Homelessness: Support for OT

In a time where funds are declining for social services, those that help individuals develop skills and utilize resources to provide for themselves and their families should receive priority (Washington, 2002). 

According to the World Federation of Occupational Therapy (WFOT; 2019), OTs can practice within communities and facilitate initiatives that aim to improve community inclusion, health, and wellbeing through a community-based approach. There is significant potential for OT professionals to establish roles within social services, charitable organizations, and healthcare settings. OTs are specially trained in health promotion, capacity building, community development, environmental design, and advocacy (WFOT, 2019).

The field of OT is also rooted in mental health (AOTA, 2013). The creation of the profession coincided with the mental hygiene movement in the early 20th century. Scheinholtz explained that in 1963, the Community Mental Health Act called for the deinstitutionalization of individuals with mental illness, and this was when OTs began working in community mental health (AOTA, 2013). These facts support OT being an appropriate service for the homeless population.

Addressing homelessness is a complex issue and OTs have the skill sets to provide beneficial interventions for individuals who are homeless (Van Oss et al., 2018). The role of OT in locations where the homeless population is served is very diverse and is influenced by the setting, the specific population, and funding availability (Heilfrich, 2019). Overall, OTs can support the homeless population through many roles, especially as direct service providers and consultants. 

When looking at the currently available literature, it is evident many barriers exist that prevent full engagement in meaningful occupations for individuals who are homeless, which indicates that occupation-based intervention services are required (Schultz-Krohn & Tyminski, 2018). OTs are required to have at least a master's degree to practice, which suggests that they have a high level of training and knowledge regarding their area of expertise: occupation (AOTA, n.d.c.). Furthermore, research shows that individuals who are homeless benefit from skill interventions that are tailored to meet their needs (Helfrich et al., 2006). Tailoring interventions to the specific client is in the true spirit of OT's client-centered approach to care.

OTs can provide service to the homeless population in multiple settings such as an emergency shelter, transitional housing facility, group homes, and in a client's natural environment (Heilfrich, 2019). Although the literature is limited, there is research that demonstrates OT services are effective in specifically helping individuals who are homeless make improvements in occupational performance within various settings (Thomas et al., 2011).

A study by Helfrich et al. (2006) implemented three life skills interventions, each designed for a specific group within the homeless population. All participants were from a shelter or supportive housing. Youths participated in an employment module, domestic violence victims participated in a finance management module, and adults with mental illness participated in a food and nutrition module. Seventy-three participants were enrolled in the assigned four-week programs. Their study reported post-intervention improvements in skill acquisition (Helfrich et al., 2006).

Another study by Helfrich and Fogg (2007) examined the effectiveness of OT life skills interventions to 51 adults with mental illness who were homeless. The study was carried out with an Emergency Housing Program, which was operated by an academic medical center psychiatry department. The department provided protected and supervised housing to 23 adult individuals who were homeless and experiencing an acute psychotic episode. More than half of the individuals also had a co-occurring substance use diagnosis. The remaining participants in the study were in Single Room Occupancy, which is for those at risk for homelessness, that are homeless, or of low-income status. The interventions consisted of six individual sessions and six group sessions. Safe community participation, room and self-care management, money management, and food management modules were utilized. The results reported substantial improvement between post-intervention and three-month follow-up results in room and self-care management and safe community participation modules led by an OT (Helfrich & Fogg, 2007).

Gutman et al. (2004) conducted a study where they provided 12 different OT interventions in weekly sessions to women who were experiencing homelessness and/or domestic violence over the course of six months. Interventions were client-centered in that they were based on each individual's identified needs. Through in-group and individual sessions, interventions were also tailored to the "just right challenge" by setting achievable tasks, utilizing adaptive devices, engaging in repetitive practice, and using compensatory strategies. Goal Attainment Scale scores converted to T scores were utilized for evaluation of whether individuals were able to achieve their expected outcome or greater post-intervention. Results showed that eighty-one percent of the individuals achieved their most favorable outcome with T scores above 50, and nineteen percent of the individuals achieved their expected outcome with T scores of 50. Therefore, all individuals accomplished their expected outcomes or greater (Gutman et al., 2004).

Furthermore, Thomas et al. (2011) conducted a systematic review of the OT literature between the years 1990 and 2008. The review included seven quantitative articles that demonstrated OT intervention as an effective method of increasing employment and education prospects, leisure skills, money management, and coping skills. Overall, the literature supports the idea that OT has an appropriate role in serving individuals who are homeless (Thomas et al., 2011).

An article by Muñoz et al. (2006) detailed a grant-funded program titled Project Employ, which provided OT services to individuals who were homeless. The overarching goal of Project Employ is to facilitate productive role involvement based on the individuals' personal interests and preferences. Ongoing assessment was a core component of the program. Support and work-place interventions and prevocational training and rapid job placement were offered to individuals for a maximum of two years. Results of the program indicate that OT best practice interventions for individuals who are homeless and have mental health deficits include the following: expectations for self-responsibility, facilitating trusting relationships, promoting engagement, limit setting for destructive behaviors, positive reinforcement, and providing structured activities. The article supports that OTs possess the skillsets to provide services to the homeless population through client-centered interventions. The article also presents the argument that the role of OT can be developed for the homeless population by creating client-centered programs that are primarily focused on life skills training as a method to removing barriers to self-sufficiency, securing housing, betterment in vocational roles, and assisting with mental health and substance abuse treatment (Muñoz et al., 2006).

Despite there being limited literature for OT intervention with the homeless population specifically, there is a plethora of literature available regarding OTs effectiveness with other populations experiencing common diagnoses in regards to mental health, physical health, and chronic health conditions.

A systematic review has found OT intervention to be effective for creating normative roles and community integration for those with a serious mental illness such as schizophrenia, major depression, schizoaffective disorder, and bipolar disorder (Gibson et al., 2011). A meta-analysis by Ikiugu et al. (2017) also found that OT theory-based interventions show positive effects in improving well-being and occupational performance among individuals with a mental health diagnosis. Moreover, a systematic review has conveyed that a variety of OT interventions can improve factors of occupational performance in individuals who have experienced a stroke and have residual motor impairments (Radomski et al., 2016). Another meta-analysis found that occupation‐based cognitive rehabilitation is beneficial for individuals who have experienced a traumatic brain injury to facilitate improvements in daily functioning and psychosocial functions (Park et al., 2015). Furthermore, a systematic review found that several OT interventions demonstrate effectiveness for improving function factors such as range of motion and grip strength, in individuals with musculoskeletal conditions of the distal forearm (Roll & Hardison, 2017). The aforementioned studies are a small sample of the available literature supporting OT's effectiveness.