Black OTs Matter: Changing Your OT Practice to Combat Racism, Address Racial Trauma, and Promote Healing

BLACK OTs MATTER

 

As I sit here in the quiet of a Sunday morning in the comfort of my home, I’m in quite a state. A state of numbness, a state of shock, a state of anger, a state of resignation, a state of…wonder.

 

Wondering if things in America will ever be different for black and brown people. Wondering if this morning is the last time I’ll talk to my dad on the phone and tell him I love him before getting That Call. Wondering if there’s any hope for a world in which black and brown people are treated as if our lives really do matter. And wondering if the people who know and love me know that I’m not okay.

 

For the past week, I’ve been going back and forth to work and keeping it together because I’m “essential” and that’s what I have to do. For myself, for my husband, for my patients. I’m one of two black people in my office, and one of a few black people in the rehab department at the hospital where I work. For those of you who don’t know, I work in a mental health setting serving people with a wide variety of mental health conditions. People always ask me how I keep from bringing my work home with me, wondering how I can keep all of the sadness and pain and trauma and heartache from saturating my life and affecting how I go about it.

 

What they should really be asking, to me and every other black practitioner out there, is how I keep all of my own struggles and trauma and emotional distress out of my work life.

 

The truth is, I’m crying for the first time since hearing the news about Ahmaud Arbery, Breonna Taylor, George Floyd, and remembering Philando Castile, Eric Garner, Trayvon Martin, and all of the other black and brown people whose lives have been cut short by forces outside their control as I write this right now.

 

After every tragedy, I find that I am unable to really process what I’m thinking and feeling to the full depth because I have to keep getting up and giving strength to other people and being strong for other people who are suffering. I just don’t have the mental resources to cry all the way to work and all the way home and still keep doing my job. Because if I started crying on the way to work I’d never stop.

 

Unlike my white colleagues, I live with the burden of being black in America every day. When I go to work, I often face microaggressions and assumptions about my abilities, backgrounds, interests, and experiences from when I walk in the door to when I walk out. On top of that, I go in with worries about whether my brother or my uncle or my dad or my cousins will be stopped on their way into work or while doing their jobs and have their lives cut short. I wonder if the black patients who I see will be restrained, ignored, marginalized, or judged based on the color of their skin and not their physical, emotional, or mental health challenges. I wonder if the black and brown teens who I work with will be around in five years to be able to change the world in the wonderful and wild ways they tell me they want to. And yet I still have to create groups, attend meetings, write documentation, and go about my business the same as everybody else. But I’m not the same.

 

Everyone keeps talking about “occupational injustice” and “occupational apartheid” like they’re these big, fancy concepts that only apply to people in prison or low income communities or war zones. The fact is, these concepts apply to me too! As a black OT, it’s an injustice for me to come to work and listen to people talking about their fun weekend or their sleep issues or their plans for the future while I’m struggling to reconcile all of the emotions and hatred that’s happening and have nobody check in and ask how I’m doing or consider how it might be impacting my occupational engagement and quality of life.

 

This week, I’ve gotten texts and phone calls from people I’ve known for all of my life and just a few years asking how I’m doing and wanting to know what I think about everything that’s going on. I’m thankful that I have people who care and who are willing to brave the awkwardness and brace themselves for an onslaught of emotional instability when they ask “How are you?” It’s honestly more than I’ve gotten in any place I’ve ever worked.

 

I don’t know if it’s because people feel like it’s not “appropriate” in the workplace to check in with their black and brown colleagues and patients or because they themselves don’t want to deal with what happens next. But that’s just another luxury that I don’t have – I don’t get to ignore what’s going on. I get to relive the generational trauma and endure another day of institutional racism in a place that doesn’t have room for the answer to be “I’M NOT OKAY!!!!”

 

A lot of people are mad about how AOTA isn’t putting out a statement or doing anything else to acknowledge everything that’s going on, but I honestly couldn’t care less about what they’re doing. Anyone can write up a stupid statement to slap on their website and claim that they are “with you.” Anyone.

 

What anyone CAN’T do is meaningfully engage and push others to engage with their friends, family members, colleagues, managers, subordinates, team members, and others who are black and living through a time when our legacy of pain is laid bare for all to see and even more to avoid.

 

So if you’re not satisfied with AOTA’s response, why don’t you take a look in the mirror and look at your own response? Who have you checked in with? How many black patients have you asked this week about what’s going on in their heads and hearts? How many people have you cried with, have you marched with, have you called, have you written to, have you hugged, have you held, have you held space for? Versus how many social media images have you shared, posts have you written, videos have you watched from the comfort of your own home? Think about it, and then let me know who’s really in the wrong.

 

If you are an OT practitioner or anyone else out there reading this, I want you to know, and I need you to know that I’m not okay. We’re not okay. We haven’t been okay for a long time and we probably won’t be for an even longer time until you start to speak up and share the burden. Until you understand that I can’t be productive when most of my day is spent avoiding my own mind and finding ways to stay busy and keep from crying in the bathroom for 8 hours straight until I can go home and do it all night. I can’t do my best work when I’m listening to a bunch of ignorant coworkers talking about riots and looting and ignoring the millions of ways in which they marginalize and bully and oppress and ignore the people in their “care.” I can’t achieve my full potential in a workplace that refuses to acknowledge or even ask about whether or not what’s happening in the world and in my life is affecting me. Answer: IT IS.

 

I need our profession to understand that we as black and brown people don’t have the same occupational rights as you do! I don’t have the same right to walk down the street, to go shopping, to go jogging, to drive my car, to go to work, to live, to love, to laugh without experiencing alienation and maybe even violence. I don’t even have the same human rights as you do. And the sooner you acknowledge it, the sooner we can start a dialogue and start making change.

 

As an OT, I know that context is such an important part of what is happening in anyone’s life and how they are able to engage in occupation. Why would that be any different for black OTs right now? The context of my life is different than that of a white clinician. Currently, my context is one of pain, misery, trauma, anger, defeat, confusion, and despair. And as a result, my occupational performance is suffering. My energy levels are down, my cognitive functioning has changed, my emotional resources are bottoming out, my spirits are weak, my motivation is low, my mood is grim, and yet…I’m expected to go and do the same as a white clinician who isn’t facing this barrier? Worrying for their family’s and their own safety every day? It’s insane that a profession that prides itself on caring about context is so blind and yet here we are.

 

Right now, I’m supposed to be participating in my typical Sunday routine of attending church, spending time engaged in spirituality, and communing with friends. But I can’t do that because I have too much emotional distress brewing to even focus on anything else. Consider that on a wide scale, and then think about why the people you work with as an OT might be having difficulty doing what you and everybody else is asking them to do.

 

You’ve probably noticed by now that this isn’t the type of thing I normally write, but that’s OK. At least, it is with me. Maybe it’s food for thought or maybe it’s just another link to share or skim or ignore, whatever. It’s what I needed to do for me, and maybe what somebody else needed too. I don’t know, and I won’t know.

 

What I do know is that as I continue to do work in mental health, physical rehab, or wherever else, I am not going to ignore the big, black elephant in the room. The experience of trauma is embodied, and impacts occupational performance. As best practice, I’m going to write about it, I’m going to document it, I’m going to talk about it, I’m going to acknowledge it, I’m going to cry about it, I’m going to scream about it, I’m going to do my best to provide interventions and support and resources and referrals for it and all this is so that I can do something about it.

 

If you’re a boots on the ground therapist, make it part of your everyday practice to stop ignoring the obvious and doing the difficult thing. Make an emotional check in part of your session and make space to listen and learn from your clients of color. Challenge the assumptions of your coworkers and other people who don’t see “why it’s a big deal” or say “it’s so sad” and change the subject. Acknowledge the pain of your black and brown coworkers and do your best to share the burden or allow them to stop pretending and unpack their minds for a few minutes or as long as it takes. And if you’re in leadership, make it your job to engage meaningfully with people of color in your workplaces and communities to understand their frustrations and learn how to make changes to make their lives more bearable.

 

I’m committed to being more open with the people around me, to allow them to be supports and to challenge them to be better and do more.

 

I hope you’ll join me.

How to Handle Loneliness in Grad School Part 2: 13 Tips for Making Friends and Making it Through

Loneliness in OT School (2)
The first post in this mini-series dealt with my experiences with loneliness as a first year graduate student and how I eventually overcame it. It was a difficult year, and I wish I knew then all the things I know now – I would have been a much happier, more social student! In any case, I made it through my first year as an OT student, and now I have several good friends both in and outside my program who have become part of my new friend groups.

If you are struggling with feeling like you don’t fit in or you’re having a hard time making friends, I hope these tips will help! After reading this post, I hope you’ll find that making friends as a graduate student is easier than you thought.
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How to Handle Loneliness in Grad School Part 1: How I Beat the Blues

Loneliness in OT School.png

Psychosocial health is an important element of any person’s daily functioning, and it can have a significant impact on performance in many other areas of life. Loneliness is something that everybody has probably experienced in life, and it’s something that I often struggle with whenever I have to start over in a new social setting – for example, moving to a new city and starting grad school!

 

Although I am often described as a talkative, friendly, and outgoing person, I’ve had several experiences when I’ve felt extremely socially isolated and lonely, such as my first year of college and a job as a camp counselor. Although in these settings I was surrounded by people and opportunities to make friends and have fun, I spent a lot of time alone and struggling to find people to connect with. It’s a challenge I’ve continued to have in my adult life, but it’s also something that has helped me better understand myself and how I can be most successful as I continue to move around, start new endeavors, and meet new people.

 

This post was difficult for me to write, because it really puts all of the negative feelings, anxiety, and loneliness I experienced during my first year of graduate school out there. It’s not easy admitting that I had a hard time, and maybe to most people I seemed fine. But if I’m honest, my first year in graduate school was a challenging transition that I was not prepared for. Knowing that many of my friends from undergrad were also in the same boat (living/working in a new place without many friends) and talking to them about my situation made it a little easier, but I had to learn the hard way that life in grad school is NOT the same as it is in undergrad – or at least it wasn’t for me!

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Stories from a Spinal Cord Injury Survivor: A Patient’s Perspectives

SCI Survivor

One of the reasons I love my OT program is that my instructors understand the importance of the “patient perspective.” Many of my homework and class activities have focused on understanding the experience of the clients OTs work with, and how personal factors (in OTPF language) can impact their recovery and the therapist’s treatment. My classes also often include guest speakers with all kinds of experience and commentary, as well as enlightening field trips to businesses I will likely work with in the future (i.e. a local medical equipment company that sells power and manual wheelchairs and other mobility devices). The OT program is also housed in a great allied health department that often hosts speakers and presentations on a variety of topics related to the patient experience, and I try to attend as many of these programs as possible.

One of my favorite things about having class speakers with various diagnoses and experiences is that it truly brings my textbooks alive. It’s one thing to read about “autonomic dysreflexia,” “intermittent catheterization,” and “psychosocial factors” in a textbook chapter about working with spinal cord injury (SCI) survivors, and another thing ENTIRELY to have an SCI survivor and his wife and caregiver talk to you about their experiences with these things across the continuum of care (hospital to rehab to discharge home).

That brings me to the point of this post: recently I was fortunate enough to meet and learn from a man named “Brian,” his wife “Sarah,” and his caregiver “Tonya.” Two years ago Brian was riding his motorcycle with a friend when he was struck by a distracted driver who was texting at the time. Although Brian was wearing a helmet and there was apparently not a physical scratch on him after the accident, he sustained a high level (C5) spinal cord injury that left him with little function in his neck, limited function in his upper extremities at the shoulder, and virtually no motor or sensory function below the shoulders. To gain an understanding of the specific regions that were paralyzed and functions that were affected, you can check out this diagram.

The accident was a very traumatic life experience, but in talking with Brian you would hardly know the true depths and trajectory of his recovery. He was a good-natured jokester with a white beard who, alongside his wife Sarah and longtime caregiver and friend Tonya, had a very positive outlook on life and a great deal of helpful information for soon-to-be therapists like myself and my classmates.

This post is about the lessons I learned from talking with Brian and his crew last week and why they are so important for me to keep in mind as I get closer and closer to being an OT practitioner.

Brian Resized
“Brian” and his wonderful wife “Sarah” were fantastic speakers, and I’m so glad I got the chance to learn from them!

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“Day in the Life” Series on OT Cafe

_Day in the Life of an OT_ SeriesonOT

Happy Friday! Today is the only day of the week when I don’t have class. Which means I actually have time to write a post! (This is clearly way more important than reading, homework, or finishing any of the 12 billion projects I have due throughout this month. -__-)

In case you didn’t know, my friend Abby over at OT Café has an AMAZING new “Day in the Life” series on her blog to celebrate OT Month. She has reached out to OTs all over the place to learn more about what they do, the populations they work with, and what they love about their jobs, and if you’re interested in a career in OT, working in a specific practice area in OT, or learning more about the OT school experience, you should check it out!

All of the posts can be found HERE, and they will be updated throughout the next few weeks as she rolls all of the posts out in April. I’ve been following all of her posts in the series, and it’s great to have practitioner stories and perspectives from different practice settings in mind as I begin thinking about what I’d like to do when I leave school.

Who needs to do work/pay attention in class/be productive on a Friday when you can spend your time being immersed in the wide and wonderful world of OT? (Answer: NOBODY)

Happy reading!

Breaking the Cycle: Occupational Therapy’s Inclusion in SAMHSA Mental Health Legislation

Back in November, I wrote about occupational therapy’s role in mental health, specifically the profession’s advocacy for occupational therapy’s inclusion in the Substance Abuse and Mental Health Services Administration (SAMHSA) legislation that will create Certified Community Behavioral Health Clinics (CCBHC).

On February 2nd, SAMHSA released their draft criteria (which you can read here) and occupational therapy is one of the professions that have been identified as potential CBHC providers! Although the document is just a draft, which means that we aren’t officially in the door, it’s still an important stride being made for the profession and for the clients who OTs have the potential to help in the future.

Occupational therapy actually has its origins in mental health, beginning with the moral treatment movement in the early 1800s and continuing throughout World War I, when “reconstruction aides” used crafts, functional activities, and their understanding of the human desire to live a productive, meaningful life to help returning soldiers cope with their physical and psychological injuries (AJOT, 2011). Unfortunately, in recent years occupational therapy has lost its footing in the realm of mental health due to political and legislative actions, professional identity shifts, poor professional advocacy, and other factors. This has led to a sort of vicious cycle of OT’s exclusion from the arena of mental health, which I’ve illustrated in the graphic below:

OT in Mental Health Cycle Graphic

Negative outcomes of this cycle include:

  • Decreased access to qualified mental health service providers by those who need services
  • Healthcare teams that are missing a valuable occupational therapist perspective on client treatment and recovery
  • Fewer opportunities for assessing or developing intervention and treatment methods that may be effective with clients with mental health concerns

However, with occupational therapy’s inclusion in SAMHSA’s CBHC draft comes a chance to break the cycle and make it known that occupational therapists bring valuable tools, insight, and clinical expertise to the field of mental health. In the same article I cited previously (available in full to AOTA members), the author offers several practical solutions to help remedy the current shortage of occupational therapists practicing in mental health, including increased professional advocacy at the state and local levels for the effectiveness of OT in mental health and high-quality research to support this conclusion.

I think that occupational therapy has a bright future in mental health, and I am hopeful that the next generation of therapists will be better-prepared, more confident, and capable of taking on the many challenges presented by working with people living with mental health concerns. We’re now one step closer to breaking the cycle, and I’m excited to see what happens when we reestablish our role as qualified mental health professionals!


Links

If you’re interested in learning more about occupational therapy’s role in mental health, check out these articles describing how the unique skills of OTs have made a difference in the lives of people with mental health concerns, including children, veterans, and families.

Military Service Members and Veterans: Occupational therapy interventions help veterans living with PTSD re-establish routines, learn how to cope with their symptoms, and successfully rejoin their communities.

Children & Adolescents: The community-based OT that the high school student in this article is seeing is helping him learn independent living skills that will help him become less dependent on his family members and likely ease the caregiver burden his mom reports experiencing.

Professional Opportunities for OT in Mental Health: AOTA President Ginny Stoffel authored a useful article that reviews the multiple opportunities for occupational therapy in mental health, including having OTs be members of primary care and “integrated treatment” teams and the important role OTs can play in the recovery of clients with mental health concerns.

References:
Special Issue: Effectiveness of Occupational Therapy Services in Mental Health Practice. Am J Occup Ther 2011;65(3):235-237. doi: 10.5014/ajot.2011.001339.

Transitions to Independent Living & Opportunities for Community-based OT

Life Juggling Act
The man in the linked Washington Post article struggled to meet his many needs with few independent living skills.

I just read a Washington Post article titled “In transition to independent living, the ‘dignity of risk’ for the mentally ill,” which focused on the experiences of a man named Kelvin who has mental illness and cerebral palsy. He had just moved from an assisted living facility to a small apartment near Charlotte, NC, and he was working with a team of “clinicians and social workers” who were helping him organize his life and transition to living on his own.

It was a lengthy article, but as soon as I began reading it I instantly felt as if there was a place for occupational therapy in this man’s life. After reading the article, I was both sad for the difficult situation in which Kelvin found himself after leaving the assisted living home and frustrated that the services he was receiving might not actually have been making it easier for him to accomplish his goals and live independently. As a future OT, I saw several areas in which an occupational therapist could intervene to improve the services Kelvin was receiving.

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Occupational Therapy in Mental Health: SAMHSA Listening Session and Comments (November 12-26, 2014)

AOTA and SAMHSA

In case you didn’t know, occupational therapists currently play an important role in helping people with mental health problems and psychiatric disabilities. They work in community-based, outpatient, inpatient, and other settings to help people living with mental health concerns learn how to best complete the activities they need and want to do.

Although there are some occupational therapists helping some people with mental health issues, there is not nearly enough supply to meet the demand. In the past, OT has not really been recognized as a profession that is equipped to meet the needs of clients with mental health problems, but this could all change in the very near future!

On November 12, 2014, there is going to be a listening session to Support Occupational Therapy’s Inclusion in New Community Mental Health Services. It is vital that as many occupational therapy students, practitioners, assistants and supporters as possible get involved and comment on the session in order to show their support and advocate for occupational therapy services that could be of great benefit to people who access mental health services in the United States. Part of being a successful therapist is being an advocate for the profession, and what better way to promote OT than participating in this crucial political event!

Here is the background on the event, straight from AOTA’s website:

In April, Congress passed the Protecting Access to Medicare Act (H.R. 4302), which established a “Demonstration Program to Improve Community Mental Health Services.” This demonstration program will expand access to quality mental and behavioral health services by establishing federally certified community behavioral health clinics (CBHCs). The demonstration will initially establish CBHCs in eight states through a competitive process, but could eventually CBHCs could be in all 50 states.

This fall, the Department of Health and Human Services (HHS) and the Substance Abuse Mental Health Services Administration (SAMHSA) will be writing the rules that define what mental health services and supports will be provided by these federally supported CBHCs. SAMHSA will be holding a listening session to help them establish the criteria for staffing, services, payment and coordination of care at the CBHCs.

For those not able to attend and comment in person, there is also the opportunity to provide comments in writing. Written comments will be considered just as important as verbal comments during the listening session.

We have been told by SAMHSA that it is important to have a strong demonstration of support for the inclusion of occupational therapy through comments and at this listening session. The development of these criteria is a watershed moment for occupational therapy’s inclusion in quality, community-based mental health services.

And according to SAMHSA:

By September 1, 2015, criteria will be published for state certification of participating clinics and guidance issued for participating states’ establishment of a demonstration Prospective Payment System for services. SAMHSA has the overall lead for the program and is responsible for the establishment of the criteria for the behavioral health clinics.

It is currently too late to register to attend or provide verbal commentary, but listeners and contributors will have until November 26 to submit written commentary, which will be considered just as important as the spoken comments listeners make. Unfortunately, I will be working for half of the day during the session, but I plan to wake up early and catch as much of it as I can before I have to leave!

 

At this point in history, occupational therapy has a chance to be included in landmark federal legislation that will have a great impact on American people living with mental health problems. It is absolutely crucial that we make our voices heard and take the time to support AOTA and the future of the profession in this endeavor, and I want to be sure I do my part!

AOTA has links to several resources that will prepare you to leave a well-written, OT-endorsing comment that will be reviewed by the SAMHSA team. Although the main (and most important) comment-writing document is for “members only,” there are still other helpful links here.

In case you don’t have time to click around and want to get straight to writing, I have compiled a brief list of tips and information from the AOTA and SAMHSA websites in order to streamline the process and hopefully make it that much easier for you to participate! (No excuses!)

Writing Comments

If you are an AOTA member, you can login and view their page of comment-writing tips here: http://www.aota.org/advocacy-policy/congressional-affairs/legislative-issues-update/2014/guidance-samhsa-comments.aspx.

In case you are not an AOTA member, I have included several of their most relevant and important points here to help you write commentary for the SAMHSA session. All information below is from the AOTA.

  • SAMHSA has provided “guiding questions” in a worksheet format to help structure your comments. Consider using the SAMHSA-provided worksheet, or write a letter using the worksheet as your guide.
  • Consider submitting comments on behalf of a larger group of occupational therapy practitioners. One letter could be sent from a facility, state association, or simply have a list of signatures from interested practitioners. The comments will count as if submitted by each individual, and this will make less work for SAMHSA. If submitting on behalf of a facility or association, be sure to mention how many practitioners or clients it represents. Get signatures from non-occupational therapy practitioners if relevant and possible.
  • Comment on as many of the guiding questions that you think are relevant, or on those of which you have expertise.
  • Instead of synthesizing your overall thoughts, comment on each question individually, even if this means repeating something you have already written. Comments will be collated separately for each section.

If you do write a comment, according to AOTA the most important thing to include is the following: Skilled occupational therapy should be a service available to clients on-site in CBHCs and occupational therapy practitioners (with their unique skill set that you will describe in your letter) should be a part of the staffing requirements.

Sending Comments

Each submission must include the Agency name (SAMHSA) and the docket number (2014-25822) for this notice.

Comments are due by 5 PM Eastern Time on Wednesday, November 26, 2014.

  • Email is probably easiest. Send your comments to section223feedback@samhsa.hhs.gov
  • If you would like to send comments by mail, hand delivery or fax, here’s how:
    • Mail: The Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, Room 6-1019. Attn: Certified Community Behavioral Health Clinic Comments
    • Hand Delivery or Courier: 1 Choke Cherry Road, Rockville, MD 20857, Room 6-1019 between 9 a.m. and 5 p.m., ET, Monday through Friday, except federal holidays.
    • Fax: 1-240-276-1930 Attn: Certified Community Behavioral Health Clinic Comments

Please help make a positive difference in the future of Americans living with mental health concerns and write a comment for SAMHSA by November 26! And please comment and let me know if you do!

Increasing OT’s Role in Healthcare for Veterans

VA

One of the goals I have for my career is to do occupational therapy with returning veterans and wounded warriors. I hope to work in a Warrior Transition Unit where I can utilize my occupational therapy training and incorporate my interests in career planning, physical medicine and psychology to help American soldiers who are returning home maintain their mental and physical health and adjust successfully to civilian life.

So I was especially intrigued when I came across a great article on the AOTA blog written by Elizabeth Hart, an occupational therapy student at UNC Chapel Hill. She was able to attend a House Committee on Veterans’ Affairs hearing titled “Service should not lead to suicide: Access to VA’s Mental Health Care.” At this committee meeting, parents of veterans who committed suicide after returning from deployment and a retired veteran who works with the Wounded Warrior Project testified about the difficulty veterans have accessing mental health care and other vital services through the VA healthcare system. Their goal was to inform our political leaders and policymakers about the systemic and policy changes that need to be made in order to prevent similar incidents and provide better primary mental and physical health care to veterans.

In her article, Hart not only outlined the multiple issues the panelists discussed at the hearing, but she also described why occupational therapists are so well-suited to help meet many veterans’ unfulfilled healthcare needs. She does a fantastic job of explaining how occupational therapists are often-neglected but important providers of physical and psychological treatments for veterans, including:

  • Supporting soldiers’ successful transition from active duty to civilian life by helping them “gain the skills and tools they need to participate in their day-to-day routines” and “reestablish their own roles within their communities”
  • Utilizing their holistic training and background to “address both physical and psychological injuries” as integral members of interdisciplinary healthcare teams
  • Acting as mental and behavioral health professionals to help increase veterans’ access to often inaccessible mental health services
  • Providing “non-pharmacological treatment options” for veterans with Post Traumatic Stress Disorder (PTSD), especially through the use of occupations like “gardening, motorcycle riding and playing guitar”

Ultimately, Hart’s article provided a great overview of the issues that exist for veterans in the current healthcare system and the opportunities OT’s have to help resolve them, and I highly recommend that you read it in its entirety here. This is an issue I care passionately about, and I hope that students, practitioners and AOTA continue to advocate for the role of occupational therapy in increasingly diverse settings.