An Argument for Guidelines for Capstones in Unhoused Settings

The capstone is a requirement for all entry-level occupational therapy doctoral programs in the United States; it includes both the capstone project and the capstone experience (Accreditation Council for Occupational Therapy Education [ACOTE^®], 2024). The American Occupational Therapy Association (AOTA; 2022) has described the capstone as

The capstone planning process varies across academic institutions but generally involves a collaboration among the student, doctoral capstone coordinator, academic mentor, and site mentor through which student learning goals and intended outcomes are defined.

In recent years, the occupational therapy profession has seen a notable rise in published literature regarding service provision for unhoused populations; many of those publications have been generated through student experiences and projects (Finlayson et al., 2002; Muñoz et al., 2006; Salsi et al., 2017; Schultz-Krohn, 2004; Shordike & Howell, 2002; Thomas et al., 2011; Totten & Pratt, 2001; Tyminski, 2018). With increased interest in providing student-driven services to the population of unhoused people, it is necessary to evaluate the impact of capstone projects on the clients and organizations they are intended to serve. At present, there is little guidance in the literature on how to design and implement student-driven services (e.g., supervision models, sustainability, processes for authentic community collaboration) to ensure that these have positive impacts on the community. Much of the literature to date has focused on the benefits of such services to students; very little has examined the long-term impact (both positive and negative) on the health and well-being of the people, organizations, and communities who receive services (Drummond et al., 2021; Lee et al., 2023). Although student-based services can increase access to health care for underserved populations, we must ensure that unintentional harm is not caused because of the distinct needs of individuals experiencing homelessness. As a group of researchers, clinicians, and educators dedicated to providing community-based, sustainable services with unhoused adults and children, we acknowledge the complexities associated with capstone projects and this population. In this column, we suggest initial recommendations to support capstones aimed at maximizing the role of occupational therapy and preventing harm to unhoused communities.

Working with adults and children who are experiencing homelessness is a complex and niche practice area that requires a specialized skill set. Unhoused people experience higher than typical rates of physical, cognitive, and mental health challenges (Fazel et al., 2014; Marshall et al., 2020), and they often live with high-acuity conditions that require a unique breadth of knowledge (e.g., mental health issues and co-occurring substance use combined with a history of traumatic brain injury or stroke). In contrast to other occupational therapy settings, serving unhoused people is a practice area defined primarily by context. Although the primary common factor may be a lack of housing, the population is otherwise diverse in terms of diagnosis, age, life experience, and other personal and environmental factors that can affect a wide range of occupational needs across the life course. For example, unhoused children and youth often experience complex developmental delays that can affect their motor, communication, social–emotional, and cognitive skills, thereby influencing their ability to navigate various environments, such as school (Aviles & Helfrich, 2006; Haskett et al., 2016). In addition, occupational therapy practitioners who work with unhoused populations operate at the intersection of many layers of contextual and system-level factors that are unique to each geographic setting. It is critical that practitioners in these settings understand the combination of systems, agencies, and policies in their geographic area so they can help support unhoused clients with resource seeking (Aldrich et al., 2017) and navigating their communities (Marshall, Cooke, et al., 2023).

Despite a growing interest from students, few occupational therapy practitioners work in settings that support people who are experiencing homelessness (AOTA, 2023). Although empirical data are lacking, potential reasons for this include a lack of awareness of the role of occupational therapy in homelessness services and limited funding mechanisms to support occupational therapy positions in these settings (Tyminski, 2021). Given the limited number of occupational therapy practitioners who work with unhoused people, the prevalence of effective and appropriate supervision for potential capstone students in this practice area is also limited, thereby justifying the critical need to develop guidelines and recommendations for student-driven services. We have personally mentored many capstone students in redesigning their experiences to ensure they were improving the health and well-being of the unhoused population and not inadvertently causing poor outcomes or harm. Anecdotal examples of improper clinical supervision leading to harm for clients include disrupted therapeutic relationships, contributing to retraumatization of the client or trauma to the student; inappropriate communication (e.g., if the norms of the unhoused population are not properly understood); and student misinterpretations or incorrect reporting of assessment results that identify functional limitations, resulting in restrictions on a client’s housing access.

Although the empirical research on the specific skills needed to support unhoused clients is limited, one study outlined preliminary suggestions. Marshall, Cooke, et al. (2023) conducted a Delphi study that identified 93 essential clinical competencies for occupational therapy practitioners to address the varied and complex health and social needs of unhoused populations. Many of the competencies they identified exceed standards for an entry-level practitioner and require increased insight, skill building, and mentoring. Examples of required skills for occupational therapy practice in the unhoused population, beyond entry-level preparation, include navigating social service programs, developing crisis intervention skills, having the ability to address functional cognition, and understanding the impact of geographic location on occupational opportunity (Marshall, Cooke, et al., 2023).

Practitioner and student competencies are vital for work with unhoused people, and models of doctoral student supervision must also be considered. Current models for supervising student-driven activities in underresourced settings such as homelessness services include as viable methods of supervision the use of peer-based mentoring, grand rounds, and student clinical teams (Black et al., 2017; Meah et al., 2009; Murphy-Hagan & Milton, 2019). Although such models may be effective, occupational therapy students providing services to unhoused populations likely require more supervision than team- or peer-based support (Tyminski, 2018). The scarcity of occupational therapy practitioners working at sites that support people experiencing homelessness may result in supervision provided by an occupational therapy faculty member who has limited experience with the population or is unavailable to provide on-site support, which further highlights the need for guidelines. An occupational therapy student would likely not be allowed to provide pediatric trauma-based services without explicit supervision from a practitioner who has experience in that field. We argue that this type of specialized mentorship should also be a requirement for students working with the unhoused population. A lack of oversight of student-driven services may exacerbate health care inequity for unhoused clients. Despite the potential benefit of increasing access to occupational therapy services through capstones, it is important to consider the potential risk for harm to unhoused populations if there is limited or inadequate student supervision.

On the basis of the complex intersection of systems and contexts that govern the occupational participation of people experiencing homelessness, as well as historical issues of trauma and marginalization, we propose four recommendations for capstone completion with this population. Although the focus of this column, and these recommendations, is specifically based on our collective experience working with the unhoused, the process outlined herein could be replicated for capstones with other historically marginalized or excluded populations, with specific competencies determined by the population or community of focus.

Before working with any population that has been historically marginalized, excluded, and stigmatized, students and faculty must reflect on their biases, privilege, and set of intersecting identities so they can become aware of their perceptions of the population and how those perceptions have been shaped. This reflection should be necessary for engagement with all client populations, but it is particularly critical for those who work with people experiencing homelessness, who have consistently been subjected to racism, xenophobia, sanism, and other prejudices resulting in trauma and “othering” in society that can manifest in occupational therapy treatment (LeBlanc- Omstead & Kinsella, 2018; Morrow & Hardie, 2014; Perlin, 1991). Students should also reflect on their status as students. Many soon-to-be graduates enter their capstone feeling great pride in their accomplishments and a sense of capability in the field. Students must recognize that although they have knowledge in the field of occupational therapy, they are not the experts in the lives of unhoused clients, community agencies, or systems. They must be prepared to set aside beliefs regarding the occupational therapy practitioner as the expert and embrace their role as a collaborator and partner with the client and community agency. Possible exercises to suggest to students and faculty mentors include those from the diversity, equity, inclusion, justice, access, and belonging toolkit (see https://www.aota.org/practice/practice-essentials/dei).

In recent work, Johnson et al. (2024) posited the importance of complementing occupation-focused models with those that acknowledge structural and social influences on health and, in our case, housing. Providing effective and equitable health care to unhoused populations requires the use of trauma-informed care, low-barrier services, harm reduction frameworks, and opportunities to build trust and relationships, along with the clinical skills to address the prevalence of complex medical and mental health issues (Hopper et al., 2010; Marshall, Gewurtz, et al., 2023; National Health Care for the Homeless Council, 2020; Purkey & MacKenzie, 2019). Although being client centered is an integral approach to occupational therapy, working with unhoused populations requires an advanced approach to developing rapport and engaging in client-centered practice. Many of these people have been marginalized or discriminated against by the very services that purport to help them, and therefore they can be reluctant to engage in these services. Building trust and rapport with populations who are marginalized by society and experience stigma and discrimination takes time, commitment, and experience. Given the disproportionate rate of homelessness among minoritized individuals in the United States, students and mentors may complement occupation-focused models with critical race theory (Delgado & Stafancic, 2023) and intersectionality (Crenshaw, 1989; Morrow & Hardie, 2014). Faculty should guide students toward other evidence-based sources (e.g., Lavalley & Johnson, 2020) to promote reflexivity (i.e., critical thinking about one’s positionality and perspectives [e.g., Feucht et al., 2017]) throughout the capstone and engage in regular mentorship meetings with the student to examine how they are implementing appropriate frameworks. Finally, faculty should support students in engaging in necessary and sometimes uncomfortable advocacy efforts as necessary throughout their experience (Johnson et al., 2022).

Community agency staff often have vast experiential knowledge of the systems, resources, and needs of the agency and the population they serve that has been acquired through years of experience. Many staff are peer support specialists or people with lived experiences who now work in community agencies. ACOTE (2024) standards require that students collaborate with a faculty member and a person with “documented expertise in the content area of the capstone” (p. 42); thus, we strongly recommend that capstone coordinators and students consider as the student’s mentor an agency staff member, such as a social worker, case manager, peer support specialist, or outreach worker, who has a history of working with unhoused populations. One option to create relationships within an agency is to obtain a site mentor using a same-site model of Level 2 fieldwork followed by a doctoral capstone at the same agency. In short, students should be prepared to go beyond what is required by the ACOTE standards to find a mentor with the skills and knowledge to ensure that the experience is beneficial for both the student and the community.

We recommend that, at a minimum, occupational therapy faculty mentors supervising capstone students working with the unhoused population meet the competencies outlined by Marshall, Cooke, et al. (2023). In addition, although many of these competencies go beyond entry-level practice, we propose that, as a starting point for the design of the capstone, potential students seeking to provide services to the unhoused population review these in collaboration with their site and occupational therapy mentors to create an individualized set of competencies to be achieved by the end of their capstone. We further suggest that services outside of the student’s competencies be supervised or not included in the capstone.

It is important that capstone students reflect on the ethical issues relevant to this population and understand that homelessness is a complex social phenomenon, a “wicked problem” (Harris et al., 2010; Head, 2019) that will not be solved by any one approach or discipline’s perspective, and certainly not by their capstone. Ethical competencies should cover guidelines for practice specific to the unhoused population and apply those guidelines to the AOTA (2020) Code of Ethics. Ethical considerations should include strategies to mitigate harm within this population, such as reducing “white saviorism,” and ensuring true community-engaged practice and research are occurring, as well as strategies to educate oneself around harm reduction principles and promote autonomy in occupational participation.

Another necessary competency is the need for sustainable practices in capstone development and implementation. Because of the 14-wk limitation of a capstone, many students implement projects without a long-term plan for sustainability within the agency. As such, many agencies have developed a mistrust of short-term student placements that are project focused because they recognize that these projects serve the needs of the student and academic institution but rarely meet the needs of the community. As a result, many community organizations are reluctant to engage with student-led projects and academic institutions. Thus, all participants in capstone experiences, whether research-focused or clinically-focused, should collaborate with the agency to develop a written sustainability plan to ensure that the capstone product is feasible, acceptable, and usable by the agency. Some examples of sustainable deliverables include train-the-trainer programs, video recorded trainings for staff, environmental assessments, and the creation of resources. It is essential that all work conducted during the capstone, in particular in an agency that does not have an occupational therapy practitioner on staff, be available to the agency after the completion of the experience.

Because of their brevity, student-led projects often do not yield long-term community partnerships unless explicit attention is paid to sustainability throughout the capstone process. If there is no plan for sustainability after a capstone experience, community partners and organizations will be left without any further services (Lee et al., 2023). The 14-wk capstone timeframe is not long enough to develop, initiate, and complete occupational therapy services for clients with complex needs or who are experiencing housing transitions. Discontinuation of occupational therapy services without a transition plan creates a risk of harm for the person receiving services and engenders further feelings of abandonment in the health care or homeless service systems. Without comprehensive guidelines for the development and implementation of sustainable student-driven services for the unhoused population, capstone projects raise the risk of potential harm to the community.

To provide appropriate care, occupational therapy capstone students must also have at least a baseline understanding of the multiple environments and systems their clients navigate on a daily basis. For capstone students, this knowledge should form part of their needs assessment, which should be conducted early, in consultation with community partners and the scholarly literature, to ensure that students are aware of what is happening on the ground before they start their capstone. Students need to have a thorough understanding of how their clients’ unique intersection of capabilities and challenges transact with the local micro-, meso-, and macroenvironments. Each community presents a unique situation that must be carefully analyzed to understand the specific dynamics present. Such detailed environmental analyses may not be as necessary for students in more traditional settings (e.g., acute inpatient care); however, they are critical to working with the unhoused population. Capstone students need to be able to think at a systems level and to have a good understanding of local health and social service systems, structures, and policies in the area. These are often complex and vary considerably from one community to another because the local continuum of care (CoC) for this population is often unstructured, scattered, and involves different organizations and agencies that may or may not work together (National Alliance to End Homelessness, 2010). An understanding of the local CoC is required if capstone students are to help clients manage their occupational participation and engagement. Navigating these systems and policies also requires that the practitioner work closely with many different professionals, community gatekeepers, and team members who have unique roles and perspectives in the local CoC. At times, there may be overlap in the types of support that many of these disciplines provide for unhoused clients, and it is up to the student to develop relationships with these disciplines to ensure the client is receiving the best and most appropriate care and to limit duplication of services.

As researchers, educators, and clinicians working with the unhoused population, we have seen a notable uptick in the number of capstone students interested in pursuing experiences with this group. However, in advising and engaging with these students we have become aware of problematic gaps in the planning process on the part of academic institutions and in students’ knowledge base that raise the risk of harming unhoused communities and the agencies that support them. Thus, we propose that all students who desire to engage with the unhoused community should reflect on their positionality; seek to form relationships with mentors who have considerable experience and skill in understanding the needs of the population; and strive to educate themselves about the necessary competencies to work effectively in this niche, nontraditional setting.

We hope that this call to action is the beginning of the development of competencies and guidelines for capstones that focus on people experiencing homelessness. Such competencies and guidelines must be developed through authentic collaboration and partnership with relevant stakeholders (i.e., people with lived experience of being unhoused, community workers who regularly work with people who are unhoused, occupational therapy practitioners working in this setting, capstone coordinators). This collaboration is essential to support occupational therapy students and, ultimately, our community members experiencing homelessness.