Role of Occupational Therapy for Homeless People

Homelessness is a notable issue in the affluent societies of the western world, including the UK (Toro,2007). Heightening awareness has been received due to a lack of appropriate housing and shrinking government funding (Marshall and Rosenberg,2014). The UK government has responded to concerns regarding homelessness, and a working group was developed with the aim of preventing homelessness and improving the quality of life of those affected (Department for Local Communities and Government,2014). Recently, the working group has published the “Code of guidance for local authorities”, with the aim of helping affected family and children out of homelessness (Department for Government and Local Communities,2017a). The UK government have also pledged £72.7 million for local authorities to find accessible accommodation for those who experience homelessness (Department for Communities and Local Government,2017b).

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The government policy has addressed homelessness as a social phenomenon. It has inspired a range of responses from the community to provide secure accommodation and employment opportunities to homeless individuals, however mostly without any input from occupational therapists. Parmenter et al. (2013) revealed that homeless people scarcely access to occupational therapy (OT) services, and consequently do not benefit from the OT profession.

The purpose of this paper is to explore the role of OT with homeless people. This essay will identify the occupational needs of homeless people and explore potential occupational engagement barriers. It is vital for OT to consider their complex needs in a holistic professional approach. To this end, this paper will critically analyse published researches to examine the potential for OT in this contemporary area of practice.

Homelessness is a complex concept, and there is no straightforward definition. Homelessness has shown to affect people of all ages with the percentage of adolescent, families and elderly rising compared with unmarried people in middle age. Grandisson et al. (2009) suggested that homelessness includes multiple classes of unreliable housing condition covering people sleeping rough on the street, sufferers of a natural disaster or immigrant worker, as well as people escaping from sexual abuse or after experiencing a traumatic event. The homeless population is hugely diverse concerning age, nationality, health condition and gender. Lloyd and Bassett (2012) had divided homelessness into three categories. To begin with, people without accommodation is classified as primary homeless. They may be rough sleeping in cars or empty buildings. On top of that, people who move regularly between short-term shelters, for example, hostels, night shelters, and friends’ houses, are regarded as secondary homeless. Last but not least, tertiary homeless refers to people who live in a substandard shelter or shared rooms on a long-term basis, in the absence of stable tenancy rights as well as kitchen or bathroom.

According to official UK figures collected in 2017 and published in January 2018, it is estimated that 4751 people are sleeping rough on any one night in the Autumn 2017 (ONS,2018). The figure represents a 15% increase from the estimated number of rough sleepers in 2016 and 269% from 2010. Of those homeless people who requested for support needs, 47% of the respondents reported a need in mental health assessment (ONS,2018). People who experience homelessness but do not show up in official figures are known as hidden homelessness. Therefore, the actual number of homeless populations are much more significant than the official statistics.

Wright & Tompkins (2006) revealed that homelessness has a disastrous effect on both physical health and mental well-being. The Homeless population, especially those who sleep rough, lack the social determinants of health. Therefore, they have a much higher rate of morbidity and death compared to the general public (Gambatese et al.,2013). Homeless individuals are vulnerable to severe health conditions including infections, different skin conditions, physical injury and respiratory disease, as well as a range of mental health illness (Wright & Tomkins,2006). It has been recognised that homeless people require support to meet their complex needs (Grandisson et al.,2009). Lloyd and Bassett (2012) pointed out that homeless people are facing multiple economic and social obstacles to fully engage in meaningful occupations. They face discrimination from various aspects of life including employment, education, housing, social networking, and healthcare.

Illman et al. (2013) pointed out that homeless people are persistently deprived from occupational engagement, which brings detrimental effects on their health and well-being. The opportunities for homeless individuals to engage in meaningful occupations are restricted, which adversely affect their well-being and obstruct integration into society (Thomas et al.,2011). Engaging in purposeful activities are closely associated with a feeling of satisfaction, personal development, sense of competence and life achievement; where disruption to occupation may contribute to a loss of meaning to life (Eakman,2015).

For the homeless population, engaging in meaningful occupations are beneficial in addressing their distorted lifestyles. However, engagement in meaningful occupations can be compromised by the more urgent need to participate in activities which satisfy their basic needs for survival, for example obtaining food, shelter, and sense of security (Illman et al.,2013). Other identified factors are related to lack of leisure time, lack of expendable income and stigmatisation from the society, which may result in excluding homeless individuals from appropriate opportunities to engage in meaningful occupations (Chard et al.,2009).

Hoffman (2010) discussed how occupational deprivation contribute to distorted occupational identity through maladaptive behaviours. For example, the challenges of living in a shelter and intrinsic factors such as low self-esteem, mental health problems or substance misuse, may all lead to occupational deprivation. The social and monetary reality have drawn outstanding attention in identifying innovative approaches to interventions at personal, social and governmental levels (Marshall and Rosenberg,2014).

Several pieces of research highlight the importance of occupations to the survival of homeless people. For example, Chard et al. (2009) revealed that occupations promote safety from the threat of harm, especially when sleeping on the streets were consequential. Lack of security brings detrimental effect to their health and well-being (Illman et al.,2013). This example is congruent with the theory of OT, which environment act as an essential determinant of occupational balance (Backman,2010). It also suggests a possible focus for OT interventions with the homeless individuals.    Marshall and Rosenberg (2014) indicated that engaging in meaningful occupations can motivate a transformation from homelessness to living in permanent accommodation. Some of the purposeful occupations directed at keeping busy were identified, including walking in the park, going to libraries and day centres as well as searching through bins (Chard et al.,2009).   

Occupational therapists adopt a holistic approach, which embraces the belief that engaging in occupations that are purposeful would benefit an individual’s health and well-being (Thomas et al.,2011). Occupational therapists aim to attain people’s maximum potential and participate in daily activities by empowering individuals to take part in their selected occupations (Townsend and Polatajko,2013). Occupational therapists have an excellent professional framework, helping people with a wide range of physical and mental confrontations to be independent and able to participate in their desired occupations (RCOT,2018). The primary goal of OT is to sustain, rehabilitate or develop congruence between an individual’s intrinsic abilities, the external environment and the demands of the occupations in the areas of self-care, leisure and productivity (Creek,2005).

Escalating recognition of the importance of occupation has developed a broadened role for OT in the avoidance of disability and promotion of health (Wilcock,2006). Occupational therapists recognised the homeless population as comprehensively deprived from occupational engagement (Urbanowski,2005). Homeless individuals have limited opportunities to engage in meaningful occupations, which accompany with detrimental effects on their physical health, mental well-being and social integration (Glass et al.,2006). Occupational therapists acknowledge that distorted physical and mental health in homeless individuals are closely associated with their reduced participation in desired occupations and lack of occupational balance (Heuchemer and Josephsson,2006).

Occupational needs of homeless people are depending on their level of homelessness. Those who experience long-term homeless usually require services to meet their basic need for survival, that means care and comfort, meals, clothing and education, as well as an incentive to establish basic life skills (Grandisson at al.,2009).

Several studies have explored the occupational needs of homeless people, and four prioritised areas of occupational needs were identified, including money management, coping skills, working, and leisure skills. Munoz et al. (2006) identified budgeting as one of the areas for OT intervention. Helfrich and Fogg (2007) reaffirmed that the lack of banking skill is associated with extreme poverty resulting from substance misuse and reduced employment. The necessity for basic education and knowledge concerning money management was evidenced. 

Interventions directing at developing coping skills were reinforced by Helfrich and Fogg (2007), which included a focus on the development of anger management, stress management as well as personal safety and assertiveness skill. Munoz et al. (2006) noted high proportions of substance misuse and mental health issue in the homeless population, suggested that the goals of interventions should also be aimed towards enhancing sobriety and mental health.

Unemployment and the absence of stable jobs result in an inability to acquire decent accommodation and shortfall in economic security (Helfrich et al.,2006). It is also linked with low socio-economic status and impacted on plans (Glass et al.,2006). Furthermore, unemployment can be associated with a lack of occupational roles and routines leading to occupational deprivation (Chad et al.,2009). Lack of money resulted in an obstacle to meaningful occupation, and their daily routines were dominated by low-cost activities with deviate degrees of meaning. These studies provide shreds of evidence to suggest that OT interventions should be focused on enhancing employment opportunities for homeless people.

Chard et al. (2009) suggested that the lack of money was a reason for not engaging in leisure activities. Homeless people experienced frustrations for not being able to engage in leisure occupations which were meaningful to them and filling their empty hours with inconsequential occupations instead. The value of OT in addressing leisure skills are evident.

Together these studies indicate an emerging role for OT with homeless people. To meet the occupational needs of the homeless people and support them to integrate into society, OT has started providing services to them. Grandisson et al. (2009) identified that part of the role of OT is to support a homeless individual by addressing their basic needs, including food, shelter, cleanliness, personal safety, mental well-being, physical health and accommodation needs.

Munoz et al. (2006) and Grandisson et al. (2009) suggested that OT services can be divided into four groups: social, practical, family and occupational support. Social support is associated with social inclusion and eliminating isolation, which could be commenced through increased community-based training as well as specific skills training and encouraging engagement (Grandisson et al.,2009). Practical support is related to support with acquiring resources, such as accessing the internet and obtain advice for employment, as well as referral to congruous services related to budgeting and advocating (Helfrich and Fogg,2007). Family support is related to maintaining healthy relationships with family members (Chard et al.,2009). For example, educating parenting skills to assist in repairing the relationship with children (Lloyd and Bassett,2012). Occupational support is to provide support in restoring self-identity by engagement in meaningful occupation and the establishment of an occupational identity (Munoz et al.,2006).

One-to-one work is classified as part of the traditional role of OT. Individual sessions were offered in a person-centred approach in order to meet their unique needs (Parmenter et al.,2013). Individual support was also offered as an intervention in Munoz et al. (2006) and Helfrich and Fogg’s (2007) study, where the content of each session was chosen by the homeless individual to allow personalised experiences.

Group work has also been identified as a notable treatment used by OT. It allows homeless people to view themselves differently (Parmenter et al.,2013). Munoz et al. (2006) identified group work as an essential tool to develop and retain productive occupation. Helfrich and Fogg (2007) utilised group work sessions with a psychoeducational approach, which contributes to a vast improvement in homeless individual’s care and social integration. 

Specific skills training is linked with the traditional role of OT (Grandisson et al.,2009). To meet the employment needs, Munoz et al. (2006) developed a role involvement program with the aim to recognise an individual’s interests and job preferences. After completion of the program, 80% of the participants were employed. Similarly, Helfrich et al. (2006) indicated the benefits of OT interventions for supporting homeless people who lacking life skills. Result revealed that participants gained life skills in the areas of personal security, money management, food administration and social integration on completion of the modules. 

Parmenter et al. (2003) suggested that part of the role of OT is to aid homeless people in developing motivation. Low motivation is one of the significant barriers to OT interventions, which avoid homeless individual in initiating goals and making changes (Parmenter et al.,2003). By facilitating a sense of competence and feeling of satisfaction from engaging in meaningful activities, it is proved to be helpful in addressing substance misuse in the study conducted by Grandisson et al. (2009).

With regards to role emerging, a few capacities are identified, including the outreach worker, advocator and case manager (Lloyd and Bassett,2012). Lloyd and Bassett (2012) revealed that there was minimal research available to guide OT practice in the outreach team. The role of OT was divided between general tasks and tasks specific to the profession, for instance, conducting assessments to assist clients to identify their selected occupational roles, as well as supporting homeless individuals with their finances. Grandisson et al. (2009) proposed that the advocacy role should be prominent at an institutional level, not only to homeless people but also to the general population in order to promote the rights of homeless people. OT can also assist homeless individuals in finding accommodation that is suitable for their functional abilities and liaise with social services through case management. It is also essential to enhance the overall awareness and promote development for OT services in this contemporary area. The role of a case manager is associated with the promotion of health, which encourages healthy routines and avoid illnesses.

The development of OT services for the homeless population can prove demanding although OT has begun in assessing occupational deprivation and marginalisation within them. Parmenter et al. (2013) suggested that a top-down approach in OT might result in adopting practices that are lack meaning for individuals living in a different socioeconomic context. An additional problem is a misinterpretation of the role of OT by hostel staff members and the homeless people themselves. The hostel residents recognised the role of OT as dissimilar to hostel workers, which had an adverse effect on interprofessional relationships and resulted in fewer OT referrals.

Theory and models are essential in providing a structure to the OT’s clinical reasoning. Munoz et al. (2006) suggested that the Canadian Model of Occupational Performance (CMOP) acts as an instrument to facilitate the establishment of purposeful occupations. Furthermore, Chard et al. (2009) identified CMOP can facilitate a client-centred framework when developing interventions. Alternatively, Parmenter et al. (2013) recommended using the Model of Human Occupation to support clinical reasoning. Parmenter et al. (2013) revealed the Person-Environment-Occupation (PEO) model can help OT to take intrinsic and extrinsic factors into consideration, which contributed to a change in homeless people’s living environment and promote psychosocially. Chard et al. (2009) also identified the PEO model had connected the living experiences of homeless individuals with interventions.    

Homelessness has brought adverse effects to homeless people concerning their social participation and desired occupational roles. This paper indicates that occupational experiences are vital to homeless individuals; otherwise, they would experience occupational deprivation. Moreover, this essay identifies the method that engagement in purposeful occupations can assist individuals to rebuild their life and prevent from occupational alienation and deprivation. The results of this paper have proved that participation in the desired occupation can effectively be utilised to re-engage marginalised people into society and provide supports that increase opportunities for homeless individuals to improve their health and well-being. The value of occupation in promoting health, boosting identity and sense of affiliation, encouraging social integration, and engaging in socially valued activities are evident in this paper.

It is evident from this paper that there is a significant congruence between the occupational needs of homeless individuals and the specific skills and values of OT. There is a relevant and comprehensible role for OT services with the homeless population, indicating a good connection between OT competencies and the occupational needs of homeless people. Occupational therapists adopt a client-centred and holistic approach in order to address the needs of homeless people. This essay confirms that OT has specific expertise in facilitating engagement in occupational roles. There is a significant match between the role-specific skills and the occupational needs of the homeless population. Homeless people have occupational needs relating to budgeting, employment, coping skills, and leisure skills. Generally, the aim of OT is directed at addressing skills deficits, provide opportunities to underpin favourable life circumstances, reduce vulnerability and improve employment opportunities.

This paper aims to identify and explore the role of OT with homeless people, however current researches mainly focus on identifying the complex needs of homeless populations and the obstacles that homeless individuals in occupational engagement. Although OTs are equipped with theoretical knowledge and unique skills, Thomas et al. (2011) highlighted the inadequate experience of OT working with this population. Therefore, the specific role of OT within the targeted population is not identified.

Despite limited, some information on the role of OT is identified, suggesting that both traditional OT and the roles emerging have a place in this area of practice. Munoz et al. (2006) and Parmenter et al. (2013) proposed life skills development programmes and vocational rehabilitation. With regards to role emerging, Grandisson et al. (2009) identified advocacy, intensive case management and outreach. Some resemblances were identified in this paper by exploring the traditional role and role emerging of OT, for example, delivering skill-based training for homeless individuals to live independently, supporting people to prevail over obstacles in occupational, re-engaging in the community and addressing their survival needs. Future research is needed to identify the specific role of OT in this contemporary area and effectiveness of occupational-based interventions with homeless people. (2998 words)

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