Understanding the Lived Experience of Formerly

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Understanding the Lived Experience of Formerly Homeless Adults as They Transition to Supportive Housing a

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Emily I. Raphael-Greenfield & Sharon A. Gutman a

Programs in Occupational Therapy, Columbia University Medical Center, New York, New York Published online: 11 Mar 2015.

Click for updates To cite this article: Emily I. Raphael-Greenfield & Sharon A. Gutman (2015) Understanding the Lived Experience of Formerly Homeless Adults as They Transition to Supportive Housing, Occupational Therapy in Mental Health, 31:1, 35-49, DOI: 10.1080/0164212X.2014.1001011 To link to this article: http://dx.doi.org/10.1080/0164212X.2014.1001011

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Occupational Therapy in Mental Health, 31:35–49, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 0164-212X print=1541-3101 online DOI: 10.1080/0164212X.2014.1001011

Understanding the Lived Experience of Formerly Homeless Adults as They Transition to Supportive Housing EMILY I. RAPHAEL-GREENFIELD and SHARON A. GUTMAN


Programs in Occupational Therapy, Columbia University Medical Center, New York, New York

The researchers conducted in-depth interviews with formerly homeless adults who had moved to supportive housing to understand their perceived occupational needs and the factors that affected their transition. A qualitative research design with four participants who had a history of substance abuse and mental illness was used. Participant interviews that addressed categories of daily living and personal satisfaction produced data that were coded for analysis using conventional content analysis. Mega themes emerged that related to factors shaping the housing transition and maintenance experience. Occupational therapists can use these findings to create informed interventions to enhance this population’s occupational performance. KEYWORDS homelessness, activities of daily living, occupational therapy

Occupational therapists use the Person-Environment-Occupation (PEO) model to describe the dynamic and interdependent relationship among environments, occupations, and people as they change and shape each other over time (Brown & Stoffel, 2011). Transition and change processes can be analyzed and understood through personal narratives that illustrate how environments, occupations, and roles transform occupational adaptation and performance. In-depth analysis of occupations and roles provides a

Address correspondence to Sharon A. Gutman, PhD, OTR, FAOTA, Associate Professor of Rehabilitation and Regenerative Medicine, Programs in Occupational Therapy, Columbia University Medical Center, New York, NY 10032. E-mail: [email protected]

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E. I. Raphael-Greenfield and S. A. Gutman

unique and often missing perspective of a population’s experiences with particular environments. Currently, there is insufficient published information examining how the occupational performance of people who have been homeless and have chronic substance use and mental illness histories are influenced by their environments (Polvere, Macnaughton, & Piat, 2013; Shibusawa & Padgett, 2009). In the United States, 610,042 people experience homelessness on any given night, and 1.7 million make use of homeless shelters each year (Homelessness Research Institute, 2013). Consistently high rates of substance use are reported in the homeless population (Torchalla et al., 2013). In a study of New York City homelessness, 53% of the study participants had a lifetime diagnosis of substance use disorder (SUD), the most common of which were alcohol, cannabis, and cocaine, and 44% of the study participants had received treatment for a SUD (Caton et al., 2005). Approximately 50 to 70% of people who are homeless have mental illness and abuse substances (Padgett, Gulcur, & Tsemberis, 2006). Interviews with people who are chronically homeless, abuse substances, have mental illness, and have transitioned to supportive housing are needed to shed light on the factors that influence occupational performance in daily functional activities and affect housing maintenance. Older adults and females are two growing sub-groups of the chronically homeless population (Washington, Moxley, & Taylor, 2009). Gathering information about their specific lived experiences will fill additional gaps in the homelessness and occupational therapy literature. Low-demand Housing First programs have demonstrated that non-abstinent chronically homeless individuals with serious mental health disorders can successfully transition to and maintain housing (Edens, Mares, Tsai, & Rosenheck, 2011). The Housing First model is an evidence-based rehabilitative public health approach for those who are chronically homeless with co-morbid mental health and substance abuse issues (Tsemberis, 2010). Housing First is based on the philosophy that stable home environments are a needed prerequisite before people can successfully manage substance abuse and mental health concerns. Housing First challenges traditional mental health and substance abuse treatment models that assert that people must attain sobriety and medication management skills before they can be housed. From a public policy perspective, low-demand housing is cost effective. The annual per capita costs of a Housing First program in New York City is $22,500, compared with $45,000 for a bed in a residential treatment program, $85,000 for a bed in jail, and $175,000 for a bed in a state psychiatric hospital (Padgett et al., 2006). Current literature identifying the specific factors that enabled formerly homeless people to successfully transition to and maintain housing is limited (Polvere et al., 2013). When considering how to offer effective services to populations confronting homelessness, health professionals and researchers


Transition of Formerly Homeless Adults

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have largely failed to consider the perspectives of the formerly homeless individuals themselves. The knowledge, insight, and experiences of these people can prove instrumental in designing client-centered and collaborative interventions that address real-world challenges and reflect the personal and societal factors that have contributed to their successful housing transition and maintenance. Failure to address issues that are important from a client’s perspective can result in recidivism born of maladaptive lifestyles and the formulation of poor public health and housing policy. Such recidivism adversely affects the homeless population and exhausts societal resources. The average age of death within the general population is 80, but among the homeless, the average age ranges from 42 to 52 (O’Connell, 2005). Most deaths stem from a chronic medical condition rather than directly from a mental health or SUD, but if a psychiatric condition is also present, the risk of early death is even greater. While the Housing First policy is an evidence-based approach to house people with chronic substance use and psychiatric disorders, our understanding of this model must expand to develop interventions that can help people maintain housing. Occupational therapy has not been significantly involved with supportive housing program interventions (Petrenchik, 2006). With the profession’s ability to address life skills and help people achieve optimal function despite impairment, our involvement could be a valuable asset when maintaining clients’ transition to housing. The purpose of this study was to conduct in-depth interviews with formerly homeless clients who transitioned to housing to better understand their perceived (a) experience of the housing transition and maintenance process, (b) current occupational needs and goals, and (c) factors that promote and inhibit housing maintenance.

METHODS Research Design This study used an exploratory qualitative phenomenological research design with four participants currently living in supportive housing and having substance abuse and mental health diagnoses (Creswell, 2013). Each participant engaged in two one-hour interviews conducted over a two-week period, followed by a one-hour member check session one month later. All participants provided written consent to be interviewed. This study was exempted by the university medical center’s IRB because data were collected as part of a course assignment in the school’s occupational therapy program.

Participants Participants were selected from a convenience sample of Housing First program residents living in a large northeastern metropolitan area. Inclusion

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criteria for participation were (1) having a substance abuse history, (2) speaking English, (3) being 18 or older, and (4) residing in a Housing First program. Residents were excluded from participation if they were non-English speaking and were not current Housing First program clients. These inclusion=exclusion criteria were provided to the director of an urban Housing First program who selected four residents demonstrating interest in participation.


Instruments A qualitative interview protocol with 15 open-ended questions that pertained to daily living and personal satisfaction was developed for this study. The interview protocol categories were based on Occupational Therapy Practice Framework (American Occupational Therapy Association, 2014) categories and included activities of daily living (ADLs) and self-care, instrumental activities of daily living (IADLs) and home management, health and wellness, anxiety=stress, anger and time management, family and social supports, leisure=recreation, school=work= volunteerism, transportation and community mobility, money management, using the Housing First program and community resources, and overall level of life satisfaction. After the authors developed the interview protocol, three specialists in Housing First programming evaluated its face validity. These specialists provided feedback and suggestions for additional interview questions, which were incorporated into the protocol.

Procedures All interviews were arranged by the director of the Housing First program and were conducted at the program’s main office in a private setting to ensure participant confidentiality. Interviews were conducted individually and each of the participant’s two interviews lasted approximately one hour; each interview was scheduled 7 to 10 days apart. All interview questions were open-ended, allowing the interviewers to explore a topic in greater depth before returning to the interview protocol. Interviews were audio taped and later transcribed. Approximately one month after interview completion, participants engaged in one-hour member check sessions in which they provided verbal feedback about the accuracy of the researchers’ analysis of interview content and themes.

Data Collection and Analysis Pairs of graduate occupational therapy student researchers who received five hours of training in interview protocol administration by the principal researchers (the authors) conducted the interviews. After the first set of interviews was completed, two student interviewers and one principal researcher


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reviewed the transcripts to identify follow-up questions to be asked in the second set of interviews. Qualitative data derived from all interview transcripts were coded for analysis using a conventional content analysis approach (Hsieh & Shannon, 2005) in which small units of data (i.e., repeated words, synonyms) were categorized first, followed by larger phrases and themes, and finally mega themes. This first level of data analysis was carried out independently by two teams consisting of (a) two student researchers (who were not interviewers) and one principal researcher, and (b) the second principal researcher. Upon completion of the first level of analysis, both principal researchers compared independent findings and further refined themes to capture the most pertinent content addressing the research questions. Data analysis was conducted until both principal researchers reached consensus in theme development.

RESULTS Participants were three male and one female African-Americans ranging in age from 35 to 62 (mean age ¼ 52). The number of years living in supportive housing ranged from 1.5 to 7; the average number of years living on the street and=or in a shelter was 4. All participants had extensive histories of substance use, ranging from cannabis, cocaine, and alcohol abuse as well as psychiatric diagnoses, including bi-polar disorders, major depressive disorder, and post-traumatic stress disorder (PTSD). Seven thematic categories emerged during interview analysis: the desire for home maintenance and budgeting occupations, striving for abstinence maintenance through occupation, transformation of occupational roles through housing, premature aging and awareness of mortality, constant fear and vigilance in daily occupations and the social environment, reengagement with society through occupation, and altruism through occupation. These themes expressed the lived experience of the participants and the factors that influenced their daily occupational performance.

The Desire for Home Maintenance and Budgeting Occupations Two occupations perceived to be highly important were home maintenance and budgeting. All participants expressed the desire to live an orderly existence and maintain their apartments through a range of daily cleaning and organizational activities. Their motivation was fueled by their past experiences of living in the chaos of the streets and shelter system—living an unpredictable, hand-to-mouth existence with periods of hunger and malnutrition, and no access to toileting and bathing facilities. Living with the disorder and danger of the street left all participants traumatized and somewhat obsessive about order. Participant 1, a 62-year old African


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American man who had resided in supportive housing for four years stated, ‘‘I can’t afford to have anything that is messy; not anymore, including me.’’ Cleanliness was highly valued by all participants; many stated that they engaged in cleaning activities of bathrooms, kitchens, bedrooms, and closets on a daily basis. Several participants linked staying healthy with living in a clean apartment. Participant 1 stated that he avoided people who were sick or smoked and washed his hands several times per hour. Some of the participants were viewed by their families as a monetary stabilizing force and experienced pressure to provide for more vulnerable family members. Participant 2, a 56-year-old African American male veteran, explained his position in his family: ‘‘I’m more or less like the calm in the storm in the whole family. I’m the oldest leader left in my family. I kind of got to be the stabilizing force.’’ Feeling guilty about having a home and a modicum of financial resources, when children and other family members continued to struggle, presented conflict for several of the participants. Participant 4, a 35-year old African American man, described family monetary concerns: I can usually make my monthly budget last and meet my needs except [when] my kids have wanted something. I budget my own money because I learned at an early age that that’s the best way to do it when it comes to your funds. But sometimes I could use help, too.

Striving for Abstinence Maintenance Through Occupation Maintaining abstinence emerged as a significant daily occupation for all participants. Participant 1 adopted the AA philosophy of living one day at a time and employed ‘‘daily vigilance.’’ Although many participants were in physical pain, they made a concerted effort to avoid pain medication because they feared re-addiction. There was much mention of ‘‘tolerating’’ and ‘‘bearing pain.’’ To maintain abstinence, participants practiced positive avoidance behavior to distract themselves from activities and occupations that formerly triggered substance use. ‘‘I knows how to stay out of trouble [substance use], how to avoid problematic situations and people.’’ Volunteer activities were often cited as a therapeutic occupation that provided incentives to stay abstinent. Cooking was described as being especially helpful in that it decreased drug use and strengthened cognitive abilities such as memory and judgment. Participant 4 believed that self-help groups ‘‘glorify the process of giving up substance; it is not as easy as they say it is.’’ He also described times when he became depressed because he ran out of food and lost his public assistance. At such times, he stayed in his apartment and drank. He realized that this behavior hurt himself and other people, and stated that the Housing First program staff helped him to ‘‘stay level, stay calm, and stay away from alcohol.’’ Participant 3, a


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54-year-old African American woman, maintained her abstinence by staying connected with the ‘‘right people who are trying to do something for themselves.’’ She believed maintaining abstinence was ‘‘like having a 9 to 5 job. I’m out every day. I am always doing something to stay clean.’’


Transformation of Occupational Roles Through Housing There was a strong belief that obtaining housing transformed the availability of positive occupations and roles in which to engage. Participant 1 expressed the belief that ‘‘having a home has made me a better person and transformed my previous existence.’’ Without a home, he was ‘‘nobody in this society.’’ He acknowledged the difference between having nothing on the street and feeling ‘‘full and busy in [his] home.’’ He voiced the opinion that having a home after years of chronic homelessness was part of a healing process which allowed him to feel greater life control, reengage socially, perceive himself as a community member, and participate in new desired daily occupations. Participant 2 stated that the kindness demonstrated by housing staff and residents helped him to view himself more positively and participate in extended family roles: ‘‘I’ve never been met with such kindness. These people really care like family do . . . . They make me feel like a human being.’’

Premature Aging and Awareness of Mortality Participant 1 stated that his greatest current concerns were his medical problems. He hoped to avoid hip surgery and found walking to be helpful for coping with arthritis’ stiffness and pain. Similarly, Participant 4 stated that he was constantly in pain because of tumors in his spine, stomach, back, and legs—a condition diagnosed as pnuemofibromytosis, Type 2. Participant 2, the 56-year-old male veteran, complained that stiffness in his back and hip made it difficult for him to rise from bed and use the bathroom. Thirty years ago, Participant 2 was seriously injured by a 90-pound jackhammer on a construction job, and 20 years ago he sustained a gunshot wound to the knee while in the service. It was disconcerting for him to be immobilized by pain: I don’t want to be the old guy with the fat belly who can’t see over his gut . . . . I’ve got to realize I’m 56 now. I can’t do some of these things [physical daily occupations] anymore and it hurts me that I can’t . . . . It’s just a fact now. Age is something that you just can’t run from.

There were also numerous complaints from all participants about cognitive changes related to aging and chronic substance use, especially memory loss; several stated that they could not handle the academic demands of a GED program or job training. Participant 3 commented on her need for a planner and her slow processing speed, particularly with new information: ‘‘When I


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tried to get my GED I was learning things slowly. It is frustrating because one week I was doing good, and the next week I was not. I just couldn’t stay up with the class.’’ Participant 2 was very conscious about not wanting to be ’’ the guy with Alzheimer’s. I don’t write things down—I’d feel like I’m getting old if I have to start writing things down.’’ The two oldest participants both expressed a premature awareness of their own mortality and made a number of statements filled with regret. Erikson’s last stage of psychosocial development, Integrity vs. Despair, involves a review by people 65 and over of the life they lived with conclusions that life has either been fulfilled or misspent (Erikson, Erikson, & Kivnick, 1986). Participant 1 expressed ambivalence about his life, vacillating between the joy he has experienced over the past four years while living in supportive housing and the sadness associated with the street and shelter. ‘‘Look at everything I have now. I am overjoyed with my life right now.’’ But he also acknowledged, ‘‘I will die soon and want to reconnect with my grown son in Germany before I leave the earth.’’ He talked also about losing his mother one year ago to Alzheimer’s and more recently, a brother who died from AIDS in prison. He acknowledged that he experienced many losses in his life and spoke of a life review process and realization that many traumatic events have occurred throughout his life.

Constant Fear and Vigilance in Daily Occupations and the Social Environment Constant vigilance in daily occupations and fears of imprisonment, death and dying, assault, using drugs again, neighbors and the neighborhood, intimacy, losing housing, and the future were commonly expressed concerns. Participant 1 stated that it was imperative to be ‘‘constantly vigilant’’ about his environment. These fears led him to a fairly isolated existence since moving into his apartment where he pursued many solitary occupations. Participant 1 reported suspicion of new people and did not allow anyone into his home. He saw only a few acquaintances at the housing office and described himself as ‘‘living in a cocoon or protective stage of [his] life.’’ Participant 4 similarly described himself as claustrophobic and felt anxious on crowded subways and streets. The only female in the study, Participant 3, attributed her constant vigilance and fear to her traumatic experience of being kidnapped and raped while homeless. I was locked in a basement for four days; I could never get over it. When you close me in, I’m . . . paranoid . . . I get flashbacks about a door jamming . . . it takes me back to where I was snatched up from the streets and was raped.

She shared how PTSD affected her daily functioning in the housing program.


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I’m not comfortable with strangers coming to my place because I don’t really know who is who. So what I do is have a new staff member I don’t know come over with an old staff member. . . . The apartment is secure but I can’t stay [there] too long. . . . Sometimes I don’t get stuff done I need to because I can’t stay there [apartment].


Reengagement With Society Through Occupation All participants verbalized how isolated they felt when they lived on the streets and in shelters. Participant 1 spoke several times about ‘‘getting on board, getting with the program, and rejoining society.’’ He viewed the Housing First program’s walking group as an opportunity for socialization while exploring the city and stated that he does ‘‘not feel lonely anymore.’’ Several participants expressed skepticism about forming close relationships at this point in their lives. Participant 1 said that he wanted to ‘‘stay above the drama’’ and was satisfied with his acquaintances such as the supermarket clerks: ‘‘I make the daily pilgrimage to the supermarket where I know the clerks and they know me and that’s enough.’’ Participant 4 acknowledged that he would benefit from more structure in his schedule: ‘‘There’s certain things I’m not going to do on my own. I don’t want to say this, but sometimes I think I, personally, need supervision.’’ He admitted that he has a problem with anger and avoids crowds in the city with ‘‘disrespectful and rude people’’ which he finds unsettling. He stated that he enjoyed community trips led by occupational therapy students because he felt safe and calm. Although Participant 4 felt that he was beginning to reengage slowly with society, he expressed a desire to maintain a safe distance within relationships as did other participants. At this point in his life he felt that he did not need friends: ‘‘I have four guitars at home and they treat me beautifully. I love all my instruments. If I have something to talk about I go pick up one of them.’’ Participant 3 recalled how she rejoined society by attending a woman’s group at a shelter: ‘‘There were so many people around me that supported me; I didn’t know where these people came from, but they reached out and that’s what made me feel special.’’ The staff and groups at the Housing First program have encouraged her to reconnect with her children and mother and build trusting relationships with them. I’m just glad I was able to wake up before it was too late to meet back with them [family].. . . I miss the times that we used to have together as a family but don’t feel depressed about it anymore because I’m out here [Housing First program] with a whole new family.

Altruism Through Occupation A consistent theme expressed by all participants was the desire to engage in occupations through which assistance could be offered to others less

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fortunate now that participants resided in stable housing with many of their needs met. Staub and Vollhardt (2008) studied the development of altruism and found that it often emerged from and contributed to healing after trauma. All participants described how they volunteer to cook for others; some saw their effort to help as a way to remain abstinent.


I like cooking and serving food because it’s giving back . . . and keeps me clean.. . . There was times when I was hungry out there when I was homeless and I cried day and night. Nobody would give me anything to eat. I’m taking advantage of something that I lost.

Several participants expressed the desire to be role models for others. One of the two participants who were veterans enjoyed volunteering at a non-profit organization where he packed boxes of medical supplies and equipment for third world countries. All participants shared altruistic feelings toward young people. Participant 2 became a coach and referee in basketball leagues in the park. Participant 3 described the goal of her volunteer work: To reach out to younger people today . . . I want them to have a shoulder to lean on and try to help guide them.. . . Like when I go out to the jails . . . I’ve been in and out of prison but not with the support of people from the outside going there.

DISCUSSION The research questions guiding this study will be addressed in relation to the themes identified in the Results section. Answering these questions can illuminate how occupational therapists can use their expertise within supportive Housing First programs to contribute to a team approach to enhance the occupational performance of this population.

Perceived Factors That Promote Housing Transition=Maintenance MAINTAINING ABSTINENCE AS A DAILY OCCUPATION All participants acknowledged that long-term use of substances had disrupted their lives, and they were now eager to reduce substance use or maintain abstinence and live more rational, orderly lives. Housing First programs that are based on a harm reduction approach–where clients are encouraged to reduce substance use, but it is not prerequisite for housing acquisition or maintenance–appear to promote stability in housing transition and maintenance. In Shibusawa and Padgett’s (2009) qualitative study of homeless subjects with co-morbid psychiatric problems and substance


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addiction, the interviewees recalled lost opportunities related to the use of alcohol and drugs and were aware of the deleterious effects that substance use had on their lives. This reflective sentiment was echoed in the current study as several participants remarked that they had grown older and wiser, and expressed feelings of greater life control through activities that promoted abstinence. At the same time, many participants acknowledged their cognitive and psychosocial limitations and expressed gratitude for a housing program that did not penalize residents for substance use setbacks. Occupational therapists can help this population maintain abstinence by assisting in the formation of new, healthier routines and occupations that can replace former substance use triggers.

LOW DEMAND HOUSING WITH OPPORTUNITIES FOR SOCIALIZATION, ALTRUISM, AND REENGAGEMENT AS A TRANSFORMATIVE EXPERIENCE

All participants in this study remarked that having compassionate and supportive staff was a transformative experience. They praised the lack of pressure placed upon them by staff members in contrast with other drug treatment and mental health programs they experienced. Participants expressed motivation to comply with their medical and mental health treatment and valued their housing providers’ guidance. They viewed the housing program headquarters as an inviting and non-judgmental drop-in center where they could develop stable relationships and adopt healthier habits and lifestyles. Occupational therapists can create opportunities for socialization, volunteer experiences that allow for beneficial altruism, and safe neighborhood and community exploration that decrease social isolation and promote reengagement with family and society.

Perceived Factors That Inhibit Housing Transition=Maintenance HIGH LEVELS OF ANXIETY AND VIGILANCE CONSTRAIN DAILY FUNCTIONING While all participants felt relieved to live in their own apartments, all expressed high levels of fearfulness. Fears stemmed from different sources including traumatic experiences, the unpredictability of street and shelter life, and high risk behaviors associated with substance use. Elevated levels of trauma and PTSD have been documented in the homeless population (Schuster, Park, & Frisman, 2011; Taylor & Sharpe, 2008). A growing area of concern and research is the co-occurrence of PTSD and SUDs among both male and female homeless; in a study of 489 participants, 20% met criteria for PTSD and 19% had co-morbid PTSD and SUD (Torchalla et al., 2013). Traumatic experiences put both men and women at increased risk for homelessness, and the psychological effects of trauma have been found to be greater


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and more enduring than the physical effects (Schuster et al., 2011; Torchalla et al., 2013). PTSD symptoms emerged as a prominent pattern in participant interviews, and all but one participant struggled with insomnia. For the male participants, there was ample evidence of emotional numbing and avoidance, which interfered with daily living activities and promoted withdrawal from social interaction and community participation (e.g., avoiding use of the laundry and elevator because such activities exposed them to others). The female participant’s rape history resulted in powerful emotional and physiological behavioral responses on a daily basis, which left her easily agitated, suspicious, and paranoid. Alongside these expressions of constant suffering was an equally eloquent and paradoxical drive for altruism, which trauma researchers have termed altruism born of suffering and have illustrated its healing powers for those diagnosed with PTSD (Staub & Vollhardt, 2008). A number of participants remarked about the spiritual satisfaction they gained from volunteer activities. The resilience of all participants as they cooked for and listened to others was an unexpected finding that social service agencies should more systematically explore. To address the demonstrated cognitive decline remarked upon by several of the aging participants, occupational therapists can help residents engage in volunteer opportunities that do not require heavy demands for new learning but employ the hard-earned emotional intelligence of residents. Occupational therapists can also help this population more functionally address PTSD symptoms as they affect daily life activities. Identifying activities that are PTSD triggers and regulating symptoms through stress management techniques and mood-altering occupations (e.g., engaging in yoga, Tai Chi, and meditation, and playing or watching favorite sports) can be used by therapists to help clients affected by trauma. PREMATURE AGING AND AWARENESS OF ONE’S OWN MORTALITY The participants also expressed fears and ambivalent feelings about premature aging and its concomitant illnesses, disability, and dying. All participants complained of major medical problems, including uncontrolled asthma, arthritis, gunshot wounds, and tumors; they described themselves as regularly visiting doctors and voiced new-found desires for compliance with medication and healthy lifestyles. Those who were 50 and over expressed fear of death, regrets about lost opportunities, a desire to leave something to beneficiaries, and an interest in re-connecting with children and families. People with a primary diagnosis of SUDs and co-morbid psychiatric diagnoses are a sub-group of the homeless population who have received less attention from clinicians and researchers; how long-term substance use affects the aging process is suggested by the current study but deserves more in-depth attention (Padgett et al., 2006; Raphael-Greenfield, 2012). Similar


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findings were attained by Shibusawa and Padgett (2009) who examined premature aging in formerly homeless New York City street people with serious and persistent mental illness; all spoke of the experience of premature aging and mortality. Occupational therapists can help this population address the physical and cognitive limitations associated with aging that influence daily life activities through energy conservation, environmental modification, compensatory strategies, and assistive technology.

Perceived Needs=Goals for Daily Occupational Function


ORDERLINESS, HOME MAINTENANCE, FINANCIAL STABILITY, AND SAFE PASSAGE All four participants focused on money management as a challenging but essential area. Budgeting appeared to be a more difficult task than any other daily requirement of community living. The most serious deficits in independent living skills among homeless women have been identified as money management (Heuchemer & Josephsson, 2006). Most of the participants in this study expressed a rigid, almost obsessive approach to cleaning their apartments on a daily basis. All mentioned the importance of attending to their personal hygiene activities and managing their clothing, shopping, cooking, and appliance maintenance. After the experience of hunger on the street and institutional food in shelters and jails, cooking in one’s home became a fulfilling occupation for all four participants. The participants commented that the provision of free transit cards as well as supervised community trips enabled them to feel safer in their neighborhood and increased trust in others.

Limitations and Future Research Generalization of the study findings is limited because of the small homogenous sample and use of convenience sampling. The participants were not representative of all formerly homeless people with chronic substance use and mental illness histories; the Housing First program in which participants resided was not representative of all low-demand supportive housing programs. Although the study was limited to two interview sessions with one member check session, we believe that data saturation was reached since themes in the first session were consistently repeated in the second interview. Member check sessions also confirmed our thematic analysis findings. Future research should involve participant observation in which researchers observe participants in their daily occupations in the community and home environments over time.

IMPLICATIONS FOR OCCUPATIONAL THERAPY PRACTICE The findings of this study suggest that occupational therapy services in supportive housing agencies could greatly benefit the homeless population. The

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chronically homeless population is aging; occupational therapists have the training to both assess and treat physical and cognitive limitations that affect daily activities and make environmental modifications that maximize function. Occupational therapists can promote abstinence maintenance by helping clients develop new routines and roles to avoid former substance use triggers. Therapists can teach residents healthier habits and routines, assist in the development of new leisure occupations, and promote participation in productive and meaningful volunteer roles. Occupational therapists can also help clients manage PTSD symptoms to enhance community participation and reduce patterns of isolation. As consultants to supportive housing agencies, occupational therapists can design programs and environments that meet the occupational and emotional needs of this underserved population.

ACKNOWLEDGMENTS We thank the following for help with interview protocol development, participant recruitment, data collection, and data analysis: Katie Bower, Konju Briggs, Vivian Chong, Stephanie Crane, Emily Querna, and Heidi Woo.

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