Occupational therapy as a health profession is concerned with the ability of individuals to optimally perform activities that they want to do, need to do, or are expected to do by others. The Model of Human Occupation, a theoretical frame of reference that guides the practice of many occupational therapists, describes humans as possessing a “complex nervous system that gives them an intense and pervasive need to act…a body capable of action” and “an awareness of their potential for doing things” (Kielhofner, 2008, p.12). These human qualities combine to result in an innate desire for action, a motivation for occupational engagement, known as volition. Volition is comprised of three components: personal causation, the belief in one’s ability to act effectively; values, personal beliefs that give meaning to activities; and interests, individual preferences based on enjoyment of experiences (de las Heras, Llerena, & Kielhofner, 2003), and thus depends on how one views the self and to what situations one is attracted.
Volition, however, does not exist as a fixed quality, but rather “is an ongoing process wherein one experiences occupations, interprets the experience through the process of reflection, anticipates further experiences based on this reflection and learning, and finally chooses activities and occupations based on the experience anticipated” (de las Heras et al., 2003, p.8). An individual with high volitional capacity views the self as being effective in his or her actions due to having experienced success; has the ability to reflect on his or her actions and find meaning; reflects hopefulness that future actions will also be successful; and exists in an environment that presents opportunities for making choices about future actions
Schizophrenia is a mental illness characterized by positive symptoms or alterations in thoughts, beliefs, and sensory perceptions; and negative symptoms, which refers to diminished emotional expression and decreased motivation for self-initiated purposeful activities (APA, 2013). Emil Kraepelin, a German psychiatrist at the turn of the 20th century, described negative symptoms as avolitional syndrome, a ‘’weakening of those emotional activities which permanently form the mainsprings of volition,’’ and resulting in ‘‘loss of mastery over volition, of endeavor, and of ability for independent action,’’ (Buchanan, 2007, p.1013).
Negative symptoms, more than positive symptoms, pose a greater risk for poor functional outcomes and long-term morbidity for individuals labeled with schizophrenia (Buchanan, 2007; Foussias, Mann, Zakzanis, van Reekum, & Remington, 2009). A study on the relationship between occupational engagement, symptoms of schizophrenia, and personal factors found that “those who had a low level of engagement exhibited little sense of coherence; external locus of control; low ratings of mastery; and more negative, positive, and general psychiatric symptoms” (Bejerholm & Eklund, 2007, p.26). The underlying reason for this may be related to difficulties in perceiving reality, which affects a person’s sense of self, and challenges in cognitive functioning that impact the ability to interpret and make sense of experiences, which disrupts the reflective stage that is integral to the volitional process (Bejerholm & Eklund, 2007).
Patricia Deegan (1988), an esteemed psychologist and person labeled with schizophrenia, describes her experience during the early days of her recovery:
For months I sat in a chair in my family’s living room, smoking cigarettes and waiting until it was 8:00 p.m. so I could go back to bed. At this time even the simplest of tasks were overwhelming. I remember being asked to come into the kitchen to help knead some bread dough. I got up, went into the kitchen, and looked at the dough for what seemed an eternity. Then I walked back to my chair and wept. The task seemed overwhelming to me. Later I learned the reason for this: when one lives without hope, (when one has given up) the willingness to “do” is paralyzed as well (p.13).
Deegan’s experience with schizophrenia began in young adulthood and disrupted her life story in a way that she perceived as a “catastrophic shattering of [her] world, hopes, and dreams” (Deegan, 1988, p.12). Deegan (1988) describes having recently applied to college and having made plans for becoming a teacher when her diagnosis was presented as an “incurable malady” that would cause her to “be ‘sick’ or ‘disabled’ for the rest of [her life]” (p.12). This diagnosis of mental illness changed Deegan’s sense of personal causation as her belief that she could be effective was devastated by being told she had a chronic disabling condition. When the individual loses belief in her ability to be effective, and experiences disruptions in the experience of doing, the cyclical nature of the volitional process is interrupted and the resulting inertia “paralyzes the will to do and to accomplish because there is no hope” (Deegan, 1988, p.13).
It is then the charge of the occupational therapist to rekindle a sense of hope, such that the individual can transition from inertia to involvement in daily life. Remarkably, “involvement in daily life has been shown to reduce negative symptoms in persons with schizophrenia” (Bejerholm & Eklund, 2007, p.22), while no other traditional treatments have been effective in addressing these symptoms. Occupational therapists, as health professionals who hold expertise in the complexities of engagement in everyday living and the underlying motivation to act, are an integral component of mental health services. Occupational therapists can support the capacity of individuals labeled with mental illness in performing activities that they want, need, and are expected to do, such that they can realize their full potential as positively contributing members of society.
Sharon Vincuilla, OTR/L
Occupational Therapy Doctoral Resident
American Psychiatric Association (APA) (2013). Diagnostic and statistical manual of mental disorders, 5th edition. Arlington, VA: American Psychiatric Association. Retrieved from https://dsm-psychiatryonline-org.libproxy1.usc.edu/doi/full/10.1176/appi.books.9780890425596.dsm02
Bejerholm, U. & Eklund. M. (2007). Occupational engagement in persons with schizophrenia: Relationships to self-related variables, psychopathology, and quality of life. American Journal of Occupational Therapy, 61, 21-32.
de las Heras, C. G., Llerena, V., & Kielhofner, G. (2003). A user’s manual for remotivation process: Progressive intervention for individuals with severe volitional challenges. Chicago, IL: Model of Human Occupation Clearinghouse.
Foussias, G., Mann, S., Zakzanis, K. K., van Reekum, R., & Remington, G. (2009). Motivational deficits as the central link to functioning in schizophrenia: A pilot study. Schizophrenia Research, 115(2009): 333-337. doi:10.1016/j.schres.2009.09.020