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Occupational Therapy and Homelessness

Competencies for occupational therapy practice in homelessness: A Delphi study

Carrie Anne Marshall, Abrial Cooke, Rebecca Gewurtz, Skye Barbic, Laurence Roy, Rosemary Lysaght & Bonnie Kirsh

November 2021 Scandinavian Journal of Occupational Therapy

DOI: 10.1080/11038128.2021.2002404



Background: Homelessness is growing internationally, and resources to guide occupational therapy practice in this area are needed.

Objectives: To identify competencies needed for occupational therapists to support individuals during and following homelessness.

Material and Methods: We conducted a three-round Delphi study with occupational therapy practitioners and researchers with expertise in homelessness.

Results: Of 35 potential participants, n = 16 participated in Round I, n = 20 participated in Round II, and n = 18 participated in Round III. Participants included occupational therapists and researchers in Canada, United States, Brazil, UK, Ireland and New Zealand. Consensus was achieved on a total of 93 competencies in 10 categories after 15 were eliminated in Rounds II and III. The categories with the greatest number of competencies included occupational knowledge (n = 18), followed by psychosocial competencies (n = 16).

Conclusions and Significance: This study represents the first to identify the competencies needed for occupational therapists working in the area of homelessness. Practitioners and educators are encouraged to view the identified competencies as a guide for the professional development of occupational therapists in this context. Stakeholders consulted for this study were able to communicate in English and situated in middle to high-income countries. As such, the competencies identified in this study only apply to these sociocultural contexts.

Bridging the transition from homelessness: Developing an occupational therapy framework

Carrie Anne Marshall, Abrial Cooke, Rebecca Gewurtz, Skye Barbic, Laurence Roy, Caitlin Ross, Alyssa Becker, Rosemary Lysaght & Bonnie Kirsh

Published online: 28 Sep 2021

DOI: 10.1080/11038128.2021.1962970


Background: Occupational therapists support individuals experiencing homelessness in traditional roles, and occupational therapy positions focussed specifically on homelessness appear to be growing.

Objectives: To develop and refine a framework to guide occupational therapy practice and research in homelessness. Method: We developed a framework and refined it through a stakeholder consultation process conducted with 17 international occupational therapy experts using an online survey. In this survey, we presented an initial framework and requested qualitative feedback. We analyzed this qualitative data using content analysis.

Results: Stakeholder feedback was categorized into eight recommendations: (1) Revision to the ‘four processes’; (2) Emphasizing social justice and systems-level advocacy; (3) Reflecting intersectionality; (4) Emphasizing meaningful activity; (5) Emphasizing peer support; (6) Incorporating a focus on independent living skills; (7) Increasing a focus on an activity for addressing substance misuse; and (8) Acknowledging cognitive and physical health. Each of these recommendations was incorporated into a refined version of this framework. These recommendations and a refined version of the framework are presented in this paper.

Conclusions: We have developed and refined a framework aimed at guiding practice and research in occupational therapy in homelessness that will be evaluated in future research.

Significance: Though a range of frameworks exists for guiding the practice of occupational therapists more generally, this framework represents the first that is focussed specifically on guiding occupational therapy practice and research with individuals who experience homelessness. Research and practice implications are discussed.

A systematic review of occupational therapy interventions in the transition from homelessness

Carrie Anne Marshall, Leonie Boland, Lee Ann Westover, Roxanne Isard & Sharon A. Gutman

May 2020 Scandinavian Journal of Occupational Therapy

DOI: 10.1080/11038128.2020.1764094



Background: Although systematic and scoping reviews have identified a range of interventions for persons experiencing homelessness, no known reviews have captured the range and quality of intervention studies aimed at supporting a transition from homelessness.

Objectives: To capture the range and quality of occupational therapy intervention studies aimed at supporting a transition to housing following homelessness.

Method: Using Joanna Briggs Institute (JBI) guidelines, we conducted a systematic review including a critical appraisal and narrative synthesis of experimental studies.

Results: Eleven studies were included. Critical appraisal scores ranged from 33.3 to 88.9 of a possible score of 100 (Mdn = 62.5; IQR = 33.4). The majority of studies evaluated interventions for the development of life skills (n = 9; 81.8%), and all were conducted in the USA. Several of the included studies were exploratory evaluation and feasibility studies, and all were quasi-experimental in design. Only three studies (27.2%) incorporated a control group. Intervention strategies included (1) integrated group and individual life skills interventions (n = 6); (2) group-based life skills interventions (n = 3); and (3) psychosocial and consultative interventions (n = 2).

Conclusions: Research evaluating occupational therapy interventions aimed at supporting homeless individuals as they transition to housing is in an early stage of development.

Significance: Implications for research and practice are discussed.

Occupational experiences of homelessness: A systematic review and meta-aggregation

Carrie Anne Marshall, Leonie Boland, Lee Ann Westover, Sarah Wickett, Laurence Roy, Jenni Mace, Rebecca Gewurtz, Skye Barbic & Bonnie Kirsh

November 2019 Scandinavian Journal of Occupational Therapy

DOI: 10.1080/11038128.2019.1689292


Background: Studies exploring the occupational experiences of homeless persons have grown in the past twenty years, and there is a need to identify, evaluate, and aggregate existing studies to direct future research.

Objectives: To capture the scope and quality of literature exploring the occupational experiences of homeless persons in high-income countries, and to aggregate the findings of these studies to inform future research efforts.

Method: Using Joanna Briggs Institute (JBI) guidelines, we conducted a systematic review including a critical appraisal, and meta-aggregation of themes in existing qualitative literature.

Results: Fifteen studies were included and were of high quality (Mdn = 8/10; IQR = 2). Meta-aggregation resulted in four themes (n = 335 participants) describing the occupational experiences of homeless persons: 1) Restrictions on time use and activity engagement; 2) Activity as a means of belonging; 3) Institutional processes as determining time use; and 4) Transcending the self through doing.

Conclusions: Homeless persons in high-income countries face multiple challenges to engaging in meaningful activity, which we argue is a disabling experience. Simultaneously, homeless persons demonstrate resilience by finding ways to engage in activities of meaning, and opportunities to connect with others in the face of multiple barriers.

Significance: Implications for research and practice are discussed.

Occupational transition in the process of becoming housed following chronic homelessness: La transition occupationnelle liée au processus d’obtention d’un logement à la suite d’une itinérance chronique

Carrie Anne Marshall, Rosemary Lysaght, and Terry Krupa

Published online: March 5, 2018

DOI: 10.1177/0008417417723351


Background: Studying the occupations of formerly homeless persons as they transition to becoming housed following long-term homelessness has the potential to offer a meaningful contribution to the ongoing dialogue on homelessness.

Purpose: Occupational transition was explored with a sample of persons with a history of chronic homelessness to contribute an occupational perspective to current scholarship on homelessness and to inform the practice of occupational therapists who support this population.

Method: Interpretive phenomenology guided the study. Eleven persons with a history of chronic homelessness were engaged in semistructured interviews 3 to 24 months after becoming housed.

Findings: Six themes emerged that highlighted occupation as a means of promoting social and psychological integration, and the meaning and experience of occupational transition.

Implications: A more comprehensive support strategy acknowledging the occupations of chronically homeless persons is essential to incorporate into future research and practice aimed at promoting community inclusion and housing retention.

The experience of occupational engagement of chronically homeless persons in a mid-sized urban context

Carrie Anne Marshall, Rosemary Lysaght &Terry Krupa

January 2017 Journal of Occupational Science

DOI: 10.1080/14427591.2016.1277548



Background: Chronic homelessness is a growing problem in many Western nations. Few studies have explored the occupations of chronically homeless persons, and most of this research has sampled from large metropolitan areas.

Purpose: This research sought to explicate the meaning and experience of occupational engagement for homeless persons in a mid-sized urban context.

Method: Interpretive phenomenology informed qualitative interviews with 12 chronically homeless participants. Analysis used a modified version of Colaizzi’s (1978) methodology.

Findings: Themes highlight the experience and meaning of the unique occupations of chronically homeless persons. Altruistic and productivity occupations held particular meaning. Occupational alienation, and the boredom that resulted, severely influenced the psychological well-being of participants. The need to engage in meaningful occupations is powerful, to the extent that it can supersede the perceived importance of housing.

Implications: An occupational perspective is a valuable contribution to a broader dialogue on homelessness, and may contribute to a more comprehensive strategy for addressing this problem. Future research should explore boredom and its association with substance use, and ways of enhancing opportunities to include chronically homeless persons in employment and other meaningful occupations.

Occupation and the process of transition from homelessness: L’occupation et le processus de transition de l’itinérance au logement

Carrie Anne Marshall & Mark W. Rosenberg

December 2014 Canadian Journal of Occupational Therapy  

DOI: 10.1177/0008417414548573



Background: The incorporation of meaningful activity or occupation in supporting those transitioning from homelessness to being housed has been promoted by researchers; however, there is little evidence to support the promotion of initiatives encouraging its use in support models.

Purpose: This manuscript aims to advocate for further research into the role of occupation in supporting persons transitioning from homelessness to permanent housing. 

Key Issues: The transition from homelessness to becoming housed can be facilitated through use of occupation as a way of promoting the security of meaningful roles and a “housed identity” among persons experiencing homelessness.

Implications: By promoting an emphasis on occupation, persons experiencing homelessness may undergo a positive change in identity. This change may improve housing tenure and the likelihood of a more permanent transition away from homelessness. More research is required to identify the relationship between occupation and the transition from homelessness.

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