The Meaning of Work

 

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     Occupational therapy is founded on the belief that participation in meaningful activities is beneficial to health and well-being. Some of the health-promoting effects associated with participation in occupation-based mental health services and in meaningful activities include improved perspective on quality of life, a sense of well-being, improved confidence and self-esteem, decreased use of crisis services and hospitalizations, and improved socioeconomic status (Gewurtz & Hirsh, 2006). While occupational therapy encompasses far more than engagement in paid employment, participation in work and related activities is recognized as contributing to the well-being and recovery of individuals labeled with serious mental illness, while the absence of engagement in meaningful work is associated with decreased signs of health and well-being for this population. The following serves to illustrate the perspective of individuals labeled with serious mental illness on the meaning of work, highlights the health benefits associated with participation in work, and enhances understanding of how occupational therapists can support the recovery process through supporting employment goals.

     A meta-analysis of qualitative studies on the perspectives of individuals labeled with serious mental illness found that this population identified many benefits of being employed, including “greater autonomy, status and acceptance within society, structured use of time, a sense of purpose or focus, feeling productive and useful to others, affirmation of ability, and opportunities for social contact and personal development (Fossey & Harvey, 2010, p.308). The perspectives of individuals labeled with serious mental illness in these studies further spoke to the meaning associated with work, including creating a sense of wellness, improved relationships, and greater optimism, which were also seen as helpful in sustaining employment throughout the process of recovery.

       A study by Eklund, Hansson, and Bejerholm (2001) explored relationships between health-related variables and satisfaction with daily activities in 74 adults labeled with schizophrenia. This study found a significant positive correlation between satisfaction with employment status and global well-being, and it was found that employed individuals were more satisfied with their overall daily activities. Employed individuals in this study were also rated significantly better by interviewers on global quality of life, internal locus of control, and psychosocial functioning.

 

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     Another study explored the importance of work as compared to other types of activities with 105 individuals who were separated into three groups: those who were participating in competitive work or formal schooling, those who participated in structured activities other than work or school, and those who did not participate in any structured activities (Eklund, Hansson, & Ahlqvist, 2004). Results supported previous findings that individuals who were engaged in competitive work or school displayed better psychosocial functioning and reported significantly better satisfaction with daily activities than the other two groups. Of note, there was no significant difference in satisfaction with daily activities between the group of individuals who participated in structured activities besides work and the group who did not participate in any structured activities, indicating that there is a characteristic of work that contributes to a greater sense of well-being than participation in other types of activities.

     Gewurtz and Kirsh (2006) noted that “there was something about working that encouraged participants and transformed them from being a person with a mental illness to being a productive member of society” (p.6). This study explored the constructs of doing and becoming as related to participation in work for individuals labeled with serious mental illness and described participants’ experiences with work while illustrating the meaning that work brought to participants’ present lives and their futures. Through interviews, researchers found that doing work provided opportunities [for participants] to connect with others, improve their economic situations, and motivated them to manage their illness to ensure their ongoing ability to follow through with their commitments at work” (p.6). Participants also described how reflecting on their experiences of work led to self-discovery of individual skills and limitations and the ability to imagine a future for themselves as workers. On the other hand, “some of the stories recounted in the interviews suggested that the absence of doing [work] was a state filled with hopelessness in which a possible future was unimaginable” (p.10).

 

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A study that further explored the differences in perspectives and experiences between individuals labeled with serious mental illness who were employed and those who were not found that, like the employed participants in the previous study, the employed individuals in this study talked about being actively engaged in improving and maintaining their health, which indicates that they perceived themselves as in a state of health (Woodside, Scholl, & Allison-Hedges, 2006) . Contrary to this perspective, the individuals in this study who were not employed held the perspective that their symptoms of mental illness were a barrier to obtaining work and they questioned the effectiveness of their medical treatment, indicating that these individuals perceived themselves as not in a state of health (Woodside et al., 2006). It is important to note, however, that both groups of individuals, employed and unemployed, valued feeling comfortable with people at work, which supports the findings in other studies that work provides opportunities for social participation.

      From the perspectives of individuals labeled with serious mental illness, participation in work is associated with increased satisfaction with daily activities, improved sense of self, better health and well-being, and feelings of hope for the future. Participation in work is associated with better functioning and provides opportunities for meaningful social interactions, personal growth, and improved socioeconomic status, while lack of participation in work is associated with hopelessness, lower satisfaction with daily activities, and decreased overall health and well-being.

     Occupational therapists can support individuals labeled with mental illness throughout the recovery process, both in helping individuals to obtain jobs and to sustain employment. The participants in the study by Gewurtz and Kirsh (2006) brought to attention the importance of having someone who “believed in them, encouraged them, or expected that they could do more” (p.8) and participants in other studies have emphasized valuing strong collaborative relationships in which a sense of optimism, interest, and encouragement in pursuit of employment goals (Fossey & Harvey, 2010). Occupational therapy’s client-centered approach in empowering individuals to do the things they want to do affords a natural fit to the purpose of supporting individuals in believing in their capacity to work.

 

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   Occupational therapists can also support individuals in navigating employment support systems, developing strategies to manage the stress of job seeking, developing self-advocacy skills, and reflecting on the characteristics of various employment settings to ensure a good fit between the individual and the job. Participation in paid work is meaningful and contributes to recovery in a variety of ways, and through bolstering efforts to obtain and maintain employment, occupational therapists can support individuals labeled with serious mental illness in realizing their full potential as positively contributing members of society.

Sharon Vincuilla, OTR/L

Occupational Therapy Doctoral Resident

PaintedBrain.org

References

Eklund, M., Hansson, L., & Ahlqvist, C. (2004). The importance of work as compared to other forms of daily occupations for wellbeing and functioning among persons with long-term mental illness. Community Mental Health Journal, 40(5): 465-477.

Eklund, M., Hansson, L., & Bejerholm, U. (2001). Relationships between satisfaction with occupational factors and health-related variables in schizophrenia outpatients. Social Psychiatry and Psychiatric Epidemiology, 36, 79-85.

Fossey, E. M. & Harvey, C. A. (2010). Finding and sustaining employment: A qualitative meta-synthesis of mental health consumer views. Canadian Journal of Occupational Therapy, 77, 303-314. Doi: 10.2182/cjot.2010.77.5.6

Gewurtz, R. & Kirsh, B. (2006). How consumers of mental health services come to understand their potential for work: Doing and becoming revisited. The Canadian Journal of Occupational Therapy, 73(4 suppl.): 1-13. https://doi.org/10.2182/cjot.06.014

Woodside, H., Scholl, L., & Allison-Hedges, J. (2006). Listening for recovery: The vocational success of people living with mental illness. The Canadian Journal of Occupational Therapy, 73(1): 36-43. Doi: 10.2182/cjot.05.0012.

Volition: Occupational Therapy’s Unique Understanding of the Human Motivation for Action

occupational therapy mental health
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).

schizophrenia mental illness

     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).

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        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

PaintedBrain.org

References

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.

Buchanan, R. W. (2007). Persistent negative symptoms in schizophrenia: An overview. Schizophrenia Bulletin. 33(4): 1013-1022. doi:10.1093/schbul/sbl057

Deegan, P. (1988). Recovery: the lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4): 11-19.

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

Kielhofner, G. (2008). Model of human occupation: Theory and application, 4th edition. Baltimore, MD: Lippincott Williams & Wilkins.