Occupational Therapy's Role in Serving the Unhoused Population feat. Dr. Quinn Tyminski

Hi, my name is Jessica Nelson, and this is the Mental Health OT podcast. Today, I'm lucky enough to be sitting with Dr. Quinn Taminsky. She currently serves as an assistant professor in the program of Occupational Therapy at Washington University School of Medicine, where she also received her master's degree in Occupational Therapy in 2012. In 2017, she earned her doctorate of Occupational Therapy from St. Louis University. She served for five years as the Occupational Therapist for a transitional housing program for men experiencing serious mental illness and homeless miss, and spent a year as the clinical director coordinating Occupational Therapy Services and students. As part of her doctoral work, Dr. Taminsky introduced Occupational Therapy Services to a local homeless shelter in 2018. She opened an outpatient student rank clinic, the community independence Occupational Therapy Clinic provides services to individuals experiencing homelessness. Dr. Taminsky's research focuses on improving occupational participation and quality of life for populations experiencing marginalization through providing occupation based services targeted at improving life skills and community reintegration. She is also currently in the process of obtaining her PhD in education at Washington University in St. Louis. Today, we will be talking with Dr. Taminsky about her work with the homeless population, as well as her work running the student brand Occupational Therapy Clinic at Washington University. We will also be talking about some of the research she has conducted to help support her practice and her clinical skills. We will also be talking about creative avenues Occupational Therapists can utilize to promote occupational therapy and advocate for the profession, one of which being a TED Talk, which she actually gave regarding occupational therapy and how we can help to serve homelessness. I am so happy and honored to welcome Dr. Quinn Taminsky. - Hello, Dr. Taminsky, welcome. Thank you for joining us. - Yeah, thank you so much for having me. I'm so excited to be here. - Yes, I'm excited as well. Why did you choose occupational therapy and what interests you about this field? - Yeah, like I've gotten that question a lot and the answer I always give is that I started sort of in college with a focus on like exercise science, athletic training. I was really interested in sports and I really thought that's where I was gonna go. And I think my mom was a really big proponent and like I don't know that that's really the path for you, Quinn. And she worked in a school district and she was like, we have this OT in the school district. You should come see what an OT does. And so I came and showed us her school based OT and I was like, this is really cool. And so from there I got a chance to shadow more OT's. And I sort of dove in having seen like a very limited set of settings. I saw a school based pediatrics and I saw like an outpatient hand clinic and I saw a cute care as when I went to the OT school. And then I got into OT school in my very first level one field where I clicked my very first semester of OT school was mental health. And I think that just like, I gotta just change my world. I was like, this is awesome. Like I love that it wasn't the same thing every day. I love that population. And so for me, I think OT was just this chance to like not sit behind a desk, do something super creative. Be out in the community helping people all the time. And so like when I initially got in, that's really where I started. And now I think for me OT is like much more about like making a change at a systems level and like affecting change in people's lives, which I think was where I started but in a much different way now. So it's interesting to how your career goals with this profession sort of evolved in a little bit over a decade that I've been doing this now. - Yeah, it's really interesting too, which I think I've talked about previously on some of the other episodes. I mean OT just looks so different in so many different settings. And so like it's so confusing to people I think who don't, who aren't OT's to like define what we do. - Oh gosh, yeah. - Yeah, I think that's one of the main problems with the profession in terms of like how we like, why the public has a hard time understanding what we do is because like they might have seen an OT in acute care. They might have seen an OT in pediatrics, but then when I'm saying like, oh, but I do OT and homelessness, they're like, I don't even understand how that works all the time. - Yeah. And then you kind of go on this like whole thing, well, OT's, we make you, or we help you to do what you want to do. And so anything can limit what you want to do. And they're just like, okay, sure. They just like appease what I'm saying. I feel like, but yeah, getting that good elevator speech and making it to like where people's eyes don't glaze over and you talk about it because it can be so like needed what to do and you're like, they're like, that seems so nebulous. So really making it, I guess, yeah, like meaningful to them. - Yeah, yeah, just like personalizing it. Like what do you like to do? - Yeah, exactly. - Well, so you kind of talked about it a little bit with like your focus a little bit shifting towards like really focusing on changing like the systems and stuff like that, which is super cool. I know that I've always kind of had that idea of like eventually I do want to get to a point where I don't know, I guess I'm knowledgeable enough or like I'm equipped enough to like start to pursue work like that. You said that your first semester in OT school was like that mental health semester. Did that kind of lead you into your interest in community-based work? - Yeah, yeah, so yeah, so I had this, we at the time Wash Use program in this again was 10 years ago we had one week level one field works four times, so one every semester. And so my very first one was at a place here in St. Louis that's transitional housing for men only who had serious mental illness, a lot of co-occurring substance use, histories of homelessness, histories of injustice involvement and things like that as well. There was an OT there who is still to this day a really good friend of mine. But so I went there for a week and I sort of was like, you know, this is what I want to do, like we took the clients to the doctors and we got to like, you know, be very functional every second, like we were at the grocery store. We took them bowling one day and like I was like, this is fun, this doesn't feel like a job. And I know like that's why a lot, that's also what draws a lot of people to pediatrics is. So it felt like the adult version of that, you know, like getting to do almost adult play with individuals. And then I also just, I felt like this was a population like that doesn't get a lot of attention. Like I really enjoyed like the sort of the systems aspect of it that I got to experience in mental health. And so, you know, after about one week, I actually asked the OT there if I could go back and like spend some time there. And I did, I would go back like a couple times a month. I remember I went back to their Halloween party and I really stayed in touch with that OT, but then in terms of my education, I've really geared everything that I was doing towards mental health, like did my master's research project on substance use and occupational participation, did my field works and inpatient psych, but which is actually, I like highly recommend if you're gonna do community 'cause I always say like, I think it's really important to see our clients when they're at their most like acutely ill so that we can understand where they've been and the trauma they've experienced while they're inpatient so that like we can understand the challenges they experience in the community. So, you know, I was able to gear then like my entire career essentially towards mental health after that point. So it was really pivotal to me and then it's sort of like seeking out these mentors who were really mental health folks who are the reason that my career is the way it is now. So that OT from the housing facility was one of my mentors and then my faculty mentor who is my mental health factor or are the two people that I credit for getting me to where I was. So I think all of those things were like the pieces of the puzzle that I was able to put in place after I had this aha moment of like, yeah, this is where I wanna go and this is what I wanna do. And a decade ago, there was only two of us in my entire class of 100 who wanted to do mental health. (laughs) So that was kind of a very unique pack. - Yeah, I feel like it still is. I haven't looked up the statistics but I know from other people who have like talked to me about it, I think it's about 5% of OT's work in mental health. - Yeah, yeah, I think it's like between like three and 4% but then like I just saw the number for community though is only at like 0.4% who are actually working community-based mental health 'cause a lot of those jobs are like an inpatient rehab. So I think that's really interesting statistic that sometimes gets thrown under the radar is that like those community jobs are few and far between. - Yeah, I mean, we'll talk about it later on but like a big issue I think is like funding and just people not knowing what we can do. - Yes. - But I do wanna say that I definitely agree with you that if people do work in mental health or occupational therapists work in mental health, well, no people in general, I think there's a huge benefit to working in like inpatient or acute mental health because like for me, how can you help someone if you don't and you don't? If you wanna try to get the whole picture, I think, and I think that that's really helped me so far. I started a state psychiatric hospital inpatient state psychiatric hospital and that's where I am right now. And it's really, really eye-opening, I would say, to put it plainly, but it's just seeing these individuals and like, I mean, this is like they're at their worst and they're at their lowest. Yeah, definitely I think puts things into perspective. Absolutely, I agree, I think that time that I spent, even though it was like three months, it was really transformative. And so for example, like, We, I was on an inpatient site unit at a, like, a pretty well established mental health hospital that's, that's pretty well known here in the US and like, I saw a lot of like, like restraint use, like takedowns and then both like vacation inducing strengths and physical restraints. And I think just like recognizing the trauma and like the distrust of the medical system that would then occur for individuals who serious mental illness who had experienced that has really led me to like, changing the way that I practice then in the community because I, I have sort of taken a lot of steps and this is something I'm pretty vocal about, about like, trying to mitigate power dynamics in the community between us and the clients and like, almost in a way like trying to distance ourselves as community OT's from the healthcare system. And sort of like, I, I would say like, my clients 100% can tell you what OT is, they will give you the most beautiful elevator speech that you ever heard. But I don't know if you asked them if I was a healthcare practitioner, if they would say yes, because I don't think that they think of me as part of that system. And I think in many ways, that's why we're able to have the relationship and the progress that we do because they sort of like don't associate then community based OT with the, the people who have sort of maybe inflicted that trauma or caused those issues. Yeah. I mean, even while working at an inpatient facility right now, I feel like they, they're really with me as like an occupational therapist is a lot different than their relationship with like the nurses or like the psychiatrist or stuff like that. So even while I'm working in this setting, I do still see kind of that disconnect of like the kind of the distrust with like other professionals. And then like, because my role is so different. And I think that that's just the nature of occupational therapy and like the models we go by aren't like typically traditional medical type models. So I think that that's really seen throughout like how we do our job and how we do and deliver our work, which can help facilitate that relation. Yeah, I absolutely agree. I think that that's why we need like inpatient OT is so that, you know, there is someone there who they can talk to, who they can rely on, who they can forge that relationship with, so that, you know, that trauma or that experience can start happening then and they can sort of recognize there is some trust that can be had there and then that can transition. And my gosh, if we could ever have like a really smooth transition from an inpatient psych OT to a community based a psych OT, like that would be incredible because that handoff would be so essential. It doesn't as far as I know exist very frequently. But maybe somebody out there is doing it and I'd love to hear more about that. There's room for progress for sure. I also think that too with like that relationship, I have noticed a little bit and still work in progress and I'm trying out kind of new things with like my approaches, try like bridging that gap between my relationship and the client and then like the client's relationship with the treatment team because I am technically a part of the treatment team. I mean, I'm a clinician like I do sit in on like the treatment team meetings and like provide my input, provide you know what I'm seeing like the strengths and like what they're doing well, what they're struggling with. But yeah, I think that our relationship with the clients can help a bridge, a better relationship with the treatment team as a whole and I think that's really important. Yeah, and then I would say like also at the same side of that sometimes it's like education of the treatment team of like why our relationship with the client is slightly different because I know that like we've had issues in the community where, you know, for example, like we see a wider birth of clients than some of the like social workers or case managers are able to see because they have limitations on their funding about who they can see. And so like when a client gets discharged from a certain program, like OT can still see them and they're like, well, I don't, you know, the case managers or social workers to be like kind of like I don't understand why you still have a relationship with this person is like, well, you know, my therapeutic relationship doesn't just end because they were immediately discharged. Like this is someone I am supporting longer term. And so I think a lot of that education is also really essential to the treatment team because they might not understand why our relationship looks different. Yeah, education both ways. I've learned that it's very important because a lot of times I think that at least coming in I was like, oh, like I'm going to educate like the clients a lot in this and that. But then like actually being in that setting, you sometimes the staff need just as much education as the clients do about certain things. And like that's not to say that I don't need education about certain things that other professions can give to me. But I think I've definitely recognized the value of OT in this setting and it's been really rewarding. Yeah, actually just to go off that like one of the biggest roles that we've actually found for OT in these sort of community based social service organizations, particularly when we're talking about the in-house, but with like, you know, mental health services too is actually education of the other staff because the other staff are very often not trained to actually work with individuals who are not serious mental healths and I'm not talking about the skilled staff. I'm not talking about like licensed clinical social workers or psychologists or psychiatrists I'm talking about sort of the maybe the case management teams or sort of the other personnel that exist within the agency, a lot of them sort of don't have that highly skilled training. And so they'll say things like, well, I you know, I don't think that this client can do this because their cognitive functioning is really low. And so like we do a lot of training on like, well, like what is cognition and what can we do? Like here's what OT is doing and how can you like support what OT is doing around cognition or like, you know, what is trauma informed care and how should we be implementing an agency wide? And so a lot of that can also just prove OT's ability to be really successful in any organization. If everyone is sort of trained to a higher level, then OT doesn't seem to have to sort of take the brunt of some of those issues. Yeah. And I think I've noticed to more particularly where I've worked a lot of the staff don't know our whole scope. And so I think I've worked really hard to any time that I see something that no tea could like help with. I bring it up to the treatment team and I'm like, well, OT could conduct an assessment or and maybe I know for like a particular case, it was hard because we weren't sure if the client was experiencing like dementia type symptoms or if it was like more behavioral because they would like continuously request like something so it would be like, oh, like I want this. I want this. I want this and be like, okay, like you can have it at this time. And then they would be redirectable. But then like five minutes later they'd come back and say the same thing. It would be like continuous. And so I was like, well, we could do like a cognitive assessment and see if they really do have issues with memory. And in that case, like, maybe we figure out how to adapt things and provide maybe the staff with education that this isn't like a behavior. This is like a memory type issue. So like getting frustrated with them or yelling at them isn't going to do anything. Or vice versa, if they weren't showing any issues with memory, then it's like, well, this is maybe like a behavior and they're just trying to like find someone to give them their desired. I mean, I'm sure that would be addressed completely differently as well. And so kind of just saying like, well, we can kind of figure out or we can help to all of the issue. And then from there, like knowing what's going on, we can plan accordingly and appropriately with like what's the best intervention to address this. So it's just a little things like that. Absolutely. We actually are sort of in the ed stages of conducting a study around like OT's in community, mental health, and around like what keeps people in that job, but also like what, you know, has people leaving that job. And that's actually one of the things that we found was that like very often we sort of get pigeonholed in certain agencies we get like that. Like I remember there was a quote from participant who was like, I was known as like the toilet lady. Yeah. Sort of a nice name to have. Right. Like we can be so much more. But then I think sometimes like I've actually been in a meeting where I've been like, oh, well, OT can do that. And OT can do that. And I've actually had someone roll their eyes at me. And I'm. Yeah. No. I'm still going to do it. I'm going to like still, like I'm obviously like, you know, I'm going to still, you know, talk about OT until I'm blue in the face because I think that there's so much that we can do. And so often we just sort of get like put in this one lane and thought that like that's the only thing we can do. And so yeah, it's a little bit of both. It's like we don't want to get pulled in every direction, but we want to be able to use our skilled services in the way that they're intended to be done. Yeah. And I think I think that also, and we talked about this a little bit before, but traditionally or like naturally, OT's have a little bit more of a timid personality that I've noticed just with like majority of my classmates and like other OT's I've worked with. But I think that if we can really like dig in and advocate and just like recognize like our worth and our value and like what we can bring to the table and have like a little bit of courage and honestly be okay with like being because I have honestly too of had people where they're just like, I'm like asking or I'm like saying, oh, we can do this or we can do this and they're like, great, just like can you shut up? But it's no, but it's important. And I think that like the people who in the professions who are there to really like, like truly care and want to provide quality care. It's important for them to know how they can utilize us, especially physicians. I know that my psychiatrist was asking if like an OTS assessment would be appropriate for one of our clients and I was like, I didn't want to say no, but like awfully top of my head, I was like, I need some time to think about this. So like I thought about for a couple of days and I was like, so this is what we could do and like this is how it would benefit and so like, but I was also like, I, it just depends on like what your goals are with the client because we can provide this and we can do this if this is like a goal that you have for them and like this is like an avenue you want to go down. So when I saw her, I was like, I know it was like kind of long winded and stuff like that. She's like, no, it's good. So you do think it will help and I was like, yeah, but I will just say, I don't think I would ever tell you O.T. can't help I'm not going to tell you no. Yeah, so it's take that with, you know, take that how you'd like. Yes, I will say I have embraced the squeaky wheel gets the grace, you know, like I don't think that I would have had the success in the community that I have had in like my life if I didn't like keep showing up, keep putting my face out there and be like, hey, it's me again. Remember me? Like the toilet lady. I'm here again, you know, and that's truly because like when I talk about my work with the on-house, like it took us years for them to hire their first full-time O.T. But that was because I showed up every single day and was like, hey, look, this is what I can do with the limited time I have, but imagine what you could do with a lot more, you know, and now like, seven, eight years later that we've been with that agency, we have champions in that agency. We have people who are as dedicated to O.T., who are not O.T.'s. Yeah, who will regularly be like, well, I think everyone needs an O.T. and I'll be like, oh, I know what you think. The world is changing. Yes, but it took us a while to get there. So like, yeah, I think that there will be, you have moments where people will roll their eyes at you and they will tell you you're annoying, you'll go, you'll leave that meeting, you'll be like, oh my gosh, everyone in that meeting was so over me, but like there is someone in there that's listening and it will eventually pay off. So that is, that's always what I have to say about that. That's, that's good to keep telling myself. Yeah. Because I like, sometimes I walk out of meetings and I'm like, oh, not more to five, but I'm just like, oh, I don't know how they feel about me now. I still do that. I'm always like, if I'm so silly in that meeting, like, oh, gosh, I don't know if I would say silly, but that's a nice way. Yeah, that was me, that was me taming my language of what I actually said to myself. I like it. So I kind of want to talk a little bit about your work with the student rank clinic that you do at Washington University. Yes, absolutely. So I'll, you know, I'll give you a little bit of like origin story and like where it is now. So back in 2015, I was doing my clinical doctorate actually at St. Louis University. And I was employed by that same agency. I was actually talking about where I did that level one field art. I actually went back and got a job there. And they were part operators of the largest homeless shelter here in the St. Louis area. And so I happened to be able to go see the shelter one day as part of my job. And I was like, I kind of walked in and I was like, there's not an OT here. Like, this is an extreme state of occupational deprivation. Like, there is no meaningful participation here. And I was like, this is my capstone project. Like, this is what I'm going to do. And so, you know, we gave them six months of free full time OT through field work students as a way to sort of trial it out. And at the end of those six months, the other agencies, so there were two agencies. So when I worked for and then these other agencies who served were both co-owning the shelter. And the other agency was like, this was the most successful service we've ever brought in here. Would you be willing to provide OT at like our main building? And I was like, yeah. So that was about the time I was transitioning to faculty. It was very serendipitous. And so I was like, yeah, I'm thinking like this outpatient student run clinic model. You know, and they were like, I was like, can we talk about space? Because I'll need space for this. And they happen to have like this beautiful space that was like a childcare center that they lost funding for. So it had like a private bathroom. It had a little kitchenette. Like, it wasn't gray and boring. It was, you know, like a colorful and had chalkboards and, you know, everything that you could want in an OT clinic. And they were like, we can give you this. This can be OT. And so we sort of started this student run clinic. I started with a really great number of students. I can't even remember now probably like six or seven. And I will say like it has been involved. My original vision for it is not the vision I have today. But like I couldn't have dreamed of what I would be today. You know, we were going to do group sessions. And we were going to do individual sessions. And at the time that we were starting this, there wasn't a ton of evidence out there on OT in the unhoused population. There wasn't sort of the amount of evidence that there is now. So it was like, we purposely chose to take clients from one of the programs that the St. Patrick Center, which is the agency that I work with, has that serves individuals with serious mental illness and substance use. Because I was like, okay, I know the evidence here. Like, you know, I know how to do evidence-based practices, population that will take these with these clients who are, you know, also happen to be on house, but then have these sort of co-occurring disorders. We'll start there. And then we sort of realized like individuals were really hard to come by because the clients would come to group. And then they didn't want to keep going to individual session. And so we sort of like a kind of evolved over years and years. And we got to the point where like, after three years of us running these group sessions every single Wednesday morning, we come in, we run our call seven-step protocol. You know, the agency was like, you know, we really liked this. And as I was saying earlier, that's when I was like, well, this is what I can do because I'm, you know, I am employed by this other position. And this is my job. And I can only spend this amount of time here. But if you all could find a way to fund full-time OT, you could have this all the time. And it would also be great to have like more help in the clinic because then we could take more students. And so in 2019, we wrote the grants and got the funding for a full-time OT. So we heard in our first one then, we've had a full-time OT since then, who sort of integrates with the clinic, which works so beautifully because then they're sort of able to help us bring clients into group. And they know the clients better and they can sort of talk up group and it works really well. And then, you know, now they're looking at expanding services to even more OT, as they're like working through grant funding to figure out how to do that now because they've just sort of embraced OT in this really wonderful way. But the clinic was a large part of that. So I take students for three semester so they start in summer and they take them summer, fall, and spring. So it's a full year. And they come every single Wednesday morning. And I actually, so our program does both masters and doctoral students. So I actually take both masters and doctoral students. So my doctoral students have to do the additional search component. My master's students are just doing clinical practice. But they sometimes help with the research as they are interested in it. They come in, we do like the first semester, we do some trainings, you know, we do trauma inform care, we do crisis intervention, things like that, we talk about the population, we get to meet the client. The clients at this point are like really familiar with the students and every time that there's like a break between students, so like, "One of the students coming back, one of the students coming back." They love students. So they know that they're students and they like they really end up enjoying them and they want to help them. So we, and then I throw them in learning groups and I always tell them like, "You're not going to kill anybody." The worst thing that you're going to do is you're going to have a really bad and the clients are going to think it's boring or they're going to laugh at you or they're going to be bad. But you're not going to kill anyone with a group session. Like that is so funny that you say that because I have definitely said that before. And I'm like, "Well, what's the worst that can happen?" There's no lines and leads. Like you're not going to pull out somebody's cat. They're like, "Literally, this is going to be pretty free in terms of the physical concerns." And so we, like I kind of throw them into running groups and they all say like, "Oh my gosh, we were scared of death." But you were right. Like we got into it. And so then they write the documentation and it is amazing to me to watch the students start the very first semester to where they are by the end of stripping. My gosh, their ability to be flexible, to like for clients to be like, "I don't want to do that today." And then then like throw the whole protocol out the window and roll with whatever, like you have something totally new. Their classmates can't do that. And they talk about like in other class experiences. They're like, "We saw a life client in class today." And my other classmates had like, you know, list pages of like, "We're going to do this. Never going to do this." And I kind of like went in there and was like, "All right, hey, how are we doing today? What are we going to do?" And I was like, "Yeah, because you've had this like real experience of clients." So it's honestly truly morphed in a way I could not imagine where the clients truly love working with the students. They look forward to it. They get so attached that every spring we do like a big going away outing. And we just did it a couple weeks ago for this graduating class. And then, you know, the students learn so much and grow so much. And a lot of them do really want to do community-based mental health practice in the future. And so this is a great foundation for them to use that as a jumping off point. So it's just been something that I could not, in my wildest dreams, have ever dreamed up, would still be working and functioning so well and being so beneficial. Critically thinking is, I think, one of the most important skills for occupational therapists just because our clients are so different. And so no intervention is like a one-size-fits-all. And I honestly feel that across the board with all O-T, but more specifically for sure in mental health. Absolutely. And I think like it's that's so hard to teach in a classroom, and you can do as many standardized patients or even live clients, but like a one-off experience does it give it to you. Like, we were running a group maybe like three weeks ago in our clinic. Luckily, these were students who were at the very end of their time in the clinic because one of the clients, brand new client, we hadn't really worked with them before, starts telling in the icebreaker of the group, starts talking about how her son was just killed, in a homicide, like that week. And my student, oh my gosh, she did an amazing job. She's a mother herself and she just like, she felt it, she felt the emotion, she left the client talk, but she limited it in a way that didn't disrupt a group. She gave the client a hug. The client came back the next week and was like, that student changed my life. Like, that was the person I needed in that moment. And like, that's not something I could ever fabricate, even if I wrote the script for that. Like that is the kind of education that students have to experience to really get. So yeah, that's the kind of clinical reasoning that occurs in those real life experiences. - Yeah, that's, wow, that is really awesome. And invaluable learning. I was gonna ask something else. - I'm so sorry. - No, you're good. I'm sure it'll come back to me, but I did want to talk a little bit more, like specifics of the population. So obviously you said it's like homeless or like unhoused population, but like more so like, what does that entail exactly? Like what's a profile of a typical patient that you see? - Yeah, so within St. Patrick's Center, sort of like we don't, the clinic itself doesn't have a ton of restrictions is just sort of like anyone who's unhoused, you have to be able to enter the St. Patrick's Center building, which means that they can't be, has been banned from the building, which generally results, like means that they have had violent incidents within the building. So that's like really the only rule we have to follow. Other than that, like we, we now accept clients from a really wide variety of programs within St. Patrick's Center and St. Patrick's Center has 20 programs. So there are so many different types of clients. One of the main programs we do take from, though, is a Women's Night program. So it's a Women's Shelter, a 90 day transitional housing for women. A lot of them have serious mental illness and histories of substance use, co-occurring trauma, justice, involvement, things like that. So I would say normally an unhoused population would be largely men, but because we do specifically take from this program, we end up with a good sort of 50/50 mix in our groups that are both men and women. We also do end up with a lot of clients who are on the LGBTQ spectrum. So we do have clients who are trans women. And we do have clients who identify as gender non-conforming, which has been a really wonderful thing to see because that is not always what you-- clients will always feel that they can represent those genders in shelters because shelters are often operated in ways that are very black and white and very like this gender or this gender. And if you're a gender non-conforming, you have to pick one. So generally older clients, though. So most of our clients, I would say, are late 40s, early 50s. We see a lot of histories of substance use, a lot of sort of untreated physical concerns. So whether that be diabetes, if you've even seen hearing loss, a lot of really poor vision, we have like reader glasses in the clinic. And those are a hot commodity. Those are something that clients are really interested in using when they're in the clinic. But the biggest hands-down across the board thing is decreased cognition. Most of the clients that we see in the clinic are ones that are seen individually by my OT Klan. And she does a lot of cognitive assessments with them. And I would say 99.9% of our clients have a mild to moderate cognitive deficit. And that is due to histories of mental illness, histories of substance use, really high incidence of traumatic brain injury in the unhoused population, over 50% of the unhoused population reports have a traumatic brain injury. And I would match and it's higher than that. As well as things like trauma and stress, which we know alter, are sort of cognitive abilities. So that is one of the biggest things hands-down that we sort of see emotional regulation and things like that, too. But like I said, a wide variety of genders, races, in the city of St. Louis, you are four times more likely to be unhoused if you are a Black or African-American. So we do see a larger proportion of individuals who are Black or African-American purely because of historic housing practices in the city of St. Louis, redlining and discrimination in the housing market. So that has led to generational poverty in our Black and African-American communities who are in St. Louis. But sort of other than that, the big thing that I would say that most of our clients have is the decreased cognition and then sort of a wide variety of other experiences. - Yeah, with a decreased cognition, sounds like, depending on like why it's decreased, a lot of the reasons you gave like TBI's, you gave a lot more, but that was when that was stuck out. Do a lot of the interventions you do is it more kind of like adaptation and modification for that, or do you ever try to like rehabilitate or like remediate cognition or both, or like what does that look like? How do you all address that? - Yeah, I would say it's a little bit of both. So there's definitely some compensate, definitely like modify. We do a lot of environmental modification. The environments of homelessness are really not designed to accommodate anyone truly. So a lot of environmental modifications, certainly a lot of compensate. Some remediation really depends on the individual and where we're at. Some of our like higher level cognitive clients can do well with remediation. And I've seen some clients who have been really successful in being able to sort of like, you know, live independently and move on under their own and manage their own IDLs, you know, with some remediation techniques. So it really runs the gamut. But I would say the, again, the biggest sort of cross-sectional experience is environmental modifications. Like every single thing that we do with this population is focused on the context of homelessness. And so a friend of mine, Caitlin Sonovick says it really wonderfully. She says that homelessness is a context based population, not a diagnostic based population 'cause you don't necessarily have a diagnosis of homelessness. So it is the environment that is often the barrier to occupation, which is true in a lot of populations that there is no diagnosis here in a lot of ways. And so it's like when we're cooking, what are the barriers to cooking? When we're even trying to do something as simple as like taking a shower, what are the barriers to that? So that is one of our major interventions. - And I guess to me, I feel like it would be pretty hard to do environmental modifications or interventions when it seems like if they are homeless, their environments are like changing constantly and there's not like a continuous environment that you can modify. Can you talk more on that and like what would that look like? - Yeah, so I would say that like for the most part, most of the clients that you end up seeing in occupational therapy who are unhoused have some sort of, I mean, it is a term like stable housing in a temporary setting. So like rarely because of the nature of like people who are unhoused in like a very transient setting, like what you're talking about who like, you know, don't have some place stable. They're not often the ones that we're seeing in OT because they're not really gonna benefit as much. Whereas like a lot of the clients that we're seeing are in a 90 day shelter program. So their, you know, their environments are gonna stay consistent for 90 days. They're transitioning to housing. Or, you know, we might see someone who lives, like we had a client for the longest time who lived in an abandoned building, but he lived in the same abandoned building for years on end and was very like stable there. And he actually had like a really interesting setup. He had like a propane tank that he used to run a heater and he used to run a hot plate and then he would come every day and get ice into putting his backpack to put his food in so that it would stay cold. He had a very, like, but he was very stable in that. So like when you would sort of think about the people who are more trans, yet the people who were coming go, they're just not as good of a candidate for OT because what we're doing there is more like triage as opposed to like more long term lasting interventions. And so I always think that that's sort of an important thought to have when we're thinking about like OT's role in the unhoused and particularly because there are so few of us working in this population. And there's so little funding, like where can we really be the most beneficial and it's definitely gonna be in places where the environments are more stable? - Yeah, that makes more sense. - Okay, yeah. - And I think that kind of brings up like a good point where people's perception of like the unhoused population is like that transient type population where they like don't have anywhere to go and they're just like kind of hopping from one place through another. But I think there's like a spectrum of, I guess, situations that they could be in. - Yeah, there's a, I won't go too deep into it, but you know, we have like a wide variety of individuals who are in house. Some people are unhoused like very briefly. Some people are unhoused for a very long periods of time. And then some people like I think when we think about people that are unhoused, we think of like people who are panhandling and people who maybe like have serious mental illness to the point where it's like untreated and unmedicated. And those necessarily like are people that we would probably not see in the situations we're in because they're probably not seeking any sort of engagement with homeless services at St. Patrick Center. So they would sort of never get funneled to O.C. services. So it's sort of the people who are already seeking services who are like wanting to make the changes that we're working with. So yeah, that helps us have a better idea of like what this population is. And you know, as we know, like there has to be a little bit of stability for O.T. because behavioral change. When we think about Maslow's hierarchy, like we have to have some basis there to move to the next levels. Yeah, they have to be ready to receive it. Yes. If we're working with those other like if we're you know if we're talking about sort of individuals who are not housed serious mental illness untreated, like we're probably working out more of like a population level, more of like systems advocacy. How can we like, you know, make sure that population is getting safety not care. Things like that as opposed to more of an individual level. Okay. How do you prepare your students to work with this population and address these barriers? Because I mean, as we said, working with this population, it's very not a direct path. So I think creativity comes to mind, critical thinking, all of these skills that as you said, they're kind of hard to teach really. So yeah, how do you work to prepare them and increase their skills and competency? Yeah, absolutely. So a lot of it's sort of like in Bebo real-time processing, you know, like the students will write a protocol for their group. I will review it. And a lot of times, especially at the beginning, you know, they'll be like thinking, I'm trying to come up with like an example that I have. So they might want to do like a home management protocol. And so we're going to talk about like, okay, I think this is appropriate, but let's talk about like, what are the things that they're allowed to keep in the shelter? You know, like what cut, what are their exact environments? How may this look different from what you're traditionally thinking? And so it's a lot of times also like removing the stigma. So we, I think students come in thinking like, oh, I have to give all this information to this unhoused population. And one of the first things I tell them is this population is incredibly knowledgeable, incredibly resourceful, and a great community. There is a great desire in the unhoused population to help each other. And so oftentimes, and we, and that's the other thing I tell them is like, we have not been unhoused. We do not know all these these resources. You're giving them a list of resources, just doing them nothing. So like instead, a lot of times when we like, okay, like let's talk about what are the resources out there for X, Y, or Z. The clients will do a great job of be like, oh, I went to so, you know, this place last week. And I learned that they have this. And like, you all should go there. They do so much sharing. And so a lot of times like we give a lot of open forum for that and let it be like this community place and do a lot of like peer-based support and a lot of learning from each other, which also creates self efficacy from these clients because they feel like they can contribute to, you know, give back to each other. And so, you know, it's those moments for students is thinking about like, do you need to go into this space and be the expert? No, you don't. Like, you are not the expert here. Here's what you can go in and do. Like, we can, we can teach this task and we can bring, you know, that our expert skills and environmental application and task analysis and all of those really wonderful OT things. But like, we are not the experts in being homeless and they are the experts in being homeless. So let them guide you there. And that is really, really essential. And so like I said, it's sort of like a little bit of like, we make missteps and then we talk about it and the clients that are there know that these are students and they don't know that they're learning. And so, you know, they're always really gracious about, about those moments and they don't let them sort of, when they're therapeutic rapport with the clinic itself, mean, mean me or the the OT Caitlin. And so it is very much those moments where I'm like, you might want to think about X, Y or Z because I think that you're assuming you're making an assumption based on your, the privilege that you have had inherently that everyone has had this experience and that's not the experience of this client population. And that is very often where you have to go on this. And then I think that's the, the other big thing that the students come away with at the end is like their world view is totally shifted. They're thinking about people's lives in a different way. People's occupational participation in a different way, systems and structures in a different way when they hear these stories of a client. And so that is something they learn case by case. It's not something I necessarily go in with a curriculum to teach, but we debrief, we, you know, I give them feedback on the protocol and then we debrief after every group. And I'm like, okay, how did that go? And they'll be like, I don't think that this part went well. And I'd be like, well, why? So yeah, that, and that brings up a good point. I think that I too have like assumed that certain clients like need certain things when in reality, that might not be the case. But like I just assumed that because that's traditionally like when we look at certain populations, we're like, well, they're probably unhoused because of X, Y and Z. So if I can plug these things in, then I can help them. But instead, I really like, it's more like about listening to them and like letting them guide the intervention and just like plugging away as they bring up their specific issues. That's like the unique role of OT in the homeless systems that don't occur in other areas of the homeless systems, because I think like you said, like, homeless systems are designed to be very wrote, like, right? Like, so you come into the homeless system, you do this thing called a VI Spada, which is like a service prioritization assessment tool, right? So you take this assessment, it tells you like, you get a score based on that score. This is the program you qualify for, rapid rehousing or permanent supportive housing or whatever. And then you get placed in that program and this is how we deliver care. Nowhere along that is it really personalized, is it really individualized? And so OT is the person that comes in there and you get case management, but again, case management is still like a little bit of a road process. OT comes in there and says, okay, this is client-centered care. What do you need? And like, I'm not the expert here. I'm here to walk alongside you. I have a little bit of expertise about this one thing, but you're life and you have a whole lot of expertise about it. And that is why we are feedback from clients as always. This is the only place I feel heard and listened to. This is the only place I feel safe. This is the only place I feel like I can be me. And I think that is why in these systems, it is so essential to OT to be part of this. Yeah, and I think that speaks a lot to what you were talking about earlier, like shifting that dynamic and that relationship between like healthcare workers and clients is everything that you're doing is empowering that client. And you know, as you said, like self-efficacy and all those like personal advocacy skills, all of those things, it sounds like you're supporting within that population. Yeah, yeah. And I think sometimes it doesn't feel like that to case managers. It's like, well, they're relying on you too much. And it's like, we're actually teaching them amazing skills in being, like you said, self-efficacious and being independent and being able to stand on their own two feet. You're going to be very impressed like when we get to the end of this and they can say like, I can do these things because they have to feel like someone has supported them in doing it and not having people just do that for them. Yeah. And this is kind of attached to that just with interventions in general for like myself as a new clinician. I did recently just graduate last August. So I'm still going to thank you, figuring out who I am as a clinician and building my skills. But I feel like I've gotten a lot better at I guess identifying needs or like figuring out like what the clients want, what their needs are. But I am having a lot of struggles like pass that like, well, what interventions do I do now? Because obviously the reason that this is a need is not because it's easily attainable. And with these, a lot of the clients that I deal with, even though they're like in impatient facility right now, they very well might be unsheltered when they leave. And so and a lot of them have criminal backgrounds too. And so issues that arise are like, hmm, work. So we have people who are going to get discharged to least restrictive alternative. And they're going to be on social security income. So with that, that affects like how much they can work. But then also it's how do they find a job with the criminal history they have. And so it's kind of like, as you said, I think if you don't critically think you're just like, oh, well, like just go on and deed and like apply and like do this. And like here's a resume. But it's like, if it were that easy, I think that they could probably do it. But that's not necessarily the problem. The problem is more of that like, semi type. Yeah. And so like, yeah, I'm just like, well, I'm not sure how to help like realistically. Like I could make it seem like I'm helping. And I could make everything look pretty. And I could like teach you like, these are the websites you can go on. But I don't know if anything would come out of that. Does that make sense? It does. Yeah. So I think in that example, and then I'll give you an example from from the house. So I think in that example, like my first question for that client would be like, do you want to work? Like is that something that really interests you? And a lot of my clients will say, no, I don't want to work. That's not something that interests me. and I'd be like, that's fine, you have income now 'cause you're gonna get SSI, but we do have to have something to occupy our days. So, what are we gonna do to occupy our days? I don't know if where you live has a clubhouse motto, we do here in St. Louis, we have Independence Center, it's a phenomenal program because it gives them, like so it's a place where they can go, it's a drop-in day program, but it's sort of the people that work there and the clients are indistinguishable from each other, you can't tell who works there and who is a client, and there's all sorts of different things to do so they can come in, they can take a workout class, they could work in the kitchen, they could work in the flower shop, like there's all these things they could do, it's just a great place to have social interactions or great place to have meaningful occupation, and so that's what I'm always talking about clients, but what is your meaningful occupation? If it's not work, could it be volunteer? Is there a volunteer job that might really interest you? Like I said, our clients love to give back. Okay, but it's not volunteering, could it be education? Like what is it we have to have something to engage our days? And so that's really like where I come back to, and if it is work that you wanna do, you know, yeah, you can still work on SSI, like yes, they're gonna take like back $1 for every $2 you make, but that is still gonna be more beneficial to you, and so do we need supported employment? Like what kind of supported employment programs are out there? What are you good at? Like let's start finding those programs, and so there's a lot there that I sort of learned over the years, but I will tell you, like I have been doing this 12 years now, and it took me a long time to get to that point. Like I'm incredibly impressive for being out, not even a full year yet, because I definitely was not where you were. There's so much that I've like learned over the years to do, but to write like very often we don't ask clients, and so the example that I was gonna give is like, so in the other house population, there's like I was saying you come in, you get the score, they house you, and the number of clients that get housed, they don't actually want to be housed, is incredibly high. We had a client once who was housed, and we got a call after about a month from the landlord, he was like he cannot continue living here, he keeps sleeping in the backyard of the apartment complex. So I went and talked to him and I was like, well let's go on, he's like I've never slept with a roof over my head. Like if I can't see the stars, I can't sleep. - Wow. - It's like, okay. You know, let's actually meet someone where they're at, and so that's why I said that related to your work example. Okay, do you actually want to work, or is that a goal that someone else is putting on you, and what is the root thing that we have to have? So with that client, it would be like, okay, we have to have safety, we have to have some place that's safe, we have to have some sort of stability, what are we gonna have? And so I think that's where OT is really beautiful, I've got creative and problems solving, and a really unique way that other professions don't think, because other professions are like this is the one way, and this is the way that you do it, and there's no other option. And that's not the way our minds work. - Yeah, coming back to like that client that you were talking about, I think that is like a perfect example of like our, like us being our like privilege and us imposing like our expectations of like, how you're supposed to live life until that person, where it's like they're happy doing this, like let them be happy, and let's support them in that, instead of like lecturing them, or instead of like, looking down on them, or being like, well, you shouldn't feel this way, or you shouldn't be living this way. So. - Right. Which also then brings me to doing a lot of education with other professions. So for example, law enforcement is a great. So like when you run up against these system issues, I think that that's sort of like my, like I think I picked that point in my career where I'm sort of making the transitions from doing more like direct interventions, do I feel like my new role is like advocacy at like a very high level, and so a lot of like what I'm doing is like, let me tell you why this population is operating this way. Like let's talk about how we can change the system. So like no law enforcement, you're a person who's sleeping outside and keeps coming back to that same place is not doing so because they're being difficult or they're being obstinate. I was actually talking to a law enforcement officer the other day, and they were telling me that they have this client who will not leave this one area of town because he has an estranged daughter who lives there and he wants to be near her. And I was like, okay, let, I don't work at this time. We were purely having a discussion this law enforcement, but I was like, as long as he is not stalking her, and as long as you know, there's never straightening order there. Like let's talk about, is he harming somewhere? Like let's talk about, can we look at like housing him if he wants to be housed in that area of town so that he can be near his daughter. Like what is the harm in that, you know, and I think so often there's this gut reaction from other professions of like, no, like that's, we could do that. Why would we do that? It's like, well, why wouldn't we? Why couldn't we meet someone's needs? - Yeah, exactly. Oh, wow, that, 'cause I just feel like we have a lot of, these type of issues at like the state facility where I work where, I mean, I work somewhere where it's literally been open for 150 plus years. So it's very like, dated ways of looking at things, dated models, dated like approaches. And yeah, I think that there's not enough people to challenge that. And so a lot of times our clients pay the price, unfortunately, and we don't. We're unable to provide them with the support and the care that they deserve. So. - Yes, absolutely. Every OT that I know that works within these sort of, and I'm specifically talking about community 'cause I'm sure this exists in every other area of OT too. But in community mental health, goes out of their way to fight systems. I know that my OT Kaelin is a regularly calling the hospital and being like, you cannot discharge this person to homeless this again. Like, what is your discharge plan? That is not in her scope of practice. Like, or not in her scope of her job. Excuse me, is her scope of practice? To be doing that, but that is what is best for this client. You know, like those are the moments. And I think that's also what leads us to high levels of burnout. But that's a whole separate discussion, but we do it for our clients. 'Cause that's what we do. - There is that, you know. So with the interventions that you guys provide in this patient, do you feel like a lot of them are like sustainable and meaningful, or do you feel like they're more like temporary fixes to a much larger problem? - A little bit of both. I would say, like I do think that in terms of our clients, their occupation on participation, I do feel like those interventions are sustainable. Like the ones that come to mind are like things around like emotional regulation and coping skills. I have seen some incredible progress in like sustainable interventions and clients implementing those in ways like across their environments and in other contexts and being able to take what they've learned to know to eat to other places and sing to law enforcement. Like, I need you to stop. I'm in the red zone right now. (laughs) And I know that I'm gonna do something bad. So I need to take a minute to cool off. Like that's an incredible intervention that like Kaylyn, my OT implemented and then we saw Kerry forward and like good gosh, that's amazing. At the same time, there's a lot of stopgap fixes. And so I think it's a little bit of both. So I always say to those of us working in this sort of area of practice, like take your wins with your losses, like take the moments where you see those victories and the moments where we really feel like we've affected change and be like, I did something awesome today because those other ones are really hard when you try something and it changes. And you know, you've got to do it again later because of the systems. I think it kind of evens out in the end. But we live another day to keep fighting. - Yeah, and when I was in school for occupational therapy, we also had like a clinic and we served a lot of clients who were like lower socioeconomic, who didn't have like healthcare. Some might have been homeless. I feel like majority maybe weren't, but they were still like on that lower spectrum. - Sure. - And I don't know. I guess I always felt like we were doing like the standard interventions of like emotional regulation and joint protection in this and that. But to me, sometimes it kind of just felt like we were there just to like practice our skills and it didn't feel all the time super client centered or like, well, we're telling you this, but I'm not exactly sure like how to tailor this to like make it meaning. And it just feels like we're kind of doing this repetitive type thing to make us feel good. And like, oh, we did something to help like this population in need, but then it's also like, well, did we help them? So I always like struggled with that a lot, working specifically with like populations like this and like at balance between like something can look great, but like, is it actually great and how to like make sure that what you're trying to do is actually achieving that. - Oh, gosh, yeah. So I think that like so that that's a really important point. So I see a lot of that in OT. I see a lot of moments particularly the unhoused population where people want to provide OT services in this population and are going in without an understanding of all of the complex needs of this population and so those services that are if you're providing in many ways are at best, not helpful, at worst harmful. - It feels like insensitive almost too. - Yes, yes, yes, yes. And so whenever I talk about this and I give this lecture on some semi-regular basis, The first thing, and then one of the biggest things for us has been truly, truly. have a strong partnership with the agency that we work with. So I've mentioned St. Patrick Center many, many times. This is an agency that I have now been with since 2015. So almost a decade now. And there are staff at the agency who I've been working with that long. So we really have, we always say we are not here to do what we want to do. We are here to meet your need. So it is always like every group that we run in that clinic is because the clients asked for that group. Or the staff at the agency said, this is what our clients need right now. We are not choosing those interventions. The clients are choosing those interventions. And so I think that's number one is that we are truly, truly saying like, what is it that we can, like what need can we meet for you right now? And like, like I said, like you know, we're bringing a little bit of information but they're also bringing a lot of information. So that's sort of like part one. And that's also true with my research. Like I am generally not doing research for research sakes because that is an incredibly harmful to this population who has had a lot of research done on them over the years. And then the other part of it is, and you were saying like, if you're delivering an intervention and it just doesn't feel like it's worthwhile, like this is a population where you have to be willing to pivot. So like that example I was giving a while back with the client who had heard his son, you know, murdered earlier that week. That is a moment where like whatever you were planning on out of tea that day is not, doesn't matter. Like that is not what that client needs that day. If you were going to do energy conservation that day, that is not what that woman needs. Like so that is one of the biggest things that we also learn and that's that skill back to clinical like reasoning is no. It is absolutely appropriate to have everything that you're going to do out the window and actually sit in that moment with that woman because what she needs is a listening ear, what she needs is emotional support. She needs to know like, you know, she needs to grieve. Like that is what we are here for. And like those are the really important things. So for us it is all about throwing our plans out the window, truly, truly, truly meeting the clients. These there have been times that like we have been told by the staff at the women's shelter where I said, we get a lot of our clients that like, there's some inner like personal conflicts happening at the women's shelter. And they're like, can you like, can you all do anything about that? And we have literally like scrapped the whole group that the students were planning on running that day. And then like, okay, we're going to do like interpersonal communication in group. And like we sort of like hash it all out and address it right then and there and like work through how like what is better interpersonal communication? Because I think that is the most harmful in student rank clinics when it's like, okay, I want the students to learn this skill and so they prepared it and where that's what's going to be delivered and like it doesn't matter what's going on with that person that day. And that's not sort of best practice. And so I say all this to say there's a group of us who work in the unhoused, who are come together and putting together a research paper right now about like best practices in particularly capstones because we see this lot in capstone planning where people want to work in unhoused for the capstones and we see kind of really harmful plans because they're not being delivered in a way that is sensitive to the clients where the person who's delivering it has had all of this training who has this understanding that they're not being mentored by someone with this enters like this understanding. And so this is something that we are really passionate about is like if OT's are going to do this, we're going to do this right and we're going to do this well. And that means that like we're not at the forefront at what's happening, the clients are the forefront of what's happening. So I'm like, that's my piece on that but I'm really glad you brought that up 'cause I do see that a lot. - Okay, that makes me feel better 'cause I don't know, it just felt like sometimes it was like I was the only one who like saw it that way. I also wanted to talk a little bit about the research that you have conducted, how your research has impacted and informed your practice. - Yeah, so I mean, the things I would say about our research is just that like I sort of do research in two buckets with the unhoused population. Everything that we do is either one to better understand the occupational participation of this population. So like, you know, we can understand what their day-to-day lives look like or better understand how we can serve them and then the benefit of OT services. That's really all we do. Everything that we do has to be run by the organ so we have to have approval from the Program Committee at St. Patrick's Center to do it and we're very particular about what we run and why. We've had, like, this was an agency actually that was distrustful of academic institutions when I first started working with them. They had had a lot of psychiatric folks come in from the School of Medicine, do drug studies with their clients and then leave them unmedicated and so they were like, I don't really trust academic institutions and so, so I really had to build up trust with them and I had to consistently show them that I had the clients best interests in mind and all these research that we were doing was really for best practices and to, like, further demonstrate that. So a lot of what we have looked at has been run ways to better serve our clients. So we did our, like, a really large skill study around, like, menstrual hygiene and, like, the occupation of menstrual hygiene when you're unhoused and what does that look like? And, like, where do you get products? And, where do you change products and things like that? Because that was something that, like, we didn't really know what's on about and so that has changed our practice because now we have menstrual stations everywhere. We actually have one in the clinic where there's free products. We hand out free products. We make sure that the clinic has a safe place to change products. We've done a lot of education in the women's shelter around products and safe places to change products and things like that. And then another one that we're just at the end of and is in review right now with a journal was looking at LGBT appearances in shelters. So we sort of did a comparative case study. We looked at two sort of individuals who identified it on the LGBTQ spectrum. And we purposely chose shelters that weren't designed for LGBTQ individuals. There was a lot of, like, LGBTQ youth shelters out there but that's not, like, we chose these shelters that were faith-based so that we could see the experiences. And so, you know, we wanted to know because where that will go will be, like, how do we change these processes and how do, you know, there are clients right now in the women's shelter who identify as male. And so, you know, how are they changing their processes? How are they making sure that those people feel welcome and that they're not discriminated against and that, you know, it feels like they have a space. So that's a big one as well. Understanding, trying to get some of the others we've done, understanding, like, health of this population, understanding, like, the barriers that exist. I know one of the ones that you and I were talking about earlier is our sort of a health management study where we did a bunch of interventions with the client around health management and maintenance and trying to improve this client's health which ultimately were not successful because of sort of the barriers we saw in the systems. And I think that was a great illustration and really important to put out there because, like, OT has such a role in improving the health of this population but it can't be done, like, in a silo. We have to, like, I'm staunchly against people sort of seeing OT as, like, the silver bullet or the solution to health or, you know, solving homelessness because that is by no means what we are. We are a tool. We are a great tool that can be added. And without us, I think we're gonna have a really hard time sustainably housing individuals who are chronically homeless, who have, you know, homelessness with an associated physical or mental disability and, you know, the cognitive deficits. I don't think that that's gonna be possible without OT but I don't want there just to be this misconception out there that, like, we're just gonna throw OT at it and everything's gonna fix it. No, the systems and the structures have to change with us because we are still fighting an uphill battle. And so that's just sort of like a brief overview of the research but essentially like all of these things to help us argue our fight in a better direction, like, evidence to prove why we're saying the things that we're saying is really what we're doing because everything that we do allows us to ask for changes allows us to put policies in place and use evidence to support it or help get grants to do that. And so that's a lot of the work that we've done. - So in regards to the menstrual study, - Yeah. - It sounds like you have kind of changed, I guess, what you offer in like the building itself that you work in to help support. As far as like going a step further, I mean, you mentioned like where would it be safe to change these products and stuff like that. And it is interesting and I'm interested for your take because even like at my place of work when I've had discussions with people, they've been like, well, sometimes we don't always have access to a bathroom and like if you try to go into a store a lot of times it's like no public access or like you have to buy something. And so what do you say to those people and like what's your solution to that or like how do you help support them in those issues? - Yeah, so we really try to identify like what are some places that we know we will have access to bathrooms in and like what are safe bathrooms? 'Cause clients talk about bathrooms that are unsafe so like even a bathroom that like would have a single stall door like you know, so you go into a bathroom and it's like a single stall. They don't feel comfortable. A lot of times just locking back door, they want to lock the main door to the bathroom so that like no one can come through that. And so you know, like from an OT standpoint, like okay, let's identify the bathroom sort of on our daily route that we can use to sort of pay out our plans and just like you would do anything else, let's plan out like when we're gonna change and like if we know it might be a while, can we wear like maybe a heavier pad or something like that so that we don't have to worry about leakage? Making products available is huge in talking about like what are the products available? I mean, we had clients in this study say that they go to the emergency department to get products because they do not know where else to get them. To just, you know, having them available, like we just have them. like open and available in the OT clinic so that any client that comes down there can take them. The other thing is like, like I was saying, not assuming the gender of a person and assuming that they do or do not menstruate. And so we do fight a little bit of an uphill battle because our agency is a Catholic agency that has tied to Catholic charities and so there are times we have to fight policies. But like, you know, really recognizing that like these products should be available in both men and women shelters because, you know, we're seeing people who menstruate in both shelters. And so that all of those things are coming into it. Yeah. Okay. Yeah, that makes a lot of sense. So you actually did a TED talk not too long ago. And yeah, I just wanted you to be able to talk about well, first like, what was that process like? Why did you decide to do a TED talk? How do you even decide to do a TED talk? Yeah, all the things around that I'm interested to hear. Yeah. So how I decided I don't know was like a total whim. But like, I think realistically, I was looking for a way. So I kind of felt like particularly in the unhoused, you know, this, and I sort of mentioned it earlier, you know, there's a lack of funding and a lack of knowledge around what OTs do. But the unhoused is a very like political topic. It's something that you see in the news all the time, but you rarely see the recognition of OTs roll there. And so I was like, you know, I really think that I need to get the word out about this outside of sort of the traditional academic circles outside of publishing because that only does mean so much good or outside of presenting at these conferences. And so I happened to across the TED talk, the St. Louis TEDx information one day and I was like, all right, like, let's try this. And so it was just such an interesting process because so to apply, you get to 300. No, no, I'm wrong. To 100 word, to 100 word, paragraphs. One is about what is your topic and why is it like necessary? And one is why are you qualified to talk about your topic? From there, they got like thousands of applications. They paired it down to 24 of us that got out into do a three minute, like out of five talk. Basically, do three minutes on your topic and answer those same questions. What is your topic? Why is it necessary? And why are you qualified to talk about it? And then after that, they chose 12 of us to actually do the TED talks. But the really interesting thing is, and I didn't know this until I actually went through the process, it's six months of training to give a TED talk. And actually, when you give a TED talk, most of them, there are a few of them, but the one I did is completely memorized. You do not have like teleprompat at all. It is totally memorization, which was very scary, to give like an 18 minute talk totally from memorization. But it's six months of training with acting coaches, people telling, teaching you about like, what is best practices in like storytelling? What is best practices in your PowerPoint? Like, how should your pictures look? What's the most eye catching? Things like that. You give this talk over and over again to the people in your cohort. And they give you tips on like, where's your body physician? And like, where's your hook? And so that was just such an experience, too, in learning like how to public speak and how to give a speech in a way that is really engaging and brings people in. And then actually doing it had a way better reception than I could have imagined. I think it's like up to like 6,000 views on YouTube, which seems small, but I think in the OT world that's the decent user number. And I know that like a lot of OT schools use it in their like mental health classes because it does talk about what is OT's role. But I think in some small ways it's getting some of the reach that we wanted. I have a friend who's in Colorado and she wrote me and she works in the unhoused as well. And she wrote me and said that one, some staff at a library near her saw the TED talk and then reached out to her because they're like, would you be willing to like start this kind of program like for the unhoused that come into our library? Because I see that like OT can have a role here. Like, do you know anything about this? And she was like, oh my gosh, yes, this is a friend of mine. I'm happy to do it. And so she's sort of developing this program as it is. And that was really what I wanted from it. I wanted people out there to see like, yeah, like we have this role that no one's talking about that no one knows about. And sort of develop programs from it. And if nothing else, people being able to use it as like fodder for starting their own program. Like to be able to reach out to a program and be like, hey, I'm really interested in no tea. Here's a TED talk you can watch about like what we do. It was a real adventure from start to finish. I learned a lot. It was not easy. Let me tell you that it was really hard, but it was well worth it. Yeah. And it's really cool that like you literally did that for that reason. And you were able to like see in real time it happen with your friend in Colorado. And I could imagine that I mean, for you, especially if you're like someone who's getting more into like advocacy and trying to like change these systems, like the skills you learn from that training are invaluable and skills that you can take on when you're speaking to different populations who hold maybe a little bit more power and who can act the changes that you want to see. Yeah, that's a really strong recommendation. I have actually, if you're someone who is really interested in advocacy and doing a lot of work at like systems and structures level, I would recommend some public speaking courses and some like communications courses. So my little sister actually is she works in communications. She's actually like a national champion in speech and debate. And she does a lecture for one of my classes on public speaking. And I like, she's someone I have her look at every speech that I give. And she helps me like rewrite it. And she does an amazing job. But there's so much that I've learned from people who are actually in the like communications and public speaking world that I think that we don't get as OTAs in terms of like how long do people actually pay attention? And how do we like, what do we do with our hands? And things like that are one of the biggest trainings that I have sort of added into my life. That is very cool. And not many people get to say that they have done a TED Talk. I thought like, I don't know, I feel like when people like hear TED Talk, they just are like, my gosh, and this must be the smartest person in the world. Yeah, I remember after the audition, I was like super nervous and I told my husband I was like, this is like a real mixed bag. Like if I don't get it, I'm like totally okay because I'm like scared, you know, about it. But like also it would be really cool because I feel like this is really bucket list. Oh, one hundred percent. That's so cool. Would you recommend, I guess, or like do you know of any other like avenues similar to a TED Talk that you would say could like disperse ideas? Yeah, yeah. I actually went to a really cool presentation. The Occupational Science Conference, the Society for the Study of Occupation, this past fall in St. Louis, he was here, by Jen Soros and Carla Reese, who run the podcast on OT and sex. I can't remember the name of it at the moment. It's escaping me, but they're phenomenal, but their whole talk was on like, how do I get our research out in innovative ways. Podcasting is a great way to do that. Like, podcasting reaches the masses in a totally different way. Blogging, social media, all of those things are really great. Like anything that I think gets us out of our traditional academic circles is really, really wonderful op-eds for the news is also cool. We just have to get out of our traditional, and I think this has been a product of the way academia has been structured that we only get credit for doing things that are peer-reviewed, right? I've given a TED Talk and I don't think that counts that much towards promotion compared to if I publish a paper. So that's part of the structure, but we have to get out of this idea that the thing that matters most is publishing. Yeah, that's important, and it's important that other people look at our evidence, and they say, yes, this is good evidence, but we also have to take that evidence and put it out there in a way that is really beneficial. And then, you know, thinking about like what we do publish, so I've just published with a really phenomenal group of colleagues recently, a really important paper around professional behaviors and the impact of that on students of historically minorities backgrounds, but we chose to publish open access, even though it was really expensive and none of us had the money to do it because we wanted everyone to be able to access it. We wouldn't want it behind some paywall. So things like that. Yeah. Well, good for you for doing that. We all spent $200 of our own money to do it, let me tell you. Well, I'm sure that people will be grateful for that, but I do agree with you, like once we can kind of get outside of like our own community and figure out like avenues to like reach the masses or like the general public, I think that's where we'll see like the most change because like people who are talking to all right, it's like preaching to the choir. Yeah, that's quite telling OTS about the wonder of OTS. Exactly. So yeah, things like that are not exactly like academic, but like more, I don't know, would you say like fun or like be a little bit less serious like podcast or like accessible like yeah, things that you would like enjoy reading. Like no one's going to pull up a journal. Maybe somebody's going to pull up a journal. You're like, I can't wait to read this journal article, but for the most part, that's not that's not the way. Probably not the people who need to know it are the ones who are doing that. Right. Yeah, no, I definitely agree with that. And I think too, with that, a lot of people maybe like OTS or stuff like that, maybe just feel like they're not qualified or like they, like, well, who am I to like create posts or like do this for OTS? Like, what do I actually know? And like, this should be someone else do. doing it who is more knowledgeable or has more experience, but I think, basically, we don't want to act like we know everything, but at the same time, like, recognizing our worth and like, recognizing that we do have things that we can say and, yeah, we have- If not you then who? Exactly. Exactly. So, well, I think those were all of the questions that I've had. Would you like to talk about anything else or have any closing remarks or anything? Gosh, no. I think we covered so much. I feel like I've had a chance to say a lot of really important things. So thank you. This was really enjoyable. I feel like I learned a lot, so- Same here. Hopefully, the people who listen feel the same. We will see. Yes. Yes. And thank you so much for having me. I truly, truly mean like you are wise beyond your years and being where you are less than your inner practice. You're going to do amazing things in your career. I was nowhere near as put together as a new practitioner as you are. So, I can't wait to see how all of this takes off. Well, I appreciate that. It was a pleasure getting to talk to you. Absolutely. And I will let you go.