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Doing Daily Life: How Occupational Therapy Can Inform Psychiatric
Rehabilitation Practice
Article in Psychiatric Rehabilitation Journal · February 2009
DOI: 10.2975/32.3.2009.155.161 · Source: PubMed
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Psychiatric Rehabilitation Journal
2009, Volume 32, No. 3, 155–161
Copyright 2009 Trustees of Boston University
DOI: 10.2975/32.3.2009.155.161
Special Section
Doing Daily Life:
How Occupational Therapy
Can Inform Psychiatric
Rehabilitation Practice
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
▼
Terry Krupa
Queen’s University
Kingston, Ontario, Canada
Ellie Fossey
LaTrobe University
Melbourne, Australia
William A. Anthony
Boston University
Catana Brown
Touro University, Nevada
Deborah B. Pitts
University of Southern California
Topic: This paper provides an overview of occupational therapy in the context of
psychiatric rehabilitation and mental health recovery. Purpose: The paper delineates practical aspects of occupational therapy’s involvement in the mental health
field with a discussion of occupation and the elements of conceptual models that
guide the practice of occupational therapy. Sources used: CINAHL, Psych Info,
Medline. Conclusion: Occupational therapy is a key discipline in the field of psychiatric rehabilitation and brings to the field a strong theoretical and knowledge
base along with unique procedures and practices. It is important for the psychiatric
rehabilitation field to learn from all disciplines, including occupational therapy.
Keywords: occupational therapy, psychosocial rehabilitation, recovery,
mental health
O
ccupation: The focus of occupational therapy.
As its name implies, occupational therapy’s central focus is on occupation as
a determinant of health and well-being.
Occupation is a broad construct that is
meant to capture “how people do daily
life,” and considers three broad categories to describe the occupations in
which people participate: self-care,
productivity, and leisure. Each category
of occupation includes a broad range
of activities, defined by their central
purpose and the ways in which they
contribute to health. Self-care includes
155
activities performed to attend to basic
needs that both ensure survival and facilitate participation in other activities
and daily routines. Personal care,
health, and hygiene activities typically
carried out in the home are included,
as are community activities such as
banking, shopping, and visiting health
care professionals. Productivity includes the range of activities in which
people engage to support themselves
and their families, and to contribute to
their communities and society. In addition to paid employment, productivity
includes education, parenting and
home maintenance, volunteer work,
Doing Daily Life
P s y c h i at r i c R e h a b i l i tat i o n J o u r n a l
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and even the play of children. Finally,
leisure includes a wide range of
nonobligatory activities, motivated primarily by personal interest, enjoyment
and quality of life (Reed, 2005).
The theoretical foundation of occupational therapy is based on the assumption that humans are occupational
beings in that human beings have a
need to participate in occupations that
are fundamental to survival, health and
the optimization of human potential
(Wilcock, 1998; Yerxa, 1998). The
knowledge base of the profession
draws on a range of basic and social
sciences to explain the relationship between occupation and well-being and
to understand common occupational
problems. The ultimate goal of occupational therapy is to enable participation
in personally and socially meaningful
occupations that support health and
well-being.
Understanding Occupation
A strength of the construct of occupation is that it is easily understood in lay
terms and relevant to most people:
after all, everyone knows something
about what people do in daily life and
why they do it. Yet this simplicity also
masks the complexities of occupation,
which are a central concern of the theoretical and practical knowledge base of
occupational therapy.
Motivation, selection, experience, performance and contextual factors underlie participation in healthy occupation
across the lifespan. Occupations in
daily life include activities that provide
a means to organize time use, meet
personal goals, provide meaning and
satisfaction, prompt human development, develop abilities, capacities and
coping, and change oppressive experiences (CAOT, 2002). The actual “doing”
of occupations is believed to be transformative, promoting adaptation, cre-
ating personal and social identities,
connecting people to their communities and enabling ongoing personal
growth and development.
Conceptual models of occupation present occupational performance, participation, and experience as resulting
from a transaction between the occupations themselves, as well as personlevel and environment-level factors.
Person-level determinants of occupation are variously classified but include
the following (McColl et al., 2003;
Baum & Christiansen, 2005):
• Spiritual dimensions refer to the personal meanings attributed to occupation as a reflection of identity of the
self, one’s connections to others and
to one’s place in the world. Personal
accounts have described how living
with mental illness can be experienced as a crisis in meaning and purpose that is expressed as profound
occupational disengagement.
• Socio-cultural determinants refer to
the internalized values and beliefs
that underlie a person’s occupational
choice and the social enactment of
occupations. For example, the need
to negotiate complex social situations is often complicated for individuals with a mental illness because
their coping strategies must include
dealing with features of illness.
• Physical determinants refer to the
movement, strength, endurance and
flexibility demands of occupations.
Physical issues affecting occupation
occur frequently in the context of a
mental illness, emerging, for example, as a result of the inactivity associated with occupational deprivation,
effects of medical treatments, co-occurring physical conditions and
changes associated with aging.
• Cognitive determinants are mental
functions that support learning, implementation and transference of oc-
article
156
cupational knowledge and behaviors.
For example, the potential impact of
mental illness on attention, memory,
problem solving and other cognitive
processes is well known, and these
can in turn affect the experience and
performance of occupations.
• Neurobehavioral determinants refer
to underlying motor and sensory
processes that support the experience and performance of occupations. Although often cited as an
“invisible” disability, people with a
mental illness can experience observable problems in refined motor enactment of task and social demands of
occupations.
• Psychoemotional determinants refer
to internal processes that motivate
and sustain occupational engagement. Negative occupational experiences of persons with a mental
illness frequently contribute to compromised self-esteem, self-efficacy
and the loss of self-agency. In addition, many people with a serious
mental illness describe a decrease in
their capacity to experience pleasure
and interest when engaged in occupations.
Environment-level factors are broadly
viewed as the social, physical, cultural,
and institutional factors external to individuals that influence occupation,
and are potentially amenable to alteration to enable participation, or alter
performance (CAOT, 2002). Social factors include attitudes about the potential for people with mental illness to
engage in meaningful occupations, the
nature and level of support for occupations received from everyday social interactions, the availability of social
supports focused on occupations, and
the social climate of important occupational environments, such as workplace. The physical environment can
include privacy conditions that support
occupation and access to the tools nec-
w i n t e r 2 0 0 9 — V ol u m e 3 2 N u m b e r 3
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essary for occupation. Cultural factors
are values and beliefs about occupation and shared rules for occupational
performance. Institutional factors refer
to broader social structures such as
government social policies, organizational and economic structures that influence (and even regulate)
participation in occupations.
Experiencing
Occupational Disruptions
Because the organizing structures of
societies are, to a great extent, connected to the occupations of their citizens, occupational disturbances have
broad impacts on communities. Many
health conditions and social situations
can evolve into significant disruptions
to the ability of individuals to participate in and benefit from daily occupations. Occupational problems can, for
example, involve family in exceptional
caregiving responsibilities, compromising their participation in other occupations, their financial resources
and their autonomy. Occupational
problems may also deprive the workforce of a pool of promising workers
and contribute to the social disorganization of communities characterized by
poverty. The construct of occupational
justice has recently been developed to
describe the importance of occupational opportunities in ensuring the growth
and development of both individual citizens and of society itself (Townsend,
2003). Given the extent of exceptional
caring responsibilities often undertaken by families of people with a mental
illness, and the extent of workforce exclusion and poverty among people with
a mental illness, the notion of occupational justice seems particularly salient
to this field.
Occupational therapists are concerned
with understanding the factors contributing to people’s patterns of participation in occupations, as well as the
quality of their performance. The profession has developed a number of
terms to define how problems in occupation might be experienced, understood and ultimately addressed. An
explanation of the terms and examples
relevant to psychiatric rehabilitation
and recovery are provided below.
• Occupational interruption is the experience of a temporary disruption in
occupation occurring because of
changes occurring in the personal or
environmental influences on occupation. Ex: Sam, a married father of two,
takes a short leave from his job as a
production manager when he notes
an increase in the symptoms of his
bipolar mood disorder. He uses the
time to collaborate with service
providers to adjust his medications,
readjust his time use patterns to decrease demands and ensure regular
periods of rest, and engage in counseling related to disclosure.
• Occupational imbalance is the experience of time use patterns which constrain the ability to meet the variety
of personal health and well-being
needs provided by occupation. Ex:
Linda’s commitment to be successful
in college with the help of the supported education program is constraining her ability to have fun with
her friends, visit her family and enjoy
her hobbies.
• Occupational disengagement is the
experience of a relative lack of involvement in occupations characterized by a lack of investment and
emotional detachment. Ex: Andrew
dropped out of his college studies before his first episode of psychosis.
Bored and isolated, he wants to go
back to complete studies but no
longer has interest and the emotional
investment needed for his studies,
maintaining friendships and pretty
much all of his former activities.
article
157
• Occupational delay is the experience
of significant deviations in the typical
development of occupation. Ex:
Wendy wants to pursue a job but she
considers herself at a disadvantage
compared to other young women who
did not have their schooling and early
work experiences interrupted by
mental illness.
• Occupational deprivation is the experience of a remarkable level of disadvantage and constraints with respect
to occupational opportunities. Ex:
Selma has been living in a board and
care facility for six months. She
spends most of the day around the
television room. She isn’t involved in
any activities outside of the home
and she lacks the supports she would
need to connect to activities.
• Occupational alienation is the experience of a lack of involvement in
meaningful occupations emerging
from social and cultural exclusion. Ex:
Kyle would like to return to his college studies but the school’s disability service doesn’t offer the services
he needs to help him negotiate accommodations.
• Occupational apartheid is the experience of participation in occupations
that are socially trivialized, low status, and poorly valued. It is used to
label and represent barriers external
to the person’s strengths, needs,
abilities or preferences. Ex: Despite
their best efforts the supported employment workers are unable to find
jobs beyond those that are entrylevel, poorly paid and with few career
advancement opportunities for the
people with mental illness.
Disrupted occupation has emerged as
an important concern for people with
persistent mental illnesses. Indeed,
one of the major failings of policy and
service development related to community-based services for this popula-
Doing Daily Life
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P s y c h i at r i c R e h a b i l i tat i o n J o u r n a l
tion has been the failure to make occupational outcomes a high priority and
subsequently to develop and disseminate practices and resources addressing their occupational needs. Many
fine evidence-based services focusing
on occupation have been developed
(for example, supported employment
and education), yet the majority of people with a persistent mental illness living in the community still do not have
access to these services. In addition,
particular factors associated with a
mental illness, such as profound social
stigma, and disrupted affective responses to occupation, can also undermine people’s power to advocate on
behalf of their own occupational
needs.
service might be asked to focus his or
her expertise in the areas of time use,
occupational balance, and activities of
daily living to complement the contributions of recreation therapists, vocational specialists, and peer support
workers. Occupational therapy practice
can also be aimed at enabling occupation at multiple levels including personlevel services addressing the needs of
the individual, and environment-level
interventions focused on the program/
service and the community.
Individual-Level Practice
Occupational Therapy Practice
While occupational therapists will
bring an “occupational perspective” to
all aspects of their work, it is not unusual for the therapist to be asked to
bring their expertise to work with individuals with serious and complex occupational problems. Occupational
therapists have available to them several process models that define phases
and strategies for collaborating with individuals to understand their occupations, define their occupational issues
and strengths and negotiate priorities
and strategies for change (Farhall et
al., 2007; Bland et al., 2007; Sumsion,
2005). The occupational therapist’s
expertise in the analysis of the actions
and skills that underlie occupational
performance can contribute to a detailed understanding of the tasks and
demands experienced by individuals
and their particular strengths, difficulties and potentials.
The major focus of occupational therapy is directed to enabling occupation.
but the actual patterns of practice are
shaped by features of the therapist’s
employment, which often creates practice constraints. For example, therapists employed by insurance
companies may have only a limited
number of visits to offer a return-towork program for an individual recovering from major depression; while the
therapist with a case management
Occupational therapists use a range of
self-report methods to explore and
learn from individuals’ knowledge and
experience of their own occupations.
For example, the Occupational
Performance History Interview II (OPHIII, Kielhofner, Mallinson, Forsyth & Lai,
2001) uses a semi-structured interview
format to build relationships with people with mental health issues and their
support networks to develop an understanding of the person’s lived experi-
A particular strength of these concepts
is that they encourage a holistic understanding of personal and environmental factors influencing occupation, and
discourage an overreliance on diagnosis, symptoms and impairments of
mental illness to explain and address
occupational disruptions. So, for example, using the construct “occupational
disengagement” instead of relying on
the biomedical construct of “negative
symptoms” encourages therapists and
the individuals they serve to focus their
efforts on addressing issues of activity,
social participation and creating environments that support engagement.
article
158
ences with occupation (Ennals &
Fossey, 2007) .
In addition, occupational therapists
have available a range of standardized
and ecologically valid observational assessments that provide detailed information about the quality of an
individual’s performance in real life occupations, which can be useful in collaborative service planning. Two
examples used in mental health are the
Assessment of Motor and Process
Skills, which focuses on how personally relevant activities of daily living are
impacted by motor and process skills
(Fossey, Harvey, Plant & Pantelis,
2006; Fisher, 2003; McNulty & Fisher,
2001), and the Assessment of
Communication and Interaction Skills
that focuses on how performance in a
range of activity contexts are influenced by underlying social abilities
(Forsyth, Lai & Kielhofner, 1999).
Occupational therapists in the mental
health arena typically use a range of interventions to, as much as possible,
meet occupational goals that are
meaningful to the individual and to collaboratively engage individuals in the
intervention process as experts on behalf of their own lives and well-being.
Engaging people directly in occupations is a hallmark of occupational
therapy intervention. Individuals with
persistent mental illnesses frequently
experience extreme occupational disturbances, and occupational therapists
will likely use all or a combination of
detailed occupational analyses; activities graded to meet personal needs;
explicit time use planning to encourage
balanced participation; education to
provide individuals with the information about their occupational situations, with which to empower an
individual to effect change; focused efforts to capitalize on strengths and
build skills; and consultation and environmental modification to secure the
w i n t e r 2 0 0 9 — V ol u m e 3 2 N u m b e r 3
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best match between the person and
the occupation in which she or he is
seeking to participate.
Occupational therapy interventions in
the mental health arena may also be
directed to resolving underlying performance problems, with a view to
building capacity for occupation. This
can take the form of adaptation or
modification of performance. For example, an occupational therapist might
use the findings from the Adult
Sensory Profile (Brown, Tollefson,
Dunn, Cromwell, & Filion, 2001), suggesting issues related to low sensory
registration in the context of activities,
to collaborate with the individual to develop ways to attend to missed sensory
stimuli (Brown et al., 2001; Brown,
2001). Resolving underlying performance problems can also take the form
of direct remediation. Tryssenaar and
Goldberg (1994), for example, describe
an example of an occupational therapist and psychologist collaborating to
deliver a cognitive remediation program for a young man with a mental illness that linked focused computer
activities directed to improving attention-focusing with improving activity
and social performance in the classroom and at work.
There have been calls to develop empirical evidence demonstrating how involvement in occupations can improve
mental health and even alleviate the
symptoms and impairments of mental
illness (Rebeiro, 1998). There is no
doubt that the relationship between
engagement in daily activities and the
experience of a mental illness is complex. This complexity is reflected in the
contradictory assumptions about activity and health that permeate the mental health field. Popular
vulnerability-stress models suggest
that participation in daily activities can
have harmful effects, overwhelming an
individual’s adaptive capacities and in-
ducing illness (Krupa, McLean,
Eastabrook, Bonham, & Baksh, 2003).
These stress models have been a factor
in the hesitation of service providers in
the mental health field to pursue avenues to involve the people they serve
in meaningful occupations, contributing to experiences of occupational disruption and deprivation. Consistent
with contemporary perspectives on recovery, the philosophical and knowledge base of occupational therapy
advances a balanced view that promotes an active and informed approach, to supporting participation in
meaningful occupations (Krupa,
Radloff-Gabriel, Whippey & Kirsh,
2002). When this support is matched to
individual need and circumstances, the
transformative capacities of “doing
daily life” are released.
Environment-Level Practice
Occupational therapists also use their
environment-level “occupational perspective”—the social, physical, cultural, and institutional factors external to
individuals that influence occupation—to enable program/service development. For example, with their
emphasis on enabling occupations,
therapists may attend to the extent to
which the program focuses on, creates
and develops meaningful and real occupational opportunities for the people they serve. They may focus on
particular populations to ensure that
services are meeting their occupational needs. For example, Bassett, Lloyd
and colleagues, Australian occupational therapists, describe efforts to
prevent the persistent disruption of
the occupational lives of young persons with first episode psychosis
(Lloyd & Waghorn, 2007) and to enable
the parenting skills of women with a
serious mental illness to ensure the
continuation of their involvement in
this important social role (Bassett,
King & Lloyd, 2006; Bassett, Lampe &
Lloyd, 2001).
article
159
In addition, serving as a “champion”
for an occupational perspective on
health may involve occupational therapists in revealing how service structures, such as resource allocation, job
descriptions, and program policies
can compromise occupational enablement. For example, it has been noted
that occupational therapists working
on Assertive Community Treatment
Teams have found their ability to offer
occupational interventions constrained by the priority given to generic duties focusing on illness
management (Krupa, Radloff-Gabriel,
Whippey & Kirsh, 2002). Likewise,
Townsend’s (1998) institutional
ethnography of practice in Canadian
Clubhouses found that despite good
intentions to support real occupational
opportunities, the participatory and
empowering elements of such services
can also be easily overruled by other
routine aspects of the organization of
mental health services.
With the growing interest in evidencebased program development built on
sound evaluation practices, occupational therapists are increasingly becoming involved in working with other
providers to identify or develop approaches to the evaluation of occupational changes affected by service
delivery. This may involve assisting
the team with developing program
logic models and outcome evaluations
that include a focus on demonstrating
the quality of service recipients’ occupational lives. Some occupational
therapy measures, such as the
Canadian Occupational Performance
Measure by Law, Baptiste, McColl,
Opzoomer, Polatajko, & Pollock (1994)
have the advantage of being both
client-centered and applicable to both
individual service planning and program evaluation, as further illustrated
in Kirsh and Cockburn’s article in this
issue.
Doing Daily Life
P s y c h i at r i c R e h a b i l i tat i o n J o u r n a l
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Community-Level Practice
Beyond a focus on program development, environment-level interventions
include community-level practices
which focus on identifying, understanding and addressing how communities themselves enable or hinder the
occupational patterns of people with
mental illnesses. Occupational therapists will use established community
development techniques, such as community assessments, community capacity building, the development of
partnerships and peer-support, health
promotion techniques, systems advocacy, community economic development and participatory approaches,
but the goal of these will be focused on
occupation and constructing communities and societies that are occupationally rich and just (Trentham, Cockburn
& Shim, 2007). An example of this type
of effort is the Northern Initiative for
Social Action, a consumer-driven occupational effort that creates, among
other things, economic opportunities
along with a participatory research unit
(Rebeiro, Day, Semeniuk, O’Brien, &
Wilson, 2001).
Summary/Conclusion
Psychiatric rehabilitation is obviously
compatible with the ultimate goal and
values of occupational therapy, with its
focus on “living, working, learning and
social environments” (USPRA, 2008)
lining up well with the notion of “doing
daily life” through occupational therapy’s concern with occupations related
to self-care, productivity, and leisure.
Attending to both the person and environment levels is common to both psychiatric rehabilitation and occupational
therapy.
The philosophical foundations of occupational therapy also are highly consistent with the elements of recovery
(Anthony, 1993, 2000; Davidson,
O’Connell, Tondora, Staeheli & Evans,
2005; Del Vecchio & Fricks, 2007;
Ralph, 2000; Repper & Perkins, 2003).
Contemporary professional standards
advocate for partnership-centered approaches that acknowledge individuals
served as experts of their own lives; respecting and enabling the personal
control and responsibility as central;
and therapists as bringing their occupation-related expertise to facilitating
meaningful and satisfying forms of participation of individuals and communities served. Renewing hope, moving
beyond illness to construct a new self,
expanding social roles, building social
connections, learning to manage symptoms, being a citizen and overcoming
stigma, are all elements of the recovery
process (Davidson, Sells, Sangster &
O’Connell, 2005), and are all seen as
integral to occupational engagement
(Krupa & Clark, 2004).
tant for the psychiatric rehabilitation
field to learn from all disciplines, including occupational therapy.
The development of a truly recoveryoriented system will depend on innovative cross-disciplinary collaborations
among service providers to effectively
use all of their available resources to
foster recovery.
Baum, C. & Christiansen, C. H. (2005). Personenvironment-occupation-performance: An
occupation-based framework for practice.
In C. H. Christiansen, C. Baum & J. BassHagen (Eds.), Occupational therapy:
Performance, participation and wellbeing. Thorofare, NJ: Slack Inc.
Consistent with psychiatric rehabilitation, occupational therapy has tended
to focus on assessment processes that
are highly client-centered and attend to
environmental and situational context.
In addition, occupational therapy has
contributed to the development of
standardized assessments that attend
to discrete determinants of performance in occupation, such as motor,
process and sensory performance components.
Occupational therapy is a key discipline in the field of psychiatric rehabilitation and brings to the field a strong
theoretical and knowledge base and
some unique procedures and practices.
All kinds of individuals who identify
with the practice of helping people
with mental illnesses recover have
much to offer the still young field of
psychiatric rehabilitation. It is imporarticle
160
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Terry Krupa, PhD, OT Reg. (Ont.), Associate
Professor, School of Rehabilitation Therapy,
Queen’s University, Kingston, Ontario.
Ellie Fossey, MSc, AccOT, is a Senior
Lecturer, LaTrobe University, Melbourne,
Australia.
William A. Anthony, PhD, is the Executive
Director of the Center for Psychiatric
Rehabilitation, Sargent College of Health
and Rehabilitation Sciences, Boston
University.
Catana Brown, PhD, OTR, Associate
Professor, School of Occupational Therapy,
Touro University-Nevada, Henderson, Nevada.
Deborah Pitts, MBA, OTR/L, CPRP, BCMH,
Clinical Faculty Division of Occupational
Science and Occupational Therapy, School of
Dentistry, University of Southern California.
Contact:
Terry Krupa, PhD
Associate Professor
School of Rehabilitation Therapy
Queen’s University
Kingston, Ontario K7L 3N6
CANADA
terry.krupa@queensu.ca