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Abstract

French

Background. Previous research addressing the use of humour in rehabilitation has demonstrated positive benefits that have potential to contribute to collaborative relationship-focused practice. Some research points toward the multidimensional functions of humour in stroke practice, although little is known about the use of humour within occupational therapy specifically. Purpose. This study aims to uncover Canadian occupational therapists’ perspectives on the risks and benefits of humour use with people who have sustained a stroke. Method. Through a Delphi study consisting of three rounds of surveys, occupational therapists identified and ranked risks and benefits of using humour. Findings. Consensus was reached on a total of 32 benefits, highlighting the role of humour in building rapport, enhancing communication, promoting emotional well-being, and increasing client motivation and engagement in therapy. These findings underscore the potential of humour to build relational capital and thereby potentially facilitate positive rehabilitation outcomes in ways consistent with collaborative relationship-focused practice. Two risks associated with humour use also gained consensus, focusing on comprehension/interpretation challenges and differences in humour preferences between clients and therapists. Conclusion. This study contributes evidence-informed insights to guide clinical practice and education, advancing our understanding of humour use as a relational practice of use in promoting collaborative relationship-focused practice for individuals post-stroke.

Keywords

Occupational therapy Humor Stroke Practice relationships Collaborative relationship-focused practice

Introduction

Occupational therapists in Canada work with individuals who have sustained a stroke in various settings. As the profession moves beyond client-centered care and into collaborative relationship-focused practice, it is important to generate knowledge that can contribute to the enactment of collaborative care in everyday practice (Egan & Restall, 2022). Collaborative relationship-focused practice calls for occupational therapists to develop therapeutic relationships that are “contextually relevant, nuanced, and safe, and that promote rights-based self-determination” when working with individuals, families, communities, and beyond (Restall & Egan, 2021, p. 3). Essential features of this shift include the enactment of relational elements such as respect, collaboration, and power-sharing.

Within this paper, it is proposed that the use of humour can contribute to collaborative relationship-focused care. With previous research, humour has been shown to aid occupational therapists in their work with clients in ways that relate to relationship building (Southam, 2003; Vergeer & MacRae, 1993). However, research on humour more generally demonstrates it can also be risky when used inappropriately or is badly timed (Kirsh & Kuiper, 2003). There is limited understanding of how humour can be used when working with specific clinical populations, especially within the occupational therapy (OT) profession. To address the knowledge gap surrounding the specific risks and benefits of using humour in OT stroke practice, a Delphi study was conducted among Canadian occupational therapists experienced in working with individuals after stroke to uncover perspectives on the risks and benefits of humour use with individuals who have sustained a stroke.

Background

Conceptualizing Humour

Humour use is often regarded as positive and useful when building relationships, coping with difficult situations, and can also be a signal of mental fitness (Martin & Ford, 2018). As humour has been conceptualized in various ways across psychology, sociology, and philosophy, several theories of humour exist. Three classic and foundational theories of humour include the incongruity theory (Schopenhauer, 1958/1818), the relief theory (Freud, 1905/1960), and the superiority theory (Hamilton & Cairns, 1961), which explore the use of humour as a means of enjoyment, catharsis, or establishing power, respectively. For this current study, humour is defined as a “broad and multifaceted term that represents anything that people say or do that is perceived as funny and tends to make them laugh, as well as the mental processes that go into both creating and perceiving such an amusing stimulus, and also the emotional response of mirth involved in the enjoyment of it” (Martin & Ford, 2018, p. 3).

Although humour has been shown to have mainly positive effects, including improved physical health (Lefcourt et al., 1990), humour can also be used in ways that are detrimental to relationships or personal wellbeing (Kirsh & Kuiper, 2003) such as when humour is used in ways that are offensive or sexually explicit (Kovarsky et al., 2011). Therefore, humour is a complex cognitive process that has the potential to both positively and negatively affect personal and psychosocial wellbeing.

Humour Use Within Rehabilitation Professions

Within a recent scoping review addressing the question of how humour has been explored in the rehabilitation profession literature, findings from 57 articles revealed the multi-dimensional ways humour was utilized in relation to self and others by both clients and rehabilitation professionals (Kfrerer et al., 2023). Within the reviewed studies, spanning physical therapy, OT, speech-language pathology, and audiology disciplines, clinicians used humour in attempts to establish or equalize power dynamics with their clients as well as manage therapy sessions, such as through offering moments of rest for their clients, drawing attention away from client errors, increasing engagement in therapy, or motivating clients to participate in difficult therapy tasks. Humour was also seen as a tool used by clinicians to humanize themselves in the eyes of their clients, and to build strong therapeutic connections (Kfrerer et al., 2023). On the other hand, clients employed humour to assist them in fostering group cohesion in therapy groups, to save “face” or identity during recovery, or to cope with their recovery overall.

Specific to humour use with persons who have experienced stroke, Kfrerer et al. (2023) also found 15 of the included studies addressed therapy with people with aphasia due to stroke or other causes, and six addressed therapy with people who had sustained a stroke/cerebrovascular incident, serving to illustrate how humour was utilized with, and by, those with stroke and stroke-related impairments. Interestingly, individuals who had sustained communicative or cognitive impairments from stroke used humour for several functions, including to communicate through non-verbal means, to assist in their coping, to relate socially, and to demonstrate confidence or self-esteem (Norris & Drummond, 1998; Sloan, 1992; Stagg et al., 2021; Williams & Murray, 2013). Stroke can limit the various functions that allow people to engage and build connection with others, and humour may offer a way to improve therapeutic collaboration and overall engagement. Bright et al. (2018) showcased the importance of clinician communication, laughter, and behaviour in building and sustaining engagement in therapy with individuals after stroke. However, these findings pertaining to stroke populations were largely focused on the speech language pathology discipline and thus do not directly attend to how humour could be useful in OT.

The OT profession has a broad scope in Canada and plays a critical role in care with individuals after stroke. Research reveals stroke occurrences in Canada has increased to 108,707 annually, or one stroke every five minutes (Holodinsky et al., 2022), warranting further understanding of how to optimize therapy with individuals after stroke (Holodinsky et al., 2022; Korner-Bitensky et al., 2011; Obembe et al., 2019). To do this, drawing upon the experience of occupational therapists is critical, so that collaborative relationship-focused care can be informed by clinical experience, a key source of evidence and knowledge (Copley & Allen, 2009; Dougherty et al., 2016; Thomas & Law, 2013).

Relational Capital

In addition to focusing on humour, this study is informed by the concept of relational capital, introduced by Stagg et al. (2021) as a concept encompassing how clinicians show care and respect, and build relational engagement with clients. In exploring the ways healthcare clinicians sustained therapeutic relationships with people with stroke-related communication impairments, Stagg et al. (2021) found that building relational capital with individuals after stroke not only strengthened the therapeutic relationship, but also allowed clinicians to prioritize therapy tasks and progress the therapy overall. Humour use was a key component of building relational capital, as humour allowed clinicians to build connections and promote reciprocity. For example, building relational capital looked like “establishing rapport, getting to know the person, and relating over humour and casual conversations, including practices to position the clinician in a non-hierarchical way within the relationship” (Stagg et al., 2021, p. 1399). The concept of building relational capital is aligned with collaborative relationship-focused OT, where balanced power dynamics and authentic relationship building is focused (Egan & Restall, 2022). Relational practices such as humour can therefore offer occupational therapists further approaches to practicing in a collaborative and relationship-focused manner. This study aims to deepen the understanding of the role of humour in OT for individuals post-stroke, exploring both its risks and benefits.

Methods

Study Design

We employed a Delphi study design which involves soliciting expert opinions through chronological questionnaire rounds. Originating in the 1950s, the Delphi methodology serves to establish agreement in areas marked by incomplete knowledge or divergent opinions (Powell, 2003; Rowe & Wright, 1999; Trevelyan & Robinson, 2015). Responses in each round are condensed through analysis to reach a consensus understanding of panel member opinions. Recognized for its cost-effectiveness and efficacy, the Delphi technique has been shown effective in harnessing the perspectives of diverse and geographically dispersed groups (Powell, 2003). The technique fosters the gradual development and refinement of ideas, while preserving participant anonymity, and has been utilized in OT research relating to professional competencies/skills, clinical reflections, as well as to determine best practice guidelines (Buys, 2015; Castro et al., 2016; Marshall et al., 2021; Wikeby et al., 2006).

The Delphi methodology has been utilized extensively in healthcare, policy, and education and some researchers have found it useful to use this method for determining risks and benefits in specific healthcare interventions (Sirois et al., 2020; Wells et al., 2014) or policy-making (Cleemput et al., 2015). In the present study, the Delphi method was chosen to condense therapists’ expertise on humour use in stroke practice. This project was approved by Western University's Health Sciences Review Ethics Board (121126).

Data Collection

Following approval by the academic institutional research ethics board, we conducted three Delphi survey rounds using the web-based survey platform, Qualtrics (2018). Table 1 provides an overview of the procedure for the three rounds. In each round, participants were contacted via email and received a total of three reminder emails, each one week apart, if they did not complete the survey.

Table 1

Procedure for Including and Eliminating Statements at Each Delphi Round.

Round	Survey Questions
1	1. Informed Consent2. Demographic Items3. Participants were asked to answer two open-ended questions, listing as many benefits and risks as possible to humour use with clients after stroke. There was no limit on the amount of text allowed.4. Descriptive statistics calculated for demographic variables, and all responses were analyzed and worded into 4-point Likert scale format. This was presented to participants in Round 2.
2	1. Informed Consent2. Participants rate each risk and benefit statement from Round 1 on 4-point Likert scale (1 = totally disagree to 4 = totally agree).3. Descriptive statistics calculated for percentage of agreement, medians, and interquartile ranges (IQR) for each risk and benefit listed using Excel. Statements that did not reach consensus were eliminated and removed from study. This resulted in a list of benefits and risks that was presented to participants in Round 3.
3	1. Informed Consent2. Participants rate remaining statements from Round 2 using the same Likert scale (1–4).3. Same analysis process from Round 2 to determine consensus of responses. Statements that did not reach consensus were eliminated. Remaining statements discussed in the results.

Participants

Eligibility

Participants consisted of registered occupational therapists in Canada, with at least 2 years of experience practicing with people who have sustained a stroke at any point in their career. Previous literature endorses the minimum of 2 years’ experience with individuals after stroke to afford therapists the sufficient practice knowledge, awareness, and experience of practicing within this population (Stagg et al., 2021). Due to available resources, participants were required to be fluent in English.

Due to the nature of the Delphi method, there is a great reliance on individuals’ lived expertise and knowledge, and at times these individuals have been termed “experts.” There is contention surrounding the use of the word “expert” within the Delphi methodology due to the difficulty of operationalizing expertise (Trevelyan & Robinson, 2015). For this work, we define an expert as someone who is “purposefully selected to apply their knowledge and experience to a certain issue based on criteria, which are developed from the nature of the problem under investigation” (Akins et al., 2005, p. 4). Therefore, this work draws on the expertise of occupational therapists, which encompasses clinical experience which is internalized and synthesized over time (Dougherty et al., 2016).

Recruitment

Participants were recruited through both convenience and snowball sampling. Recruitment advertisements were placed on the Canadian Association of Occupational Therapists (CAOT) research posting page for the six-month duration of recruitment. As well, 10 provincial level OT associations were contacted for recruitment, and recruitment advertisements were circulated by seven associations. There was no response from two provincial associations, and the final provincial association was unable to assist. Snowball sampling was also used as participants were asked to invite any other occupational therapists to join the study via email, and emails were also sent to existing research team contacts.

Participation in the Delphi study was voluntary, and all answers remained anonymous via the online survey platform. Although no standard sample size for Delphi studies exists, recent Delphi studies in the OT discipline commonly recruit between 15 and 35 participants (Hung et al., 2022; Marshall et al., 2021). Recruitment ended upon the completion of round 1, and the sample size slightly decreased across the three Delphi rounds.

Data Generation and Analysis Procedures

Round 1

Round 1, which began in May of 2023 and concluded in September 2023, consisted of delivering a semi-structured survey with open-ended questions. The purpose of this first round was to generate items for the consensus process in rounds 2 and 3. Before participants answered these questions, they were asked to complete demographic information which was not linked to their survey responses. The demographic items included their role (occupational therapist practitioner; occupational therapist practice lead; occupational therapist clinical director; researcher; other); gender (man; woman; non-binary; other); age; region/location of practice in Canada; and years of OT practice with persons’ post-stroke. Participants were also asked to rank how often they use humour in practice (always, often, not often, not at all) and the extent to which they believed the following statement: “humour contributes to relationship-building with clients” (very true of what I believe, somewhat true of what I believe, somewhat untrue of what I believe, very untrue of what I believe). Descriptive data was calculated from the demographic questions.

Participants were then presented with the following open-ended questions: 1) “The benefits of using humour in OT practice with persons who have sustained a stroke are…”; and 2) “The risks of using humour in OT practice with persons who have sustained a stroke are…”. Participants were asked to list as many risks and benefits as possible. These responses were analyzed according to the process outlined by Hasson et al. (2000), which has been used in Canadian OT Delphi studies (Leclair et al., 2016; Marshall et al., 2021). Because the questions were open-ended, it was critical to capture both frequency and comprehensiveness in responses. To achieve this, all responses from round 1 were collated and content analysis was completed by the first author to group similar responses together into like categories (Hasson et al., 2000). Participant responses were coded based on similarity, where responses interpreted as addressing the same issue were coded in the same groupings. These coded responses were then grouped into categories of risks and benefits to humour use. All responses were categorized, including those only mentioned once, allowing all insights to be captured.

To provide overarching descriptions for responses addressing the same issue, categories were renamed based on the area or topic of focus, so that they could be formulated as a statement of risk or benefit in round 2. Renaming was done by taking all the original responses in a category, for example that were similar to humour “allows clients to feel that the occupational therapist is equal” (P23) and humour “decreases any power dynamics that may occur” (P3) and rewording into a statement such as “humour use can minimize perceived power imbalances between the therapist and client” (See Table 3). The principal author (MK) completed this for all categories, ensuring the statement began with “humour…” so that it may be presented in round 2 as full statements. This was done carefully, to ensure words that were repeated were integrated, and meaning was retained, with only minimal editing. To further verify this grouping system, two additional authors, (CM) and (DR), then compared the initial survey responses with the derived statements independently, and then with the principal author, ensured original meanings were maintained. As noted, no responses were excluded, and all original participant responses were maintained and reworded into statements for round 2.

Round 2

Round 2 took place during October and November 2023. The purpose was to generate consensus opinion on the statements of risks and benefits from round 1. Participants were asked to rate their agreement with each risk or benefit using a Likert scale: “Below are a list of risk and benefit statements from Round 1. Please rate your agreement of each risk and benefit statement on a 4-point Likert scale, ranging from 1 = Disagree to 4 = Agree.” A 4-point Likert scale was utilized intentionally to force a decision without a neutral option (1 = disagree, 2 = somewhat disagree, 3 = somewhat agree, 4 = agree).

Standards for item exclusion vary across Delphi studies, however criteria for exclusion were derived from standards published in the OT literature (Leclair et al., 2016; Marshall et al., 2021). Using these criteria, a risk/ benefit statement was excluded in Rounds 2 and 3 if: 1) 70% or more of participants did not rate the statement ≥3; 2) the median was not ≥3; and 3) the interquartile range (IQR) was >1. Once a statement was eliminated based on these criteria, it was removed from the study. The statements remaining after analysis were combined to create round 3.

Round 3

Round 3 took place from late December of 2023 to early February of 2024. The purpose of round 3 was to further establish consensus using the analyzed choices from round 2. Participants were again asked to rate their agreement with each risk or benefit using the same Likert scale. Responses were analyzed using the predetermined exclusion criteria to result in a final consensus of benefits and risks.

Results

Thirty occupational therapists responded to Round 1, 23 in Round 2, and 21 in Round 3 (see Table 2). Participants median age was 40 years old (IQR = 17.5, Range = 25–68) and 96.7% identified as women (29 women, 1 man). Twenty-nine (96.7%) identified as OT practitioners, and 1 identified as an OT practice lead. Participants reported having practiced with persons post-stroke for a median of 7 years (IQR = 10, Range = 2–25). Of the 30 participants, 20 practiced in Ontario (66.7%), 5 in Alberta (16.7%), 3 in British Columbia (10.0%), 1 in Nova Scotia (3.3%), and 1 in Newfoundland and Labrador (3.3%). All respondents believed humour was at least somewhat important to building relationships with clients, with variance in their actual use of humour in practice (see Table 2).

Table 2

Participant Demographic Characteristics.

Demographic Characteristics	n (%)
Age	Mdn = 40; IQR = 17.5; Range = 25–68
<40	13 (43.3)
≥40	17 (56.7)
Gender
Women	29 (96.7)
Men	1 (3.3)
Practice Location (province)
Ontario	20 (66.7)
Alberta	5 (16.7)
British Columbia	3 (10.0)
Nova Scotia	1 (3.3)
Newfoundland and Labrador	1 (3.3)
Role
Occupational therapist	29 (96.7)
Occupational therapy practice lead	1 (3.3)
Practiced with persons’ post-stroke (years)	Mdn = 7; IQR = 10; Range = 2–25
<5	7 (23.3)
≥5–10	9 (30)
≥10	14 (46.7)
Frequency of humour use in practice
Always	4 (13.3)
Often	20 (66.7)
Not often	6 (20)
Not at all	0 (0)
Extent believes humour contributes to relationship-building with clients.
Very true of what I believe	15 (50)
Somewhat true of what I believe	15 (50)
Somewhat untrue of what I believe	0 (0)
Very untrue of what I believe	0 (0)

Round 1

A total of 125 benefits and 73 risks to using humour in OT practice with individuals who have sustained a stroke was generated by participants. Corresponding to Hasson et al. (2000), we generated initial themes from this original list, resulting in 37 benefits and 20 risks. Table 3 lists Round 1 responses and the derived statements that were utilized for Round 2.

Table 3

Round 1 Responses and Derived Statements.

1. The Benefits of Using Humour in Occupational Therapy Practice with Persons Who have Sustained a Stroke are…
Responses	Statements Derived from Responses
“Develops rapport. My therapy is not helpful unless there is trust and rapport.” (P1)“Build rapport” (P4)“It helps build rapport” (P5)“Build rapport” (P6)“Build rapport” (P7)“To develop rapport” (P8)“Often helps in building rapport with clients” (P10)“Promotes rapport” (P11)“Rapport development” (P12)“Helps build rapport” (P13)“Helps with rapport building” (P14)“Build rapport” (P15)“Improved rapport” (P16)“Increased rapport” (P17)“Maximize rapport” (P18)“Building rapport” (P19)“Develop rapport” (P20)“Rapport building” (P21)“Building rapport” (P22)“Build rapport and trust” (P23)“Improved therapeutic rapport” (P25)“Relationship building” (P26)“Develops rapport” (P27)“Building rapport” (P29)“Using humour while doing therapy is always helpful and…builds a therapeutic relationship.” (P28)	Humour fosters the development of trust and rapport between therapist and client.
“It can also reduce power differentials” (P1)“Decreases any power dynamics that may occur” (P3)“Meet[s] the client at their level” (P4)“Minimize power imbalance” (P18)“Allow clients to feel OT is equal” (P23)	Humour use can minimize perceived power imbalances between the therapist and client.
“Allow clients to feel OT is human” (P23)	Humour use by the therapist humanizes them in the eyes of the client.
“Help[s] them feel like we are a team” (P4)	Humour fosters a “team” feeling between the therapist and client.
“It makes the therapist more relatable” (P10)	Humour use by the therapist can make them more relatable to the client.
“Humour can lighten the mood in the therapy session” (P2)“It helps to lighten the mood” (P5)“Lighten the mood” (P6)“Lighten the mood” (P9)“I believe that using humour helps to set a lighter tone” (P10)“Lightens the mood” (P15)“To lighten the mood” (P17)“Lighten the mood” (P24)“Lightening the mood” (P25)	Humour can lighten the mood of a therapy session.
“Humour can bring out positive emotion” (P2)“Bring out a smile” (P6)“May increase mood” (P13)“Improve mood” (P24)	Humour can bring out positive emotions in the client.
“Increase enjoyment of therapy” (P4)“Have fun in therapy” (P9)“Clients may feel sense of enjoyment doing therapy” (P23)“Make therapy more enjoyable” (P24)“Helps OT sessions to be more enjoyable” (P30)	Humour can increase the client's enjoyment of therapy.
“Allows a sense of comfortability between client and therapist… allows patients to feel comfortable” (P3)“Makes the client feel at ease” (P5)“Helps to make them more comfortable” (P7)“They are often more at ease” (P10)“Provides a more relaxing environment” (P13)“Helps to put the patient at ease” (P17)“Promote[s] a comfortable environment in an attempt to direct the focus to a “fun” and safe environment instead of a “rigid” hospital environment” (P18)“Increase comfort” (P24)	Humour use allows for a sense of comfortability between the therapist and client.
“It can be a powerful antidote against post-stroke depression” (P1)	Humour can be used as a remedy against post-stroke depression.
“Humour forces us to find the brighter and lighter side of difficult situations” (P2)“Can be used as a coping strategy” (P5)“Finding light in an otherwise grim situation” (P19)“Coping mechanism” (P19)“Making a difficult situation lighter” (P29)	Humour can help clients find the bright side within the difficulties associated with stroke.
“Allows patients to feel comfortable with therapist to share more information” (P3)“Open up lines of communication” (P6)“Medium for communication” (P12)	Humour is a way to open communication lines between the therapist and client.
“Conversation starter” (P6)“Break[s] the ice with new patients” (P20)	Humour can be used to start conversation in therapy.
“Opens the door to honest conversations” (P6)“Engage patients in meaningful communication/discussion” (P24)	Humour offers an opportunity for meaningful conversations.
“Can help decrease the effects of anxiety, depression” (P5)“To decrease stress” (P8)“Reduces anxiety, alleviates depression” (P12)“Humour is a good way to deal with stress and anxiety of certain situations” (P13)“Diffuse stressful situations, if appropriate for the specific context” (P15)“Relieves stress” (P26)“Ease any tension” (P20)“Decreased tension” (P26)“Relieves tension and anxiety” (P27)“To reduce anxiety during therapy” (P8)	Humour can alleviate feelings of anxiety in the client.
“Minimize stress/tension specially in the initial assessment” (P18)	Humour can minimize stress related to the initial occupational therapy assessment.
“Feeling more positive and lighthearted may help rebuild the self-esteem of stroke clients” (P2)	Humour promotes feelings of positivity which may lead to increased self-esteem.
“Increased participation” (P16)“Increases the patient's engagement in therapy” (P26)“Engages the client” (P27)“Using humour while doing therapy is always helpful and…engages.” (P28)“Keeping engagement” (P29)“Helps client more engaged in OT sessions” (P30)	Humour can increase patient engagement in therapy.
“Maximize motivation to participate in therapies” (P3)“Motivation in treatment” (P15)	Humour can increase patient motivation to participate in treatment.
“It might help the client put their situation into perspective” (P5)“Perspective” (P16)“Framing their injuries in a way that aids their coping with their stroke is important.” (P28)	Humour can assist clients in gaining perspective on their situation.
“A lighthearted approach which facilitates learning” (P21)	Humour can facilitate a client's learning.
“Smiling helps with neuroplasticity” (P24)	Smiling associated with humour use improves neuroplasticity.
“Encouraging acceptance of current circumstance” (P22)	Humour may encourage clients to accept their current circumstance.
“Bringing normalcy into patient's life. Having the patient not feel like they are being treated differently because they have had a stroke” (P22)	Humour use can help to bring normalcy back into the client's life.
“Distraction” (P19)“Using humour while doing therapy is always helpful and distracts.” (P28)	Humour use during therapy can offer a helpful distraction for the client.
“Allowing for moments of rest” (P21)	Humour allows for moments of rest during therapy.
“Compassionate care” (P16)	Humour may help to facilitate compassionate care.
“May deflect negativity patients/families have” (P11)	Humour may help deflect negativity from clients and their families.
“Connect with family members” (P6)“Connecting with clients and their family” (P25)	Humour offers a way to connect with the client's family or support members.
“Help[s] to build insight” (P9)	Humour may help to build insight.
“Tap[s] into client's personality” (P6)“Allow clients to feel like they can be themselves” (P23)	Humour facilitates opportunities for the client to show their personality.
“Poke fun at the environment, self, therapist” (P6)	Humour can allow for poking fun at the environment, the client, or the therapist.
“Assessment of their cognition and communication skills (I.e., when a client jokes in a meaningful and appropriate way I take this a positive sign of cognition)” (P25)“It's a cognitive skill in itself” (P15)	Humour can be used as therapeutic assessment tool to understand communication and cognition skills.
“Allows patients to feel comfortable with therapist to grow connections…and help with appropriate discharge planning.” (P3)“Develop a connection with patient” (P9)“Helps me connect with my patients” (P13)“Connecting with clients and their family” (P25)“Clients can also feel closer to their therapists.” (P30)	Humour helps the therapist connect with their clients.
“Sustains hope” (P15)	Humour can be used to foster a hopeful perspective.
“Solution focused approach” (P15)	Humour can facilitate solution-focused therapy.
“Foster a healthy banter” (P13)	Humour can foster healthy banter with clients.
“When working with teens and children it's helps with therapeutic use of self and therapeutic alliance and motivation” (P15)	Humour can be a helpful element of the therapeutic use of self.
“Able to increase inter-client interaction when not in treatment” (P9)	Humour can increase inter-client interaction when not in treatment.
“Assess memory, cognition during therapy” (P9)	Humour can be used to assess cognitive functions during therapy.
“Provide opportunity for client to learn new information” (P9)	Humour can facilitate learning opportunities for clients.
“Provide opportunity for client to express” (P9)	Humour provides opportunities for clients to express.

2. The Risks of Using Humour in Occupational Therapy Practice with Persons Who have Sustained a Stroke are…
Responses	Statements Derived from Responses
“At worst it can be insulting or offensive.” (P1)“May become offended” (P9)“Offend[s] the patient” (P17)“Insulting someone or offending them” (P19)“May offend” (P23)“May offend some clients” (P11)“Risk is offending client or sending the wrong message if not done carefully” (P4)“The risk could be that the client does not “get” the joke or the context of what has been said and could take something the wrong way (may be offended)” (P5)	Humour can be perceived as offensive by a client.
“When it's not used with the right client or at the right time, at best it can be tone-deaf” (P1)	Humour use can be perceived as insensitive by a client.
“Unsure of how clients will respond: are they more emotionally fragile than I think?” (P2) “Not knowing if the client will respond” (P19)	Humour can have an unpredictable impact.
“Can backfire in a highly labile client bringing out tears instead of laughter (but this can also become a conversation starter if you lean into the emotion)” (P6) \“Emotional lability” (P22)“Patients who are emotionally labile could have uncontrolled laughing or crying which impact therapy sessions” (P26)“Difficult with patients lability” (P24)	Humour use can accentuate emotional lability.
“Has the potential to damage the therapeutic relationship if I don't have a good understanding of the client” (P2)“May have negative consequences on relationship building” (P13)“Rupture in therapeutic alliance” (P15)“Breaking rapport” (P19)“If not approached/ use correctly it can negatively affect therapist/patient relationship” (P26)“Can be detrimental to relationship” (P22)“Not received in the way it was expected by OT Affecting therapeutic rapport” (P25)“Has the potential to damage the therapeutic relationship if I don't have a good understanding of the client” (P2)	Humour can cause breakdown in the therapeutic relationship.
“There are also cultural aspects that need to be considered as humour may not be well received given the circumstances of a patient being in hospital after a traumatic brain injury.” (P3)“Cultural differences in humour” (P15)“Cultural safety” (P16)“Cultural offence if humour is not done tactfully and carefully” (P4)	Humour can be culturally inappropriate.
“Will the client process the humour too ‘concretely’… i.e., don't have the cognitive flexibility to see past the humour” (P2)“Depending on the location of stroke, use of humour could be misunderstood as a serious statement and offend others” (P3)“Some clients lack insight and their cognitive deficits may prevent them from understanding the use of humour” (P5)“If client does not have the cognitive capacity to comprehend the meaning behind the humour they may feel insulted or diminished” (P6)“May not understand the joke” (P9)“Misunderstanding due to cognitive deficits sustained from CVA” (P12)“Misinterpreting” (P15)“Client may not be at a cognitive level to understand” (P15)“Misunderstanding due to cognitive level” (P15)“Misinterpretation” (P18)“Misinterpretations” (P21)“May not be received the right way” (P24)“Using it with someone who from a cognitive standpoint is not able to interpret the joke correctly” (P25)“Client may have poor comprehension” (P25)“Patients with cognitive deficits may not understand the humour” (P26)“Cognitive impairment can prevent understanding of humour” (P27)“Some may not take humour too well due to being in early stage of stroke.” (P30)	Humour can be misinterpreted by client due to cognitive impairments.
“Unable to understand if communication problems” (P27)	Humour use may lead to miscommunication.
“If patient is not able to engage or misunderstands due to cognitive deficits, aphasia. Would need to use caution and implement on case-by-case basis” (P22)“Difficult with patients with aphasia or difficulty understanding” (P24)	Humour can be misinterpreted by client due to aphasia.
“Some clients may not like humour” (P14)“Some people don’t appreciate or understand humour” (P13)“Some people like to remain serious” (P23)	Humour use may not be appreciated by some clients.
“They may not appreciate your style of humour and this might affect ability to build collaborative relationships” (P7)“Patient doesn’t find it funny or understand” (P20)“Jokes may not hit with certain people” (P23)	Humour may not be perceived as funny to the client.
“Breaking the focus within a session” (P21)“May interrupt session due to emotional lability.” (P30)	Humour can break focus in a therapy session.
“May think you are unprofessional” (P20)“Professionalism” (P16)“Takes away from professionalism/professional” (P11)“May cross professional boundaries/impact professional relationship (clients may feel more like friend vs client)” (P11)“Diminishes professionalism of therapist” (P27)	Humour use may diminish the therapist's professionalism.
“Occupational therapy assessment and treatment is not be perceived as serious” (P8)“May think you are not taking treatment seriously” (P9)“A risk of using humour could be that the client believe that they, or their situation, is not being taken seriously” (P10)“Relationship (clients may not see OT using humour as being serious in treatment or may believe that profession is a joke too). They could be grieving the event and the effects of the stroke and humour could be interpreted as making light of the situation” (P11)“Risk being perceived as not taking the patient's care seriously” (P17)“Individual may not take the OT seriously” (P18)	Humour use may lead client to perceive therapist as not taking their situation seriously.
“Communication challenges may leave clients frustrated” (P15)	Humour may elicit frustration in clients with communication challenges.
“There is also a significant relation between experiencing a stroke and post-stroke depression; thus, humour may not be well received in these cases” (P3)	Humour may not be well received due to post-stroke depression.
“I feel I need to know the client well enough to assess if humour is appropriate” (P5)	Humour can be perceived as inappropriate if the therapist does not know the client well enough.
“Don't know how the humour will be interpreted with the client… their biases, pre-conceived assumptions” (P2)“Can get off on the wrong foot if you aren't perceptive or reflective on client's place in their journey or usual temperament” (P6)“I believe that you need to have an appreciation for the client (their temperament, personality, culture) prior to introducing humour so as to not offend them” (P10)	Humour use can lead to challenges in relationship building if used too early
“Sarcastic humour is not always interpreted well, especially in those who have cognitive deficits or executive functioning deficits” (P8)“Due to cognitive deficits the person with a stroke may not understand or appreciate some humour i.e., Sarcasm and may take it the wrong way” (P13)	Sarcastic humour may not be interpreted correctly due to cognitive deficits.
“[Client] does not understand that this would be a treatment modality” (P9)	Humour is not understood as therapeutic by the client.

Benefit statements collectively emphasized the importance of humour in building rapport and trust with individuals after stroke. Establishing a strong therapeutic relationship through humour was seen as essential for effective therapy, with repeated mentions of rapport development and enhancement using humour. Humour was also seen as enhancing expression and communication from individuals after stroke, as well as therapists. There was also repeated mention of humour facilitating aspects of learning, coping, engagement, and motivation in therapy post-stroke. Additionally, there was a recognition of humour aiding in minimizing power imbalances between therapist and client to create a more equal and supportive environment.

Risk statements highlighted concerns such as offending or insulting clients, especially those who may be emotionally labile. There was recognition of the possibility of misunderstandings due to cognitive deficits, aphasia, or general communication problems, which could lead to the breakdown of rapport or the therapeutic relationship. Additionally, the statements touched on issues related to professionalism, with humour sometimes being perceived as unprofessional or diminishing the seriousness of therapy. Overall, statements underscored the importance of carefully considering the appropriateness of humour, based on the client's characteristics, cultural background, cognitive abilities, and therapeutic context.

Round 2

In Round 2, 23 participants responded to the survey, a 77% response rate. Statements were eliminated based on the predetermined criteria, eliminating five benefits and 18 risks due to lack of consensus, resulting in 32 benefits and two risks at this stage.

The final 32 benefits underscored humour in enhancing the client-therapist relationship, increasing motivation and engagement in clients, and allowing clients to better communicate and express themselves. There was also consensus on benefits related to emotional and cognitive advantages, such as facilitating coping and learning. The two risks maintained focused on individual differences in humour appreciation and cognitive impairments leading to the misinterpretation of sarcasm.

Round 3

For round 3, 21 participants completed the survey, 70% response rate. Responses from round 3 were analyzed using the predetermined exclusion criteria, and no further risks or benefits were eliminated. Therefore, consensus remained. Table 4 showcases all statements generated in round 1, along with the consensus after rounds 2 and 3 of the Delphi.

Table 4

Consensus After Each Round on Benefits and Risks of Humour Use by Occupational Therapists With Clients Who Have Sustained a Stroke.

The Benefits of Using Humour in Occupational Therapy Practice with Persons Who have Sustained a Stroke are…	Round 2			Round 3
	Mdn	IQR	% Agreement	Mdn	IQR	% Agreement
Therapist-Client Relational benefits
1. Humour fosters a “team” feeling between the therapist and client.	4	1	95.7	3	1	91.3
2. Humour use allows for a sense of comfort in the relationship between the therapist and client.	4	0.5	95.7	3	1	95.7
3. Humour use by the therapist can make them appear more relatable to the client.	4	1	91.3	3	1	91.3
4. Humour fosters the development of trust and rapport between therapist and client.	4	0	100	4	1	95.7
5. Humour can minimize power imbalances between the therapist and client.	4	1	91.3	3	1	91.3
6. Humour use by the therapist humanizes them in the eyes of the client.	4	1	100	3	1	87
7. Humour helps build therapeutic connection.	4	0	100	3	1	95.7
8. Humour can be a helpful element of the therapeutic use of self.	4	1	100	3	1	95.7
9. Humour helps to facilitate compassionate care.	4	1	95.7	3	1	87
10. Humour offers a way to connect with the client's family or support members.	3	1	95.7	3	1	87
11. Humour can facilitate solution-focused approaches.	3	1.5	69.6	–	–	–
Communication/Expressive benefits
12. Humour provides opportunities for clients to express themselves.	4	1	100	3	1	91.3
13. Humour facilitates opportunities for the client to show their personality.	4	1	100	4	1	95.7
14. Humour can foster healthy banter with clients.	4	1	100	3	1	95.7
15. Humour can increase interactions among clients.	4	0	100	3	1	91.3
16. Humour provides a foundation for meaningful conversations.	3	1	95.7	3	0	78.3
17. Humour is a way to open communication lines between the therapist and client.	4	1	91.3	3	0	91.3
18. Humour can be used as a therapeutic assessment tool to understand communication and cognition skills.	3	2	69.6	-	-	-
Cognitive benefits
19. Smiling associated with humour use improves neuroplasticity.	3	1	91.3	3	0	78.3
20. Humour can facilitate a client's learning.	3	1	91.3	3	0	87
21. Humour helps build insight.	3	1	65.2	–	–	–
Emotional benefits
22. Humour can help rebuild a client's self-esteem.	3	1	91.3	3	0	78.3
23. Humour can assist clients in gaining perspective on their situation.	3	1	82.6	3	0	78.3
24. Humour can lighten the experience of stroke.	4	1	87	3	1	73.9
25. Humour can lighten the mood of a therapy session.	4	0	100	4	0	91.3
26. Humour can bring out positive emotions in the client.	4	0	100	4	1	95.7
27. Humour can foster a hopeful perspective.	3	1	95.7	3	0	91.3
28. Humour can be used as a remedy against post-stroke depression.	4	1	87	3	0	78.3
29. Humour can alleviate feelings of anxiety in the client.	4	1	100	3	1	87
30. Humour helps deflect negativity of clients and their families.	3	1	87	3	1	69.6
31. Humour may encourage clients to accept their current circumstance.	3	1	65.2	–	–	–
32. Humour allows for poking fun at the environment, the client, or the therapist.	3	2	52.2	–	–	–
Motivation and Engagement benefits
33. Humour can increase patient engagement in therapy.	4	0.5	95.7	3	1	91.3
34. Humour can increase the client's enjoyment of therapy.	4	0	100	4	0	91.3
35. Humour use during therapy can offer a helpful distraction for the client.	4	1	100	3	1	87
36. Humour allows for moments of rest during therapy.	4	1	95.7	3	1	87
37. Humour can increase patient motivation to participate in treatment.	4	1	95.7	3	1	91.3

The Risks of Using Humour in Occupational Therapy Practice with Persons Who have Sustained a Stroke are…	Round 2			Round 3
	Mdn	IQR	% Agreement	Mdn	IQR	% Agreement
Comprehension/Interpretation risks
1. Humour use can lead to miscommunication.	2	1	39.1	–	–	–
2. Humour can be misinterpreted the by client due to cognitive impairments.	3	1	65.2	–	–	–
3. Humour can be misinterpreted by client due to aphasia.	3	1	65.2	–	–	–
4. Sarcastic humour may not be interpreted correctly due to cognitive deficits.	3	0	73.9	4	0	91.3
5. Humour may not be well received due to post-stroke depression.	2	1	34.8	–	–	–
6. Humour can be perceived as offensive by a client.	3	1	52.2	–	–	–
7. Humour use can be perceived as insensitive by a client.	3	1	47.8	–	–	–
8. Humour use can accentuate emotional lability.	3	1	39.1	–	–	–
9. Humour can be culturally inappropriate.	3	1	56.5	–	–	–
10. Humour may elicit frustration in clients with communication challenges.	2	1	21.7	–	–	–
11. Humour can have an unpredictable impact.	2	1	30.4	–	–	–
Risks of damaging the therapist-client relationship
12. Humour use can lead to challenges in relationship building if used too early.	3	1	43.5	–	–	–
13. Humour use may diminish the therapist's professionalism.	2	3	13	–	–	–
14. Humour use may lead client to perceive therapist as not taking their situation seriously.	2	3	13	–	–	–
15. Humour can cause breakdown in the therapeutic relationship.	5	3	8.7	–	–	–
16. Humour can be perceived as inappropriate if the therapist does not know the client well enough.	3	1	13	–	–	–
17. Humour can break focus in a therapy session.	3	3	5	–	–	–
Differences in humour preference between client and therapist
18. Humour use may not be appreciated by some clients.	3	1	73.9	4	0	91.3
19. Humour may not be perceived as funny to the client.	3	1	65.2	–	–	–
20. Humour is not understood as therapeutic by the client.	2	2	4.3	–	–	–

Note. Interquartile range (IQR) refers to a measure of dispersion based on lower and upper quartiles, where the range or difference between the lower and upper quartiles is where the middle half of the data points lie (Statistics Canada, 2021).

Benefits were arranged into categories as follows: therapist-client relational benefits (n = 10), emotional benefits (n = 9), communication/expressive benefits (n = 6), motivation and engagement benefits (n = 5), and cognitive benefits (n = 2). The two risks were categorized into differences in humour preference between client (n = 1) and therapist and comprehension/interpretation risks (n = 1).

Discussion

We conducted this study to understand the risks and benefits of using humour in OT practice with individuals after stroke, as perceived by therapists. Our findings highlight the multifaceted benefits, as well as critical risks, to using humour with individuals after stroke. The 32 benefits and two risks associated with using humour with individuals after a stroke suggest that humour is one tool or relational practice that is useful to foster collaborative relationship-focused practice in OT practice with people after stroke.

Benefits to Humour Use

More specifically, the present research highlights benefits of humour use in forming trust and connections with people after stroke. Of the 32 benefits, 10 specifically addressed relational benefits, while others, including communication and expression, also contribute to relationship building and optimal therapy relationships. Participants agreed that using humour in the initial stages, and throughout therapy, could foster a “team” like feeling with their clients and allowed the therapist to create relationships with the client's family and support members, both of which are critical in fostering open communication about care. These findings highlight the importance of building relational capital, which consists of the value created from nurturing therapy relationships over time. This allows for the creation of positive rapport, trust, and a comfortable environment for therapy (Stagg et al., 2021). Building this “capital” or trust has been shown to have positive effects on overall therapy through increased treatment adherence and reduced depressive symptoms in patients with brain injury (Hall et al., 2010). In addition, strong therapeutic relationships have been shown to have positive effects on somatic outcomes such as chronic pain (Kinney et al., 2020). In combination with these previous and related findings, there is potential for humour to be one technique to build relational capital and thereby contribute to collaborative-relationship focused practice (Restall & Egan, 2021).

Additionally, the present study suggests humour use can have beneficial effects on an individual's motivation and engagement in therapy and care, through increasing their enjoyment of therapy sessions, and affording helpful distraction and/or rest. As OT practice with people after stroke often addresses basic activities of daily living and cognitive interventions which can be taxing on individuals after a stroke, humour may be an important way to sustain motivation in therapy and offer helpful breaks when needed (Bright et al., 2018; Steultjens et al., 2003). Emotional benefits showcased in the findings suggest humour use can alleviate feelings of anxiety in the client and help to foster a hopeful perspective. Timing the use of humour at moments of fatigue or frustration in therapy sessions can therefore create a moment of reprieve.

Humour involves cognitive and communicative functions that are associated with engagement in therapy, communicative intent, working memory, and problem-solving (Bright et al., 2018; Cheang & Pell, 2006; Zhou et al., 2021). This study's findings support humour to foster communication in situations in which individuals face communication challenges, as well as empower them to showcase their personality in therapy sessions. Similarly, previous speech-language pathology research showed humour was a way for people with stroke-related aphasia to expand communicative confidence in therapy sessions (Simmons-Mackie & Schultz, 2003), and functioned as a dynamic tool for various social and communicative purposes (Simmons-Mackie & Damico, 2009). At the same time, one of the risks highlights the potential for misunderstanding, as sarcastic forms of humour may be misinterpreted due to cognitive deficits.

Participants proposed that humour and associated smiling can facilitate learning and neuroplasticity in the brain. Previous research has pointed to the ability of humour use to promote the development of new neural pathways that aid learning through improving engagement, delayed recall (Sambrani et al., 2014), short term memory (Stoutenberg et al., 2016), and insight problem solving (Zhou et al., 2021); important findings when considering interventions with post-stroke individuals, as both right and left hemispheres are intricately involved in the comprehension and appreciation of humour (Bihrle et al., 1986; Horton et al., 2011; Sambrani et al., 2014; Shammi & Stuss, 1999). Stewart et al. (2016) explored the neuroscience behind play therapy, suggesting that the humour used by magicians and play therapists encourages the development of new neural pathways. Therefore, humour in therapy may optimize learning and neuroplasticity involved in recovery from stroke, although additional research with persons with stroke is warranted.

Risks to Humour Use

The present study's consensus resulted in two risks occupational therapists could consider when working with individuals who have sustained a stroke, specifically, that (1) sarcastic humour may not be interpreted correctly due to cognitive deficits, and that (2) humour use may not be appreciated by some clients. Previous research demonstrates that personality and individual characteristics affect the use and appreciation of humour, which may explain the risk that not all people will appreciate its use (Booth-Butterfield & Booth-Butterfield, 1991; Martin et al., 2003; Schermer et al., 2013). Given previous research highlighting using humour at inappropriate or sensitive times can damage rapport or potentially offend individuals who have sustained a brain injury (Kovarsky et al., 2011), further work is needed to understand when and when not to use humour in therapy. Risks that were identified in round 1 that were close to meeting consensus criteria, such as the risk of humour not being perceived as funny and the risks of an individual misinterpreting humour due to cognitive impairments or aphasia, should be revisited and explored in future research.

Practice Implications

Within this study, humour use was found to be experienced by occupational therapists as primarily a beneficial practice when working with people who have sustained a stroke. Using humour with people after stroke can assist occupational therapists in creating a supportive therapeutic relationship, a “team” like feeling, while benefitting the therapy process overall, through enhancing enjoyment and motivation, and opening communication lines. When considering using humour as a relational practice, occupational therapists should consider its timing and use of humour to offer moments of rest when fatigue is present. Also, humour should be considered when looking to facilitate learning and neuroplasticity in stroke recovery, although this area warrants further research. This work also supports the recommendation that humour can assist in tempering feelings of anxiety and depression after stroke and can assist in building relational capital with clients and their support networks, leading to improved therapy relationships and outcomes. We encourage occupational therapists to reflect on their own use of relational practices with stroke populations, and to pay close attention to relational practices that can benefit people after stroke, but also may be risky to use. For example, it is important for occupational therapists to avoid the use of sarcastic humour in stroke populations, as impairments in cognition may lead to misinterpretation.

With the rise of collaborative relationship-focused practice, it is crucial that OT education include a focus on the use of relational practices, such as humour, that can optimize therapeutic relationships and therapy outcomes. It is also important that future research seeks to understand humour use in OT from the perspectives of individuals after stroke. This could be done through observational study designs that allow researchers to explore what is happening in real time practice and track outcomes. Additionally, future research should further explore the various risks identified in all rounds of this study, and how they may be important in understanding what therapists can avoid when using humour to foster collaborative relationships with the individuals they work with.

Strengths and Limitations

When employing a Delphi study, the representativeness of the participants can effect the depth of data generated, as well as external validity. In turn, Delphi studies should focus on recruiting as diverse of a group as possible (Trevelyan & Robinson, 2015). The inclusion criteria utilized (2 years’ experience with individuals who have sustained a stroke) was intentional, to ensure a range of experience on the topic, while still ensuring participants had adequate experience with this clinical population. As seen, the participants possessed a large range of years working in with people after stroke, as well as diversity in age. Participants practiced in five Canadian provinces, although 83% were from two provinces. Moreover, almost all participants identified as women. The predominantly female composition of the participant sample is reflective of the gender distribution in the profession (Canadian Institute for Health Information, 2024) and the focus on Canadian occupational therapists may limit the generalizability of findings to other cultural contexts or healthcare systems. As well, the requirement that participants be fluent in English may have limited the generalizability of the findings.

A limitation of this study may also be the absence of a “no comment” option in the survey rounds. While this was intended to encourage definitive responses, it may have restricted participants, particularly on topics with limited knowledge (e.g., learning and neuroplasticity). Including a “no comment” option, as recommended by Trevelyan and Robinson (2015), could have provided a more accurate reflection of participants’ views on areas where they lacked expertise. Attrition can often be a concern in Delphi studies (Keeney et al., 2006; Trevelyan & Robinson, 2015). Across rounds, the 30 participants decreased to 21, and this has the potential to introduce bias into the study results. A final limitation relates to the Delphi methodology, which is unable to capture key contextual elements due to its electronic completion, and inability for participants to fully expand on their thoughts and responses, especially in rounds 2 and 3. Future studies related to this work may include qualitative descriptive interviews to further explore and contextualize humour use in stroke settings and further uncover contextual factors that shape the risks and benefits found in this study.

Conclusions

Participants identified that the use of humour in OT with people after stroke has multiple benefits, including enhancing the therapeutic relationship and positively impacting emotional, cognitive, communicative, and engagement aspects of therapy and the client. However, two risks identified included comprehension difficulties and differing humour preferences between client and therapist. This Delphi study advances our understanding of humour's role in OT stroke practice, providing evidence-informed insights to guide clinical practice and education. By harnessing the collective wisdom of experienced practitioners, this study contributes to the ongoing growth of collaborative relationship-focused practice in this profession, fostering a deeper appreciation for the potential of relational aspects such as humour in promoting positive rehabilitation outcomes for individuals post-stroke. Future studies should look to contextualize these findings to better illustrate the important situational factors at play and provide further evidence of the benefits derived from the use of humour.

Key Messages

Occupational therapists need to tailor their use of humour to individual's backgrounds and contexts, recognizing that contextual differences and personal experiences and locations shape how humour is received and interpreted, especially after stroke.

Humour holds significant potential in enhancing collaborative relationship-focused practice within OT, particularly with individuals who have sustained a stroke. Canadian occupational therapists have identified humour as a valuable tool for building rapport, improving communication, promoting emotional well-being, and increasing client engagement.

Footnotes

Declaration of Conflicting Interests

The author(s) declare that there is no conflict of interest.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Marisa L. Kfrerer

Debbie Laliberte Rudman

Julie Aitken Schermer

Carrie Anne Marshall

Author Biographies

Marisa L. Kfrerer is an occupational therapist and PhD candidate at Western University. Her research explores the dynamics of practice relationships and relational practices within occupational therapy, with a particular focus on the role of humour in therapeutic contexts.

Debbie Laliberte Rudman is a Distinguished University Professor in the School of Occupational Therapy at Western University. Her critically informed research focuses on unpacking socio-political forces (re)producing occupational inequities and aims to inform praxis that expands occupational possibilities for equity-deserving groups.

Julie Aitken Schermer is a Professor in Psychology and Management and Organizational Studies. Her area of research is individual differences with a focus on personality.

Carrie Anne Marshall is an Associate Professor and Advancing Research Chair in Homelessness Prevention and Mental Health Equity at Western University in London, Ontario, Canada. Her research explores intersections between poverty and mental health, with a particular focus on homelessness among individuals living with serious mental illness.

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