Community-Based Practice with Refugees & Survivors of Torture

Community-Based Practice with Refugees & Survivors of Torture:
Innovations in Academia, Practice, and Student Fieldwork
AOTA Annual Conference, Nashville, TN, April 16, 2015
Mary Black MS, OTR/L • Jyothi Gupta PhD, OTR/L, FAOTA • Anjali Nigam OTD, OTR/L • Natasha Smet OTD, OTR/L • Yda Smith PhD, OTR/L
The US is a nation of immigrants; American society illustrates cultural pluralism. As occupational therapy nears its centennial celebration, it is
important to reflect on the legacy of its founders, who brought a surge of optimism and a sense of justice to the issues of their time.
The current social issues that confront the nation are similar to that of our founders and include a sizeable, underserved population, a subset of
which are immigrants and newly-arrived refugees. OTs are well positioned and needed to serve these populations as they transition to a new and
unfamiliar cultural context. Practice with immigrant communities embodies the social vision of our founders and is aligned with the contemporary
values and ethics of occupational therapy.
Occupation-Centered Practice
Occupations and daily life patterning (habits & routines) are socially constructed, particular and context-specific.
Occupational performance, experiences, meaning, and identity are based on values of a particular sociocultural context.
Immigrants’ experience transitions in their roles, identity, health, and well-being. Threats to health & well-being due to:
Occupational disruptions/Loss of culturally meaningful occupations /Self-Efficacy (Ways of doing)/
Identity (Ways of being & belonging) /Occupational deprivation /Occupational challenges
Reconfiguration of occupational lives and identity is necessary for social integration and participation (Gupta & Sullivan, 2013).
Survivors of Torture
Countless refugees and asylum seekers are survivors of torture. Torture is the deliberate infliction of severe mental and/or physical pain or
suffering by or with the consent of state authorities. The overall goal of torture is to instill fear, control, and disempower an individual. It strips one
of their roles and identity, invokes feelings of isolation, insecurity, and distrust, and deprives an individual of their freedoms. Consequently, the
dehumanizing nature of torture has lasting effects on an individual’s doing, being, and becoming. An estimated 500,000 survivors, many asylees,
live in the U.S. coping with the effects of torture, displacement, and uncertain legal status. Occupational deprivation and consequences of torture
impact performance and affect 5 main intrinsic factors: cognitive, psychological, physical, spiritual, sensory. (Figure 1, Nigam, 2014)
Figure 1. Grounding Roots through Occupational Performance: The Acculturation of Survivors of Torture
An Educational Approach to Enhancing Cross-cultural Adaptation of Immigrants, Gupta, J., & Sullivan, C. (2011)
Rationale: Many new immigrants have to learn English and ELL centers are good places for working with this population.
Method: Community-based Participatory Research: Negotiated with community partners and matched benchmark of school district to our research
themes and identified key topics. Participants’ input shaped curriculum content and delivery process.
Curriculum Modules: Introduction to research, occupation, and informed consent process. /Cultural transition - self-efficacy – well-being. /Time
norms, routines, scheduling stress. /Sleep, time management & health/ Healthy eating, physical activity & health. /Work: culture, norms, stress,
injury, body mechanics & ergonomics.
Curriculum Outcome Measures: Individual interviews & Focus groups/Pre-post content knowledge measures: On content of session/Self-report
surveys: Cultural Adaptation & Adjustment Scale (CAAS), General Self Efficacy (GSE) Scale, & the Short Depression-Happiness Scale (SDHS).
Work & Ergonomics
Results: Significant changes noted in pre-post tests in the following modules: Routines & Habits; Sleep & Stress; Physical Activity; Nutrition.
Although immigrants struggled with security and competence, they were determined in learning about host culture, seeking resources towards the
goal of integration and participation. Despite day-to-day hardships participants reported (1) feeling hopeful and satisfied with their lives; (2)
adequate levels of functioning; and (3) experienced high levels of self-efficacy.
Conclusion: OT can impact the cross-cultural adaptation, foster social integration and enhanced participation of new immigrants.
Working with Populations from a Refugee Background: An Opportunity to Enhance the Occupational Therapy Educational Experience
Smith, Y.J., Cornella, E., Williams, N. (2014)
Methods: The purpose of this study was to investigate first-hand perspectives of occupational therapy students who have had a 12 week, full-time
fieldwork experience in this program.
Results: Analysis of qualitative data resulted in the emergence of three major themes:
OT at its Core “I felt like with this fieldwork experience I was able to really hit the core of occupational therapy. That is, helping people do the
occupations they want or need to do. It was some of the most occupation-based, client-centered OT that I have seen yet.”
Cultural Awareness and Competence “I developed a cultural sensitivity that could not have been learned anywhere else… I am [now] able to put
aside my own agenda or American perspective to really understand the occupational profile of an individual, which so often is incredibly influenced
by culture, and use that information to develop meaningful treatment.”
Basic Skills for Any Setting “I was surprised at how much the skills I developed during this FW transferred over to traditional practice areas…
There were different barriers, different goals, and different types of treatments, but… this FW provided me opportunities to develop the basic skills
that any therapist needs in any setting: clinical reasoning, being occupation-based, being client-centered, documentation writing, rapport building,
treatment planning, designing and leading groups...”
Results demonstrate that this is program provides occupational therapy students the opportunity to develop the core skills necessary to become
effective and competent occupational therapy practitioners along with cultural awareness strategies. Students develop the ability to work with
diverse and under-served populations, which is a necessity in our growing and changing world. While participating in this program, students are
able to practice and provide client-centered, occupation-based training that promotes client engagement in meaningful occupations.
Community Practice Examples
AACI Center for Survivors of Torture (CST), San Jose, CA Therapeutic Photography Project
Level II fieldwork at the Kovler Center inspired the development of a practice model (see Figure 1) and to seek out an OTD apprenticeship at the
San Jose CST. Only OT at CST was a challenge and opportunity to introduce activity-based treatment through a trauma-informed lens.
Created & implemented a therapeutic photography project for survivors coping with isolation, occupational deprivation, PTSD, anxiety, and
depression. Therapeutic photography allows one to visually capture experiences, environments, and emotions through photos. When accompanied
by a caption, story, or poem, they can be used as a means to communicate thoughts & feelings otherwise masked in verbal expression alone.
Group workshop over 5 weeks culminated in a public photo exhibit and reception, “A Lens of Hope”. OT-facilitated and participant-driven with
focus on visual, verbal, and written expression. Emerging themes in discussions: homesickness, missing loved ones, everyday struggles, and
importance of hope. Outcomes: improved ability to ascribe meaning, identify stressors, communicate with others, and express selves, with
carryover into talk therapy with psychologists. Clients reported feeling “confident”, “creative”, and “relaxed”.
OT at The Heartland Alliance Marjorie Kovler Center, Chicago
OT at The Heartland Alliance Marjorie Kovler Center is concerned with how torture, trauma, displacement, and acculturation affect the occupations
& roles of survivors. Survivors waiting for political asylum often have no work authorization, live in substandard housing, “think too much” about
past horrors and feel a profound diminishment of their roles and status. Our imperative is to create safe environments and build on existing skills
and strengths to support meaningful occupation. An occupational history and adapted COPM are used to assess client’s strengths, interests, and
performance. Individual OT work concentrates on skill adaptation and development, with a pervasive need for prevocational and vocational
support. Client inspired programming for the past 10 years includes our international cooking group, urban gardening, rural farm visits and more
recently, “Photovoice”. Groups offer the continuity of familiar rituals that clients can look forward to, providing a powerful source of safety,
predictability, and meaning. Many survivors have reclaimed their voice and personal spirit that the torturers sought to destroy and are now
enriching and shaping their new found communities
Black M. (2010). From Kites to Kitchens: Collaborative Community Based Occupational Therapy with Refugee Survivors of Torture In: Kronenberg
F,Pollard N, Sakellariu D (eds) Occupational Therapies without Borders, Volume 2 Towards an Ecology of Occupation-Based Practice, 217-225.
Gupta, J. & Sullivan, C. (2011). Enhancing Participation and Health in New Immigrants: Translating Occupational Science into Occupational Therapy
Practice. Presented at Society for the Study of Occupation, October 19-22nd, Park City, UT.
Gupta, J., & Sullivan, C. (2013) The Central role of occupation in the doing, being and belonging of immigrant women, Journal of Occupational
Science, 20:1, 23-35.
Nigam, A. (2014). Grounding Roots through Occupational Performance: The Acculturation of Survivors of Torture. (Unpublished doctoral model of
practice). Washington University in St. Louis.
Smith, Y. J., Cornella, E., & Williams, N. (2014). Working with populations from a refugee background: An opportunity to enhance the occupational
therapy educational experience. Australian Occupational Therapy Journal, 61:1, 20 - 31.
Smet, N. (2014). Advocating the role of occupational therapists with immigrants and refugees. (Unpublished doctoral capstone dissemination). The
University of Toledo, Ohio.
Also see OOFRAS- Occupational Opportunities for Refugees & Asylum Seekers Inc
Contact Information
Anjali Nigam <[email protected]>, Yda Smith <[email protected]>, Natasha Smet <[email protected]>,
Jyothi Gupta < [email protected]>, Mary Black <[email protected]>
This information is the copyright of the authors and use of any information from this poster must be credited to the authors. Thank you!