20Q: Mental Health and Homelessness Advocacy

Sharon Gutman, Mental Health and Homelessness Advocacy

Sharon Gutman is a distinguished author, researcher, and professor at Columbia University. Sharon was the editor of the American Journal of Occupational Therapy from 2008 to 2014 and has published six books in occupational therapy as well as numerous research publications. Her most recent publication is Powers Dirette, D., & Gutman, S. A. (Eds). (in press). Occupational therapy for physical dysfunction (8th ed.) Philadelphia, PA: Wolters Kluwer. Her work with homeless adults with mental illness has received national recognition.

 

 

 

Franklin Stein, PhD, OTR/L, FAOTA

Contributing Editor

Salute to OT Leaders Series

20Q: Mental Health and Homelessness Advocacy

PhD, OTR/L, FAOTA

1. Describe your recent research on helping homeless adults with mental illness.

In the last years, I’ve designed and assessed the effectiveness of a number of occupational therapy interventions for sheltered homeless adults with mental illness. These included housing transition and maintenance programs, which taught basic skills needed to leave the shelter system and obtain supported housing, such as housing interview skills; apartment management; social skills for interaction with neighbors, supers, and landlords; community living skills; money management; and skills needed to manage chronic illness and maintain health.

I also designed and assessed the effectiveness of supported education programs for adults with chronic mental illness, many of whom were formerly homeless and now residing in supported housing. Many adults with chronic mental illness have never completed high school or have gaps in their education as a result of illness onset occurring in late adolescence and early adulthood. There is often a history of childhood homelessness and foster care placement that has further disrupted the attainment of basic educational skills. The supported education programs that I ran addressed education and job exploration, study and time management skills, basic writing and reading skills, basic computer skills, using library resources, social skills and public speaking for school, and student stress management.

Last year Dr. Lenin Grajo and I ran and assessed a functional literacy program for sheltered adults, which addressed participation in client identified daily living skills requiring reading and decoding symbols including (1) food package and nutrition labels, clothing care, and household products; (2) community signage including maps, transportation schedules, and store aisle signs; (3) automated teller machines and transportation ticket kiosk directions, (4) utility bills, bank statements, and check writing; (5) monthly and weekly budgets, (6) prescription and over-the-counter medication labels; (7) medication administration, sorting, and storage according to package instructions; and (8) leisure activities including game directions and newspaper movie listings.

I also designed and assessed the effectiveness of a program to help women who became homeless as a result of domestic violence to learn basic living skills, including safety planning; drug and alcohol awareness; safe sex practices; assertiveness and advocacy skill training; anger management; stress management; boundary establishment and limit setting; vocational and educational skill training; money management; housing application; leisure exploration; and hygiene, medication routine, and nutrition.

Because the shelter system is often a stressful environment with possible violence, drug use, and theft, last year I ran a stress management group for sheltered homeless adults that addressed anger management and conflict negotiation; meditation and breathing techniques; diet and nutrition; exercise, leisure, and recreation; sleep hygiene; and wellness recovery action plan construction.

Homelessness prematurely ages people and reduces life expectancy by 30-40%. Premature aging likely results from poor conditions while living on the street including unsanitary bathing and toileting; little to no physical, mental, and dental health care; substandard nutrition and lack of consistent food supply; and exposure to physical assault and victimization. Many adults in the shelter system have chronic physical conditions including cardiopulmonary, circulatory, musculoskeletal, and endocrine disease that impact their ability to carry out desired daily life activities. A couple of years ago I, along with a group of students, went into a New York City shelter and made safety modifications to the environment. We also trained participants in home safety strategies. Environmental modifications included the provision and installation of grab bars in shower areas and around toilet frames, safety treads in tub/shower areas, shower benches and chairs, raised toilet seats, nonskid shower mats outside the tub/shower area, bed rails, adjustable standing aids (to help participants rise from low chairs/couches), memory foam mattresses (for participants with chronic pain syndromes), reachers, long-handled sponges and shoe horns, 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, wall-mounted storage and drawer systems were installed to create clear walking paths and reduce floor clutter, and all electrical wiring was secured to the wall. Although we did not need to provide mobility devices (as these had already been secured for participants through Medicaid), we repaired the brakes on rollators, replaced worn-out rubber feet on walkers and canes, and readjusted appropriate mobility device length. We measured falls and emergency room visits 1-year pre and post-intervention and found a statistically significant reduction.

2. How do you think occupational therapists can help this population?

Occupational therapists can help the homeless population in every way. They are a population needing a great deal of help and can benefit from the many skills that occupational therapists are proficient at facilitating. As I mentioned earlier, homelessness usually has its roots in unstable childhoods—childhoods with unstable home lives due to periods of homelessness, foster care placements, violence in the home, and the onset of mental illness occurring in adolescence and sometimes even in childhood. As a result, this population commonly lacks knowledge of basic self-care skills (both BADLs and IADLs), meal preparation, nutrition, money management, and health management. There are often profound educational gaps and illiteracy or low literacy, which impact all activities of daily living. This population also tends to isolate themselves, perhaps because of mental illness and histories of violence. Social skills to interact with others in the community is often lacking, as is knowledge of healthy leisure activities—particularly to replace substance use activities. And as I mentioned earlier, chronic homelessness prematurely ages people and this is a population that severely needs help to manage their physical disabilities in order to carry out desired ADLs. Environmental modification to support safety is also critically needed both in the shelter system and in supported housing.

3. How did you first get involved with this research?

Living in New York City, the disparity between people who are struggling and people who are affluent is strikingly apparent. You can’t walk down the street without readily observing this. I felt that helping this marginalized group was important work, and I could see how my skills as an occupational therapist could benefit this population.

4. How did you find the population to work with?

I reached out to shelters in the area. I also had access to a couple of shelters that were being used as Level I fieldwork sites.

We first tried to understand many of the situations that commonly cause stress in the shelter environment. Much of the stress clients reported was generated from conflict with other residents and staff, and frustration regarding their life situation. To address this, we formulated modules addressing anger management and conflict negotiation. Modules provided the opportunity to learn new skills and practice them in role-play activities. But we also knew that clients needed other types of skills to deal with stress and so we taught them meditation and breathing techniques. Because there is a link between nutrition and stress, we had a module that addressed healthy eating and foods to avoid that could increase agitation (such as caffeine, nicotine, alcohol, and sugar). Lack of and disrupted sleep are common in shelters and are known to heighten stress. So we incorporated a module on sleep hygiene. And because this is a population that tends to isolate themselves, even once they attain supported housing, we provided a module about the stress-reducing benefits of exercise, leisure, and recreation—as well as how to find free and low-cost community options for exercise, leisure, and recreation. Finally, we helped clients to create wellness recovery action plans (WRAP) which 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 enable participants to identify which specific types of intervention, service providers, and family members should and should not be involved in a client’s care if he or she is no longer able to make self-determining decisions.

7. What was the research methodology that was applied?

All of the research that I mentioned was intervention effectiveness research in which we delivered and then assessed an intervention for its effectiveness using various outcome measures. Many of these studies were two group controlled designs in which one group received intervention and was compared to a control group that did not receive intervention. Some of the studies used one group pre- and posttest designs. Randomization is often difficult with this population because there is usually a limited amount of clients interested in participating and of that interested group, some will be able to attend the program while others can’t because they are receiving other services or working during the time when the program is held.

8. How are students involved in your research?

I involve students in almost all of my intervention effectiveness research. Students are provided with the opportunity to help design intervention activities, delivery intervention to groups of clients and in one-to-one sessions, collect data through assessment administration, and analyze data. Many of my research projects involving students have been published and presented at the national conference—these opportunities provide students with a unique chance to disseminate research knowledge.

9. What have been the results of the studies?

We found that the housing transition programs helped participants to learn needed skills to attain supported housing. One of our studies showed that participants in the housing transition program were able to attain housing more quickly than those in the control group.

We similarly found that the supported education programs helped more participants to enroll in and complete GED programs, vocational training programs, and college courses compared to control group participants.

The functional literacy program that we ran helped more participants to increase their participation in and satisfaction with daily life activities requiring reading compared to control group participants.

Participants receiving the stress management program reported lower stress levels compared to control group participants at intervention end.

And participants in the falls prevention and environmental safety program sustained fewer falls 1-year post-intervention compared to 1-year pre-intervention.

One problem affecting research with this population is the ability to carry out follow-up data collection to determine whether gains observed were sustained at 3 months, 6 months, and 1 year after the intervention. Because this population is in transition, they are often lost to follow-up.

10. What are your future research plans in this area?

Sleep is problematic in shelters. Clients commonly report disrupted sleep as a result of noise, surrounding activity, and stress. Lack of sleep decreases cognitive function and motivation, and impedes clients’ ability to learn new skills needed to transition from the shelter to supported housing. I would like to carry out research to better understand the factors contributing to poor sleep in shelters and then implement an intervention to address these problems.

11. Now I would like to discuss with you your career as an occupational therapist. Why did you select occupational therapy as a career?

I had received a BA in psychology and found that I couldn’t do very much with it. When I made the decision to go back to school, I wanted a degree that was directly linked with a viable ad employable profession. I had been exposed to occupational therapy during my undergraduate psychology internships and was attracted to its focus on practical real-life skills and integration of physical, cognitive, psychosocial, and visual-perceptual client factors in assessment and treatment.

12. What was your first clinical position?

In my first clinical position after graduation from OT school, I worked for a head injury facility that had varying levels of care. They had a campus of residential-like units providing services for clients needing 24-hour care/supervision. These clients had severe physical, cognitive, visual-perceptual, and psychosocial impairments. The facility also had group homes in the community housing approximately five adults who lived together with moderate supervision. Although these clients also had physical, cognitive, visual-perceptual, and psychosocial impairments, they were higher functioning and could carry out many daily life skills with assistance and supervision. The facility also had scattered site apartments throughout the community that enabled one or two adults to live together with some supervision. These clients were the highest functioning and many held jobs. As an occupational therapist, I helped clients to relearn desired daily life activities needed to function as optimally as possible in the home and community (e.g., self-care, dressing, meal preparation, money management, shopping, community mobility).

13. Can you describe your teaching career?

When I went to New York University for my doctoral degree, I was awarded a teaching fellowship, which provided me with full tuition in return for teaching in their entry-level OT program. This was how I first began teaching. After graduating from NYU I worked at my alma mater, Thomas Jefferson University, but soon returned to New York as faculty in the OT program at Long Island University, Brooklyn Campus. After 6 years I had been promoted to the program director and was awarded tenure but decided to take a position at Richard Stockton College. After 2 years there, I took a position at Columbia University and went back to New York. I’ve been at Columbia for 13 years and have been in full-time academic positions for 22 years.

14. You’ve written a number of textbooks. Can you speak about them?

It was through my teaching that I realized that specific educational textbooks for OT students were not available. For example, I taught clinical neuroscience for 8 years and because there was no textbook that described the basic neuroanatomical and physiological principles critical to occupational therapy assessment and intervention, I wrote Quick Reference Neuroscience for Rehabilitation Professionals: The Essential Neurologic Principles Underlying Rehabilitation Practice. This book is now in third edition.

I also observed that there was no one source that compiled commonly used rehabilitation screening procedures including those for joint range of motion; muscle tone; peripheral nerve function; deep tendon reflex function; balance, postural control, and automated movements; visual-perceptual function, cognition, and cranial nerve function. In response, I authored the textbook with my colleague Alison Schonfeld, Screening Adult Neurologic Populations: A Step-by-Step Instruction Manual. Each chapter includes sections describing functional implications of impairment, screening procedures, signs and symptoms, and available evaluations to use when quick screening procedures identify possible disorders. This book has also gone into third edition.

Based on my 6-year tenure as editor in chief of AJOT, I authored the textbook, Journal Writing and Publication: Your Guide to Mastering Clinical Health Care Reporting Standards, in 2017. This book provides specific guidelines for manuscript preparation, based on commonly accepted reporting standards for general research studies, intervention effectiveness studies, instrument development and testing studies, and case reports (e.g., Consolidated Standards for Reporting Trials [CONSORT], Consensus-based Standards for the Selection of Health Status Measurement Instruments [COSMIN], and Equator Network Case Report Guidelines [CARE]). Separate sections help authors understand the manuscript preparation and submission process, the revision process, and the etiquette guiding communication with editors and reviewers. Information is also provided to help authors better understand the ethical considerations of the publication including plagiarism, dual submissions, inappropriate authorship, copyright, and conflict of interest.

My most recent textbook has been a collaboration with Dr. Diane Powers Dirette. Upon the retirement of Dr. Catherine Trombly, who authored the first 7 editions of Occupational Therapy for Physical Dysfunction, Dr. Dirette and I were selected as the next editors of this seminal textbook, which is a primary text used in physical dysfunction courses in occupational therapy programs nationally and internationally since the 1970s. The 8th edition is due to be published in 2020 and marks major updates including a video library, new assessment and intervention content, and newly added clinical condition sections.

15. Can you describe your work as Editor for AJOT?

I was the AJOT editor in chief for 6 years from 2008-2014. Prior to my editorship, AJOT’s impact factor averaged .641 over the previous decade (1998 -2007). An impact factor is a reflection of the yearly average number of citations received by articles published in a given journal in 1- and 5-year periods. When I completed my 6-year term as editor, the journal achieved a 5-year impact factor of 2.113. At the end of my term, AJOT was ranked as the number 1 occupational therapy journal (out of 9) in the Journal Citation Reports (JCR) and ranked 19 out of 66 in JCR’s rehabilitation subsection. As an editor, I advanced the journal in a number of ways:

• I developed reciprocal access agreements with the British Journal of Occupational Therapy and the Canadian Journal of Occupational Therapy so that members of each professional association would have free online access to the research articles published in all three journals. 
• In 2014 I was the 10th editor in chief to join the Equator Network Reporting Guidelines Committee. The mission of the Equator Network is to increase transparent clinical research reporting that can easily be evaluated for methodological rigor and applicability to clinical populations. As an editor, I wrote editorials helping occupational therapy researchers understand how to use reporting standards in manuscript preparation.
• I facilitated the journal’s membership in the International Committee on Publication Ethics (COPE), which helps editors and reviewers meet set standards of publication conduct. As an editor, I wrote and disseminated guidelines to educate authors and reviewers about publication misconduct.
• I increased the number of intervention effectiveness studies and instrument development/testing studies published in the journal by 50%.
• I published 24 editorials and guidelines about reporting standards, intervention fidelity, research methodologies, health literacy, copyright issues, and manuscript writing.
• I implemented the Research Scholar’s Program through which the Editorial Board and I mentored 9 research teams in the implementation of controlled clinical studies examining the effectiveness of specific occupational therapy interventions. These nine studies were published in AJOT after peer review.

16. How you define OT to a new graduate student?

Occupational therapists help people of all ages to newly learn or relearn desired daily life skills that have been lost, impaired, or never acquired as a result of disability, injury, or disease. We help clients to increase their participation in desired daily life activities in the home and community. We use activity analysis and grading to modify the activity, environment, and/or client factors to facilitate a client’s optimal performance. We also use remediation, compensation, and adaptation as primary intervention principles. Remediation is the application of therapy to enhance client factors, such as therapy activities to increase strength and motor function. Compensation is the use of a strategy or device to aid a client’s function when client factors cannot be remediated—such as the use of a memory book or smartphone app when memory functions have been impaired. Adaptation is the modification of activity, device, or environment to promote function—such as the use of a shower bench when a loss of lower extremity strength and balance prevent standing in the shower.

17. What trends in occupational therapy education have you observed?

Over the last years, I have observed a growing trend to educate students in the provision of occupational therapy in the community, particularly with marginalized groups—whether in mental health clubhouses, homeless shelters, lower socioeconomic schools, and prisons/juvenile delinquency facilities. This trend reflects our historical roots—many of the profession’s founders worked directly in the community with immigrant populations, those with mental illness, residents of tuberculosis sanitariums, and impoverished families. As our healthcare system continues to break down, and more and more care is pushed to the community environment, our profession will have the opportunity to assume a greater role in community practice.

18. How can we generate more research in OT?

Faculty can implement research projects with student involvement. But faculty also need protected time to engage in research while relieved of some teaching.

The profession also needs many more researchers prepared at the research doctoral level (e.g., PhD, EdD, ScD). Clinical doctorates typically do not adequately prepare students to engage in research and contribute to the profession’s body of research. Students who obtain entry-level OTDs may be financially prohibited from seeking advanced research doctoral degrees.

19. What do you see as the future of OT?

The future of our profession is linked with the nation’s healthcare crisis, as are all healthcare professions. Right now, our healthcare system is monetarily driven, and insurers seek to cut costs at the expense of best care practices. However, the drive to cut costs has also moved the provision of many services out of the hospital and into the community. And this push to move care to the community is congruent with occupational therapy’s objective to help people newly engage or reengage in desired daily life activities in the home and community. But we have to advocate for our role in the home and community, as well as reimbursement of our services. We must also generate the research evidence demonstrating support for our practices.

20. Summarize your contributions to the profession.

My contributions to the profession have been in three main areas: (1) I have produced a body of 60 peer-reviewed journal articles to date, largely addressing intervention effectiveness with marginalized populations; (2) I have authored 6 textbooks that have been widely adopted nationally and internationally in OT programs; and (3) as editor in chief of AJOT during my 6-year term, I increased the journal’s impact factor, JCR ranking, and the amount of published empirical evidence supporting practice.

References

Powers Dirette, D., & Gutman, S. A. (Eds). (in press). Occupational therapy for physical dysfunction (8th ed.) Philadelphia, PA: Wolters Kluwer.

Gutman, S. A., & Schonfeld, A. B. (2019). Screening adult neurologic populations: A step-by-step instruction manual (3 rd ed.). Bethesda, MD: American Occupational Therapy Association Press.

Gutman, S. A. (2017). Journal writing and publication: Your guide to mastering clinical health care reporting standards. Thorofare, NJ: SLACK.

Gutman, S. A. (2017). Quick reference neuroscience for rehabilitation professionals: The essential neurologic principles underlying rehabilitation practice (3 rd ed.). Thorofare, NJ: SLACK. Grajo, L. C.,

Gutman, S. A., Gelb, H., Langan, K., Marx, K., Paciello, D., . . . Teng, K. (2019). Effectiveness of a functional literacy program for sheltered homeless adults: A two group controlled study. OTJR: Occupation, Participation, and Health. https://doi.org/10.1177/1539449219850126

Gutman, S. A., Barnett, S., Fischman, L., Halpern, J., Hester, G., Kerrisk, C., . . . Wang, H. (2019). Pilot effectiveness of a stress management program for sheltered homeless adults with mental illness: A two group controlled study. Occupational Therapy in Mental Health, 35(1), 59-71. https://doi.org/10.1080/0164212X.2018.1538845

Gutman, S. A., Douglas, D., Carmiencke, A., Freudman, L., Huerta, M., McCaa, M., . . . Schreibman, D. (2018). Assessing environmental safety modifications in the chronically ill sheltered homeless: A pilot study. Annals of International Occupational Therapy, 1(2), 95-102. https://doi.org/10.3928/24761222-20180620-04

Gutman, S. A., Raphael-Greenfield, E. I., Berg, J., Agnese, A., Gross, S., Hashmi, S., . . . Weiss, D. (2018). Feasibility and satisfaction of an apartment living program for homeless adults with mental illness and substance use disorder. Psychiatry: Interpersonal and Biological Processes. https://doi.org/10.1080/00332747.2018.1502555

Gutman, S. A., Amarantos, K., Berg, J., Aponte, M., Gordillo, D., Peery, A., . . . Schluger, Z. (2018). Home safety fall and accident risk in the prematurely aging, formerly homeless. American Journal of Occupational Therapy, 72, 7204195030. https://doi.org/10.5014/ajot.2018.028050

Gutman, S. A., & Raphael-Greenfield, E. I. (2017). Effectiveness of a supportive housing program for homeless adults with mental illness and substance use: A two group controlled trial. British Journal of Occupational Therapy, 80(5), 286-293. doi:10.1177/0308022616680368

Gutman, S. A., Kerner, R., Zombek, I., Dulek, J., & Ramsey, C. A. (2009). Supported education for adults with psychiatric disabilities: Effectiveness of an occupational therapy program. American Journal of Occupational Therapy, 63, 245-254. doi:10.5014/ajot.63.3.245

Gutman, S. A., Brandofino, D. N., Holness-Parchment, S. E., Pacheco, D. G., Jolly-Edouard, M., & Jean-Charles, S. (2004). Enhancing independence in women experiencing domestic violence and possible brain injury: An assessment of an occupational therapy intervention. Occupational Therapy in Mental Health, 20(1), 49-79. doi:10.1300/J004v20n01_03