Importance of Occupation in the Mentally Ill
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This select list of references on Occupation and mental illness is a follow-up of last week's Resource Note on Terrorism and Mental Health .  You will find a reference from 1911 that I threw in to remind us of how long occupational therapy practitioners have recognized the value of occupation.  Also, I added Christiansen's Slagle lecture, as an underpinning to the subject.

Aubin, G., Hachey, R. & Mercier, C.  (1999). Meaning of daily activities and subjective quality of life in people with severe mental illness. Scandinavian Journal of Occupational Therapy, 6(2), 53-62.                   

ABSTRACT:  The occupational therapy services for adults with severe and persistent mental illness are concerned with their quality of life.  A correlational study explored the relationship between the meaning of daily activities and the subjective quality of life of this group of people.  In this study, the meaning of activities was defined by three elements, related to the Human Occupation Model: perceived competence, value and pleasure, measured by the Occupational Questionnaire.  The Wisconsin Quality of Life-Client Questionnaire provided a global score for the subjective quality of life.  A total of 45 people with severe and persistent mental illness, living in downtown Montreal, participated in a semi-structured interview.  The results suggest that perceived competence in daily tasks and rest, and pleasure in work and rest activities are positively correlated with subjective quality of life.  The influence of occupation and its meaning on quality of life, an occupational therapy assumption, is supported by these results.  It also supports occupational therapists' interventions with these clients when aiming to help develop their sense of competence and their enjoyment in the performance of activities.

Blair, S.E.E. (2000). The centrality of occupation during life transitions. The British Journal of Occupational Therapy, 63(5), 231-237.           

ABSTRACT: This article seeks to examine the nature and experience of transitions in life.  It explores pertinent theoretical underpinning and considers the ways in which people manage and adapt to change.  In particular, it attempts to synthesize the ideas from the psychology of transition with those from occupational science.  Throughout, the article is informed by the contributions both from experiential workshops over the last 5 years (including one held at the Inaugural United Kingdom Occupational Science symposium in York in 1999) and from students who have chosen an elective level 3 module entitled 'Adult Development - Life Transitions and Crisis' in a BSc/BSc(Hons) Occupational Therapy programme. Among the conclusions from those experiences is the acknowledgement of the centrality and personal meaning of occupation at the point of transition.

Challis, T. (1996).  Purposeful Activity and Elderly Mentally Ill People: Why? (Opinion).  The British Journal of Occupational Therapy, 59(4), 183-184.

Christiansen, C.H. (1999).  Defining lives: Occupation as identity: An essay on competence, coherence, and the creation of meaning. The American Journal of Occupational Therapy, 53(6), 547-558.

Abstract:  This article presents a view of occupation as the principal means through which people develop and express their personal identities.  Based on a review of theory and research, it proposes that identity is instrumental to social life because it provides a context for deriving meaning from daily experiences and interpreting lives over time. The article proposes that identity also provides a framework for goal-setting and motivation. It is asserted that competence in the  performance of tasks and occupations contributes to identity-shaping and that the realization of an acceptable identity contributes to coherence and well-being. Within this framework, it is  postulated that performance limitations and disfigurement that sometimes result from illness or injury have identity implications that should be recognized by occupational therapy practitioners. By virtue of their expertise in daily living skills, occupational therapy practitioners are well positioned to help address the identity challenges of those whom they serve. In so doing, they make an important contribution to meaning and well-being.

Coviensky, M. & Buckley, V.C.  (1986). Day activities programming: Serving the severely impaired chronic client. Occupational Therapy in Mental Health, 6(2), 21-30.

ABSTRACT: The severely impaired chronic clients have often been viewed as treatment failures due to their severe functional limitations. A day activities program is described using an occupational model to help clients establish a health-enhancing work/play/rest balance.  Improving the quality of life is stressed. Work and recreational activities are offered within a supportive milieu environment, emphasizing consistency, concreteness, and normalization. Suggestions for future research are discussed as well as challenges of this type of programming. Occupational therapists can make a valuable contribution to the treatment of the severely impaired client through concentrating on occupation.

Crist, P.H., Davis, C.G. & Coffin, P.S. (2000).  The employment and mental health status on the balance of work, play/leisure, self-care, and rest. Occupational Therapy in Mental Health,  15(1), 27-42.

ABSTRACT: In occupational therapy, a fundamental belief is that a healthy lifestyle reflects the adapted balance between  work, play/leisure, self-care and rest activities, which promotes occupational function.  Adolph Meyer (1922) stated that our existence is structured through occupation.  The occupational balance may be disrupted when an individual experiences a mental health problem.  Mental health problems vary in terms of diagnosis, but more importantly, they vary in the amount of occupational dysfunction.  In this study, the type of environmental support needed to function with a mental health problem is an indicator of differences in abilities to perform daily activity patterns.  This study describes this balance of occupations as the temporal adaptation between two comparison groups.  The effects of gainful employment and mental health status on the activity patterns for work, play/leisure, self-care and rest are discussed in terms of hours utilized, and the perceived competence, importance, and enjoyment for these activities. 

Davis-Kosaka, A,  Kraml, D.,  Miyake, S. & Rochford, C. (1986).  Using purpose to engage the patient with depression. Occupational Therapy in Health Care, 3(1), 41-53.

Gerhardsson, C. & Jonsson, H. (1996).  Experience of therapeutic occupations in schizophrenic subjects: Clinical observations organized in terms of the flow theory.  Scandinavian Journal of Occupational Therapy, 3(4), 149-155.

ABSTRACT: Some basic assumptions in occupational therapy are that participation in occupations is necessary for human development.  Yet the relationship between health and participating in occupations is largely unexplored, and there is a need for concepts to describe this relationship.  The purpose of this study was to examine intrinsic motivation and flow experience as an effective agent in therapeutic occupations for persons with schizophrenia.  Three persons who had been psychiatric inpatients for more than 5 years participated in the study.  The Flow Questionnaire was used to identify flow experiences in their lives and observations were made of the participants performing selected activities based on their interests.  Each activity session was followed by an interview aimed to find the participant's experience of the activity.  Two of the participants managed to identify flow experiences in their lives.  During the activity sessions, flow experience was observed in all three participants.  In the following interviews this was confirmed.  The results suggest that the six elements from the Flow Theory are useful concepts for describing effective components in therapeutic occupation.  The method used here makes it possible to conceptualize what happens in therapeutic occupation

Green, S.  (1995).  Elderly mentally ill people and quality of life: Who wants activities?  The British Journal of Occupational Therapy, 58(9), 377-382.

ABSTRACT:  Purposeful activity, accepted as an important constituent of quality living by many people, has not been well researched in relation to elderly mentally ill people.  In a 43-bed nursing home in the north west of England, a small study explored initial patient, relative and staff reactions to a newly introduced part-time activity programme.  The results highlighted the importance of a flexible programme of activities, coordinated by an appointed person and providing mental stimulation for the residents.  The willingness of staff to become further involved as the programme expands suggests that additional staff training and specific time allocation would be needed.

Green, S. &   Cooper, B. A. (2000). Occupation as a quality of life constituent: A nursing home perspective. British Journal of Occupational Therapy,  63(1), 17-24. 

Abstract:  Investigated the relationship between nursing home environment and philosophy of care, daily routines, and activity provision through matrons' implementation of activities. 20 matrons of northern England nursing homes specializing in elderly or mental health care participated in semi-structured interviews. Employed models included the Quality of Life Model of B. Hughes (1990) and the Person-Environment-Occupation Model of M. Law et al (1996). Results show 4 key factors pertaining to residents' activity involvement were ability and level of motivation, and residents' control over and choice of activity. Matrons were generally caring, and wanted to provide their residents with viable activity choices. Their role was crucial in recognizing  the therapeutic value of non-traditional activities and in maximizing the use of staff and resources to enhance quality of life for residents. Flexibility and the creative use of resources exerted a greater influence on the quality of life of severely disabled residents than official policy. Occupational therapy was provided in 5 residences, on a part-time basis.

Holm, M.B., Santangelo, M.A., Fromuth, D.J., Brown, S.O. & Walter, H.  (2000).  Effectiveness of everyday occupations for changing client behaviors in a community living arrangement  The American Journal of Occupational Therapy, 54(4), 361-371.          

ABSTRACT: Objective. This study examined the effect of three occupation-based interventions for reducing the frequency  of dysfunctional behaviors (disruptive vocalizations, distraction of others, withdrawal from appropriate social interactions) in two women with dual (i.e., developmental, psychiatric) conditions.  Additionally, the duration of time spent appropriately engaged was examined.  Method.  A single-subject, multiple baseline, across-subjects design, with two dually diagnosed residents in a Community Living Arrangement (CLA), was used to evaluate change in four  behaviors under three alternating conditions.  Condition 1 was CLA (morning and evening combined) compared with the school and sheltered workshop, Condition 2 was CLA morning, and Condition 3 was CLA evening. Intervention consisted of engagement in everyday occupations associated with the school-workshop and CLA settings as well as a positive reinforcement program.  Results. Using occupations-based interventions and a behavior modification program, 5 of 6 behaviors improved significantly in the school-and-workshop setting compared to the CLA, under Condition 1.  Under Condition 2, the morning occupation-based intervention in conjunction with positive reinforcement for active participation significantly improved 4 of 6 behaviors for the two residents.  Similarly under Condition 3 - the evening occupation-based intervention-4 of the 6 targeted behaviors improved significantly.  Conclusion. The use of everyday occupations as interventions, in conjunction with positive reinforcements for active participation, was effective for decreasing dysfunctional behaviors and increasing functional behaviors in two women with dual conditions who resided in a CLA.

Kielhofner, G.,  Barris, R. &  Watts, J.H. (1982).  Habits and habit dysfunction: A clinical perspective for psychosocial occupational therapy. Occupational Therapy in Mental Health, 2(2), 1-21.

Abstract:   Systems theory and the model of occupation are used to describe a conceptualization of habit structure. Habit function and dysfunction can then be defined in terms of whether or not existing habit patterns are meeting the needs of the individual's volition subsystem and the demands of the environment. Case examples illustrate the use of this schema in classifying  psychosocial function and dysfunction.  Principles of habit formation and change for clinical intervention are presented.

Legault, E. & Rebeiro, K.L.  Occupation as means to mental health: A single-case study.  The American Journal of Occupational Therapy, 55(1), 90-96.

Lloyd, C. & Bassett, J,  (1997). Life is for living: A pre-vocational programme for young people with psychosis. Australian Occupational Therapy Journal, 44(2), 82-87.

ABSTRACT: Young persons with psychosis require programmes that specifically address their needs for meaningful activity.  The "Life is for Living" programme was developed by occupational therapists to provide a comprehensive pre-vocational programme for young persons under 25 with psychosis.  The focus of this programme was on developing links with community supports and agencies, self-development and work experience.

Mee, J. & Sumsion, T. (2001).  Mental health clients confirm the motivating power of occupation. The British Journal of Occupational Therapy,  64(3), 121-128.

ABSTRACT: Most occupational therapists, like the founders of the profession, believe that engagement in meaningful occupation is fundamental in helping to overcome the effects of disability.  This paper describes the method and one of the resulting themes of a study that investigated the value, related to personal meaning, of occupation from the perspective of people with enduring mental health problems.  Qualitative research methods were used in two mental health day service settings: a workshop, where woodwork was provided as a medium for creative therapy, and a drop-in facility.  Clients were asked about their motivation, their occupational experiences and any benefits that engagement in occupation might have had for them.  Participant observation was undertaken over 10 sessions and six in-depth interviews were conducted.  The findings emerged through content and inductive analysis, as well as analytical triangulation of the data.  Occupation was identified as a means for generating intrinsic motivation.  By providing a sense of purpose and a structuring of time, within an empowering environment, engagement in occupation was seen to be of value and had personal meaning for the clients. However, more research needs to be undertaken to augment the findings.  Such evidence will support increased provision of occupation for people whose lives have been severely disrupted by mental health problems

Moulton,  H.J.  (1996).   The impact of crime and violence on lifestyle of elderly living in mixed population housing: A pilot study. Physical & Occupational Therapy in Geriatrics, 14(1), 53-65.

ABSTRACT: Qualitative data was collected by a community-based multiservice organization to explore the impact of crime and violence on seniors.  In addition to its own private non-funded senior center, the organization sponsors two senior centers and operates four satellite programs through funding by the City of New York.  Two of the satellite centers are housed in predominantly African-American, mixed population (all ages) city housing projects in an area with a reputation for high violence and crime.  Underserving in these two particular sites has been problematic.  The directors of these sites feel the elderly living in these projects are reluctant to come out of their apartments to even attend the hot lunch programs due to fear of crime and violence.  The organization wished to gain a clearer understanding of this issue so that programs could be developed to address the needs of this population.  Seniors who agreed to share their experiences were interviewed in an effort to collect preliminary data for the development of future research.

Purdum, H.D. (1911).  The psycho-therapeutic value of occupation.  Maryland Psychiatric Quarterly, 1(2): 35-36.

Rebeiro, K.L. (1999). The labyrinth of community mental health: In search of meaningful occupation. Psychiatric Rehabilitation Journal,  23(2), 143-152.

Abstract: Mental health reform poses unique challenges for professionals who are attempting to enable meaningful occupation in the community for people who have a psychiatric disability. A qualitative research study was conducted in order to describe, from the participants' perspective, their experiences of pursuing meaningful occupation, and to identify aspects of the community environment which either enabled or constrained their participation in occupation. In-depth interviews and participant observation were the methods utilized in the research. The results of this study indicate that the community is experienced as a labyrinth of bureaucracies and services in which people with a psychiatric disability become lost.  In general, the study illustrates how the continued focus on psychiatric disability as a personal problem of the individual, rather than as a social issue within the community environment, serves to submerge the occupational needs of people with a serious mental illness and to foster ongoing dependency upon various social, economic, and health systems.  The results support the need for mental health professionals to consider the environment of the community in greater depth, and well beyond the limitations imposed by a "personal problems" approach to care.

Rebeiro, K.L.& Allen, J.  (1998). Voluntarism as occupation.  The Canadian Journal of Occupational Therapy, 65(5), 279- 285.            

ABSTRACT: An exploratory, single-case design was conducted to explore and describe the personal experience of a voluntarism occupation for one individual with schizophrenia who resides within the community.  Non-participant observation and in-depth interviewing were utilized to explore the voluntarism experience of this individual.  The findings suggest that voluntarism is both a meaningful and purposeful occupation for this individual.  Volunteering is perceived to be a valued and socially acceptable occupation, which allows for the individual to contribute to, and be a  productive member of society.  In addition, John (a pseudonym) perceived that his participation in voluntarism occupation helped him to construct a socially acceptable identity and to maintain his preferred view of himself, as a competent individual, not as a mental health consumer.   These finding suggest that participation in a voluntarism occupation may benefit some consumers of mental health services.  While these findings were based upon the experiences of one person, occupational therapists are encouraged to consider voluntarism as therapy and as a means of enabling the occupational performance of their clients.  Implications for further research are suggested.

Rebeiro K.L. &  Cook J.V. (1999). Opportunity, not prescription: an exploratory study of the experience of occupational engagement. The Canadian Journal of Occupational Therapy,  66(4), 176-187.

ABSTARCT: Occupational therapy practice is based upon the belief that the use of occupation-as-means can promote the health and sense of well-being of individuals with disability. Despite a firm commitment to the construct of occupation by the profession, little empirical evidence has been generated which supports the basic tenets of practice. In the psychosocial literature, no studies could be located which directly investigated the use of occupation-as-means to mental health. An exploratory study was conducted with eight participants of an occupation-based, women's mental health group. In-depth interviews and participant observation were utilized to explore the meaning of occupational engagement for these women. The experience of occupational engagement is presented in the form of a conceptual model named occupational spin-off. Occupational spin-off represents conceptually the experience of occupational engagement for the participants in the research study and describes a process of occupation-as-means to mental health. The processes of affirmation, confirmation, actualization, and anticipation collectively contribute to and maintain occupational spin-off. The process of occupational spin-off contributes to an understanding of why these participants have remained out of hospital, and why they are feeling better. Implications of this process model for clinical practice and future research are suggested.
Williams, J.  (2000). Effects of activity limitation and routinization on mental health. The Occupational Therapy Journal of Research, 20(Supplement), 100s-105s.
 
ABSTARCT: Habit was measured as a trait of routinization in a sample of 72 older people selected as participants in a study of major life stressors and mental health. The relationship between routinization and psychological distress was assessed by tests of main effects and interactions of one component of routinization (disliking disruption in daily activity), activity limitation and perceived health, and recent stressful life events. Both sets of multiple regression tests of these variables showed significant triple interactions qualifying the significant main effects. The interactions complemented one another, revealing that less routinized participants reported greater distress when experiencing ill health and higher levels of negative events. These effects did not appear for the more highly routinized participants, however. The latter group showed high levels of distress regardless of their activity limitation or perceived health. The results suggest that routinization (in the form of disliking disruption in daily living) is associated with distress beyond the effects of major life stressors.

Wing J.K. & Furlong R. (1986). A haven for the severely disabled within the context of a comprehensive psychiatric community service.  The British Journal of Psychiatry, 149, 449-457.

The priorities accorded severely disabled or disturbed long-stay patients in Regional and District planning strategies vary enormously. A scheme to cater for the needs of this group is described. The scheme includes: non-stigmatising housing; a domestic regime, daytime occupation and leisure activities offering forms of enabling and caring that foster the highest possible levels of functioning; a secure home; private and peaceful outdoor space; and graduated steps towards independence that allow for the possibility of relapse. The central concept is the establishment of a Community for people with severe difficulties in making social contacts. The importance of integrating the scheme into a comprehensive District psychiatric service is emphasized.