping and laundry.

5 Occupational therapy interventions

Prior to OT interventions, Roger demonstrated independence in activities of daily living (ADL’s) related to personal care. This included wearing multiple layers of clothing, likely a habit formed while homeless. His room came furnished with a bed, microwave, small refrigerator and sink. Bathrooms and a kitchen were communally shared amenities. Due to his compromised health, Roger was provided a shower chair which he chose not to use due to the lack of privacy associated with the community shower.

6 Discussion

Using a low-barrier, strengths-based approach the team aimed to engage Roger by responding to his needs and supporting the achievement of his self-identified goals without judgement. The team utilized the evidenced-based frameworks of motivational interviewing (MI), harm-reduction, housing first (HF), and trauma-informed care (TIC) when applying therapeutic interventions and providing case management. The outcomes highlighted in Roger’s case are well-aligned with what the evidence suggests about these frameworks, specifically that of MI and HF.

By first increasing client engagement through empathy and later eliciting and strengthening the client’s self-identified motivations for change, MI has been proven to roughly double the rate of change talk (related to substance use) and halve the rate of resistance compared to action-focused, confrontation-style counseling [14]. Within the field of disease prevention and health management, MI is identified as the only health coaching technique to have been “consistently demonstrated as causally and independently associated with positive behavioral outcomes.” [15] When paired with a HF approach, wherein people are provided housing without any preconditions (such as abstinence, stabilized mental health, medication compliance, etc.), evidence suggests that programs like the pilot described here may achieve improved behavioral outcomes for clients as well as improved economic benefits for the community. Namely, a review of the HF literature reveals a reduced reliance on, and subsequent decreased costs of, shelter and emergency departments [16].

As is demonstrated by both the case study and related research, neither the societal nor client-level benefits of these approaches to care are achieved overnight. Behavior change is expected to be incremental and participant-driven. As the literature on TIC indicates, “because control is often taken away in traumatic situations, and because homelessness itself is disempowering, trauma informed homeless services emphasize the importance of choice for consumers” [17]. Informed by this research, the care team in this case study emphasize choice and collaboration with their clients while incorporating harm reduction by exploring practical strategies aimed at reducing the adverse consequences of drug use. Although research on harm reduction programming is nascent, preliminary studies correlate such programming with gradual and life-sustaining improvements in drug users’ lives [18].

By operating from a harm reduction framework, the care team acknowledges that abstinence, though desired by some, may not be possible for all and therefore aims to reduce the harms associated with drug use while honoring client autonomy throughout [19]. The care team tailors their harm reduction approach by assessing each participant’s stage of change and matching their interventions accordingly. All services meet the participant where they are, physically and emotionally, as care providers come alongside to recognize and support each person’s inherent dignity and internal wisdom to engage purposefully and achieve personal wellbeing. A key feature of this model of care is flexibility—of time, location, and spirit of service provision. Participants are seen when they arrive or when they are found, for the time it takes, and their priorities are responded to. The care team can transmit optimism and hope which can help sustain the participant during times of discouragement and despair. The team approach also serves to widen the participant’s circle of care as they engage and develop relationships with multiple providers.

The addition of occupational therapy to the care team has provided a distinct perspective in working with individuals who are experiencing homelessness, have complex social, legal, cognitive and health issues and lack the skills and opportunities to participate in desired and needed occupations for successful community living. As was found in D’Amico, Jaffe, & Gardner’s systematic review of the research, this case study further demonstrates the value of using occupation-based interventions tailored to the individual’s context and performance environment [20]. The occupational therapist provided expertise in assessing the personal, environmental and activity factors that contributed to or limited performance. The results of the functional and cognitive assessments identified the level of support needed and informed the intervention strategies, including skill development, adaptive and/or compensatory strategies and/or environmental modifications aimed at supporting Roger’s goal of maintaining housing and developing healthy habits and routines.

7 Summary

Roger’s story exemplifies the complexities of individuals experiencing homelessness who have behavioral health needs, the system barriers and policy challenges they face and the outcomes that can be achieved through the multidisciplinary care team services described herein. Roger has made significant gains since enrolling in the program. He has been successfully housed for one year and has not had any legal involvement in over two years. Roger’s overall stability has improved his physical health with increased adherence to recommended medications, regular engagement with health care providers and significantly reduced emergency room visits. He has continued to appropriately comply with methadone treatment, while reducing use of heroin, alcohol and cocaine. With ongoing assistance performing desired and needed daily activities, he has maintained housing for the first time in his life. When asked recently what his goals are now, Roger stated “I want to keep my housing, stop using drugs and quit smoking.”

The unique program will continue to provide flexible and individualized services for as long as Roger demonstrates need. The occupational therapist will continue to collaborate with Roger and the multidisciplinary care team, adjusting and adapting interventions as needed, to sustain him in occupations which bring him joy, connection and meaning.

Conflict of interest

None to report.