Linda Mathews

ASSIGNMENT TITLE:

Professional Studies Essay

Human Occupation ­ Introduction to the theory

and practice of occupational therapy

An assignment submitted in partial fulfilment of the requirements for the

MSc/Pg Diploma Occupational Therapy

DATE OF RESUBMISSION:

3rd March 2008

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The definition of the concept of quality of life (QOL) has long been debated with

contributions varying according to the different scientific disciplines, including social

sciences, psychology, geography, philosophy, health economics, advertising, medical

science, and history (Bowling 1995; Faruqhar 1995, Liddle & McKenna 2000).

Taking into account the difficulty of defining QOL (Bowling 1995) this essay will

critically discuss the suggestion that "...the experience of quality of life is not

dependent upon the quantifiable, material conditions of life but upon subjective,

qualitative factors: the content of life" (Hammell 2004, p299). Beginning with a brief

definition of the concept QOL in relation to the concept of human occupation and the

philosophy of occupational therapy (OT), it will be discussed whether quantifiable

conditions in terms of socio-economic resources and measurable physical function are

appropriate indicators for QOL. The discussion will then move towards the question

of a suitable approach to QOL measurement and explain the implications for the role

of OT.

In an attempt to define the concept of QOL, Zhan (1992) proposes an example of a

conceptual model which speaks of four measurable dimensions of QOL, namely: "life

satisfaction, self-concept, health and functioning and socio-economic factors" (Zhan

1992, p796), and suggests, in consensus with Liddle & McKenna (2000), that QOL is

both, a subjective as well as an objective concept. Niemi

et al

(1988) prefer to define

QOL as referring to "a person′s subjective wellbeing and life satisfaction", which

includes health, material well-being, interpersonal relationships", as well as "personal

development", work and recreation (Niemi

et al

, cited in Mayers 2000, p591). In

support of Hammell′s (2004) statement, many researchers emphasise that QOL is a

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matter of subjective individual perception, which in turn is influenced by the

individual′s values that are formed in relation to the individual′s cultural environment

(Liddle & McKenna 2000; Bowling 2001). The aspect of subjectivity and

multidimensionality of the concept of QOL is also supported by the definition given

by the World Health Organisation (WHO) QOL group, which states that QOL is:

"...(the) individuals′ perception of their position in life in the context of the culture

and value systems in which they live...It is a broad ranging concept..."(WHO 1997,

p3).

The view of QOL being a multi-dimensional and subjective concept (Bowling 2001)

corresponds with the philosophy of OT (Liddle & McKenna 2000), and the concept of

human occupation. The philosophy of OT is based upon a holistic view of the client

(Sumsion 2006) and on the belief that humans are occupational beings (George

et al

2001). In this context it is said that engagement in personally meaningful occupations

delivers a sense of identity, worth and purpose and facilitates health and wellbeing

(Liddle & McKenna 2000; George

et al

2001; Mee & Sumsion 2004; Brott

et al

2007).

According to Turner (2002), occupations can be described as "driven by people′s

aspirations, needs and environments", as "the fabric of `doings", "the purposeful use

of time", and as "a means through which people control the balance of their lives"

(Turner 2002, in Turner

et al

2002, p26). The named balance aspect is also seen as a

goal of OT practice, for example, the Canadian Model of Occupational Performance

(CMOP) (CAOT 2002, in Sumsion 2006), illustrates the interaction and need for

balance between the personal, the occupational, and the environmental component of

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occupational performance and aims to remind practitioners of the core of occupational

performance, which is spirituality or meaning (CAOT 2002, in Sumsion 2006).

In citing Wilcock (1998), Hasselkus (2002) points out that occupation not only

implies the "doing" of activities but also contributes to people′s "being and

becoming". In other words, `being and becoming′ are seen as "the

meaning

aspects of

occupation", which contribute to a human being′s sense of identity and ability to

comprehend life (Hasselkus 2002, p16). Wilcock (1998, cited in Hasselkus 2002, p16)

defines the term "becoming" as holding "the notions of potential and growth, of

transformation and self-actualization" and defines the role of the OT in terms of

enabling people to reach their potential for self-actualization and growth. The

transformative power of engaging in meaningful occupations is also highlighted by

Hammell (2004), who states that a traumatic life-event, such as illness or

bereavement, may be followed by a process of transition as the person begins to re-

evaluate what he or she finds meaningful in life. During this process the OT may play

a significant role in actualizing the person′s potential and thus facilitating `becoming′

(Hasselkus 2002), which can be suggested to influence a person′s sense of wellbeing

and experience of QOL.

A qualitative study with seven people diagnosed with Motor Neurone Disease

highlights the disruptive impact the disease can have on people′s ability to perform

occupations that used to give "meaning to life, expressed identity and filled time"

(Brott et al 2007, p24). The significant role of occupational performance in relation to

people′s experience of wellbeing is also pointed out by another qualitative study,

during which clients with mental health problems were interviewed after participating

in a woodwork workshop (Mee & Sumsion 2004). The authors reference Wilcock′s

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theory of "being and becoming" and suggest that engagement in occupation can serve

as a means to developing a sense of self-identity and competence, by fulfilling the

"innate need to create", and feeling "useful" (Mee & Sumsion 2004). Similarly,

Frances (2006) points out the value of using outdoor recreation as a therapeutic

medium in OT to enhance QOL in people with mental health problems, as it enables

engagement in meaningful occupations and fosters identity development, which "has

been shown to be paramount to individuals′ wellbeing" (Frances 2006, p.185).

Therefore it can be argued that engagement in meaningful occupations enhances ones′

sense of identity and individual potential for self-actualization, which are domains

that can be seen as inherently subjective and qualitative and, in favour of Hammell′s

(2004) statement, contribute to the content of ones′ life as well as ones′ sense of

wellbeing and experience of QOL.

A person′s experience of QOL as the "quantifiable, material conditions of life"

(Hammel 2004) implies the dimension of socio-economic resources, meaning

financial resources, cars and houses (Farquhar 1995), as well as objective and

measurable social indicators, such as "divorce rates" and "the number of households

with two cars" (Farquhar 1995, p1439). According to Zhan (1992), many social

scientists and social psychologists would regard socio-economic factors as significant

for the measurement of a person′s QOL, as the degree of availability of socio-

economic resources is related to psychological wellbeing, conferring "a sense of

security and self-esteem" (p799). This aspect can be viewed in relation to Maslow′s

`hierarchy of need′ (Barry 1990), which illustrates that basic physiological needs have

to be met in order to ensure and sustain a person′s health and safety and thus fulfil the

need for love, self-esteem and self-actualization (Maslow 1999). In contrast to

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Hammell′s (2004) statement it could therefore be argued that the availability of

quantifiable, material conditions of life is necessary for the experience of "subjective,

qualitative factors" (Hammell 2004) such as health, safety, love, self-esteem and self-

actualization (Maslow 1999), and thus the experience of an enhanced QOL.

However, some scientists offer a different perspective and argue that once basic needs

have been met, emotional and social needs become more prominent (Bowling 2001,

p3). In citing Michalos (1986), Bowling (2001) points out that some theorists argue

that people in more affluent societies tend to relate to QOL in terms of their

expectations and achievements, also in comparison with those of others. In line with

this, Murray & Lopez (1996, cited in Hammell 2004, p299) point out that depression

can be "considered an epidemic of the minority (developed) world", despite "what is

termed a high standard of living" (Murray & Lopez 1996, cited in Hammell 2004,

p299). Therefore it can be suggested that health, well-being and experienced QOL is

indeed not primarily a matter of sufficient "material, quantifiable conditions"

(Hammell 2004, p299) as affluence does not appear to prevent mental health

problems, but may even enhance the human need for meaning and worth.

Quantifiable conditions also include the area of physical wellbeing, which has been

defined as an objective, measurable indicator of QOL (Karnofsky & Burchenal 1949,

cited in Zhan 1992). Some outcome measures used in OT practice, such as the Barthel

Score (Mahoney and Barthel 1965, cited in Hammell 1995) or the Functional

Independence Measure (FIM) (Granger

et al

, 1986, cited in Hammell 1995) focus

solely on the client′s degree of functional ability to carry out purposeful occupations

of "self care, productivity and leisure" (Townsend

et al

1997, cited in Turner 2002,

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p63). Bergsma & Engel (1988) claim that in order to measure a person′s QOL, the

focus is often set on measuring physical function ­ an approach the authors find

problematic, as QOL "is a judgement, an unmeasurable thing." (Bergsma & Engel

1988, cited in Mayers 1995, p147).

Furthermore, it has been argued that health is a reflection of subjective and objective

dimensions of QOL (Zhan 1992), which means that a person′s sense of physical

wellbeing also depends on the person′s subjective experience, values and expectations

with regards to how health is judged. Similarly, Hammell (1995) lists 11 elements of

perceived QOL and remarks that if it is the goal of OT to enhance a person′s QOL it

would be insufficient to limit the focus of OT rehabilitation programmes to the

improvement of a person′s self care skills and degree of functional mobility. This

view clearly supports Hammell′s (2004) statement as it underlines the fact that the

experience of wellbeing and QOL is a matter of subjective experience, and also

accentuates the need for a more holistic approach in OT intervention that includes not

only the physical occupational performance component, but also the personal

meaning the person assigns to the specific activity.

Robinchaud

et al

(2006) point out that quantitative QOL studies work with

"predetermined" indicators and tend to miss out relevant themes relating to

experienced QOL, which could only be expressed in qualitative studies. In line with

this, Zhan (1992) suggests that as QOL is largely a matter of individual experience,

the use of both, objective (quantitative) and subjective (qualitative) methods of QOL

measurement are recommended. Questioning the ability and necessity of measuring

objectively all aspects of QOL Mayers (1995) recommends the use of the Lifestyle

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Questionnaire (Mayers 1993, cited in Mayers 1995), which can be used by OT′s as a

tool to identify the areas that people regard as priorities in their subjective experience

of QOL (Mayers 2000).

The emphasis on the subjectivity of QOL and the impact of occupation on QOL

appear to point towards the use of a client-centred frame of reference and/or approach

within OT practice. Liddle & McKenna (2000) highlight that the OT goal of

improving the client′s QOL ensures the therapy intervention is designed according to

the individual occupational performance needs of each client. Furthermore, in order to

gain a holistic understanding of the client (Sumsion 2006), which encompasses "the

individual′s beliefs and values, economic and cultural background, social

environment and life stage", including the client′s perception of QOL (Hammell

1995, p152), the therapist is required to engage in a respectful and non-authoritarian

partnership with the client (Hammell 1995; Parker 2002; Sumsion 2006). Following a

client-centred approach in OT practice also implies giving the client the opportunity

to make informed choices with regards to the goals of the intervention (Sumsion

2006) and to encourage the client′s sense of control and responsibility over his own

situation (Foster 2002). The client-centred approach could be described as

incorporating the "subjective, qualitative factors: the content of life" (Hammell 2004,

p299) with regards to the client′s experience of QOL and is thus also aligned with the

philosophy of OT (Liddle & McKenna 2000).

In conclusion, it can be said that QOL is a multidimensional concept, which cannot be

measured on a single quantifiable scale (Mayers 1995). In order to adequately

measure a person′s level of QOL both objective and subjective variables have to be

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taken into account (Zhan 1992; Mayers 1995). Although, there are indications that the

availability of quantifiable, material resources, as well as a measure of functional

physical ability are important for the experience of wellbeing (Zhan 1992), many

authors suggest that a sense of wellbeing largely depends on subjective factors. In

relation to human occupation, engagement in meaningful occupations has the

potential to enhance a person′s self-identity and competence (Mee & Sumsion 2004),

which are seen as factors that contribute to a sense of wellbeing (Frances 2006).

Therefore, it can be suggested that it is not so much the measurable functional ability

in carrying out purposeful occupations, but rather the subjective `meaning′ that the

individual associates with the occupations that is significant in the experience of

wellbeing and QOL.

Self-actualization and a sense of identity and purpose have been described as

important for the experience of wellbeing (Mee & Sumsion 2004; Frances 2006) and

can influence a person′s QOL. Consequently, in order to help the client to experience

an enhanced QOL, therapists need to base their practice upon a holistic understanding

of the client, which takes into account both objective and subjective aspects of the

person′s experiences of himself, his occupations and environment (CAOT 2002, in

Sumsion 2006).

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