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    CANADIAN JOURNAL OF OCCUPATIONAL THERAPYVOLUME 63 NO 1

    BONNIE KIRSH

    KEY WORDSOccupational therapy

    in psychiatrySpiritualityValues clarification

    A narrative approach toaddressing spirituality inoccupational therapy: Exploringpersona meaning and purpose

    Bonnie Kirsh, M.Ed., B.Sc. 0.T.) s aTutor in the Department of Occu-pational Therapy, University ofToronto, 256 McCaul St., Toronto,ON. M5T 1W5.

    ABSTRACT pirituality has been recognized and documented as essential component to be included by the occupational therapy professiin client-centred service delivery. However, methods of addressing aenhancing spirituality in occupational therapy practice remain relativeunexplored within the profession. This paper discusses the benefits onarrative approach in addressing spirituality in everyday practice.explores narrative as a mode of expression, its relationship to occupationtherapy and its usefulness in addressing the spiritual component of tindividual. A case study is provided to illustrate how a narrative approaenables an understanding of meaning and purpose in one's life.

    RSUM l est reconnu et do cum ent que la spiritualit constitun lmen t essentiel de l 'ergothrapie dans la prestation des soins c entrsur le client. Il semble toutefois que les mthodes pour tenir co mp te de spiritualit et la mettre en valeur dans la pratique de l'ergothrapidem eurent relativement inexp lores au sein de la profession. Cet article fatat des aspects posit ifs d 'une approche narrative p our tenir com pte de spiritualit dans la pratique quotidienne. Cette appro che ex plore la narrtion com me mo de d'expression, sa relation avec l 'ergothrapie et son utiit pour aborder la com posante spirituelle de la personne. Une tude de cavient illustrer comment rapproche narrative permet une comprhensiode la signification et de la finalit de sa propre vie.

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    Spirituality has been recognized as an essentialcomponent of the individual within the model ofoccupational performance (Canadian Associationof Occupational Therapists (CAOT), 1991). Assuch, efforts to clarify spirituality as a term and aconcept have been undertaken (Egan Bz D eLaat,1994; Urbanowski tk Vargo, 1994) and occupa-tional therapists have articulated their viewsaround ways in which the spiritual componentinfluences occupational performance (Townsend,Krefting Burwash, 1991). However, methodsof integrating this performance component intodaily practice remain elusive, largely due to ourlimited knowledge in this area as well as a lack ofclarity around methods to assess and address spir-itual health. This paper will discuss the use ofnarrative approaches in occupational therapy toaddress the spiritual component of the individ-ual, that is, to facilitate the exploration of mean-ing and purpose in one's life.

    Narratives are fundamental and universal ways ofinterpretation in which humans make sense oftheir life experience through stories andmetaphors (Spencer, 1993, p.120). The cognitivepsychologist Bruner (1990) describes humannature as deriving meaning through story: ourcapacity to render experience in terms of narra-tive is an instrument for making meaning thatdominates much of life in culture - from solilo-quies at bedtime to the weighing of testimony inour legal system... our sense of the normative isnourished in narrative but so is our sense ofbreach and exception. Stories make reality a mit-igated reality (p.97). Narrative recreates experi-ence through the eyes of the experienced, andbrings with it the richness of personal and socialhistory. It tells not only of past actions and eventsbut how individuals understand those actions,that is, meaning. Individual realities are createdbased on subjective experiences of the objective,and narrative structures provide a format intowhich experienced events can be cast in anattempt to make them comprehensible, memo-rable, and shareable (Olson, 1990, p.100). The

    creation of individual narratives represents a pri-mary means by which individuals make sense oftheir experiences.

    NARRATIVES AND OCCUPATIONALTHERAPYRecently, interest in eliciting stories from clientsaround the experience of illness and disability hasgrown in the health professions (Coles, 1989;Kleinman, 1988). Although occupational thera-pists have always drawn informally on clients'personal stories to develop goals and plan inter-vention strategies, the profession is now recog-nizing and utilizing narrative in a more formalway. The consistency of this approach with occu-pational therapy philosophy and values makes itan appealing choice. Eliciting narratives, or facil-itating the emplotment o one's life, is a n approachdirected at the individual as a whole - his or herfeelings, thoughts, perceptions and beliefs -rather than the pathology itself. It places the nar-rator or client at the centre of the process,empowering him or her to voice himself or her-self as he or she chooses. Narrative as a cognitivescheme is actively used to organize and interpreta person's encounter with the environment; itpresents an awareness of a world in which humanactions are linked together according to theireffect on the attainment of individual desires andgoals (Polkinghorne, 1988). As such, the narra-tive approach embodies the values and principlesupon which our profession is built: holism,client-centredness, and the significance of per-son-environment interaction.

    Some documentation of narrative as aform of hermeneutic expression in which humanaction is understood and made meaningful canbe found in the occupational therapy literature,though it is written primarily from the point ofview of finding meaning in the therapeuticencounter itself. Hasselkus and Dickie (1994)elicited experiential narratives from practisingoccupational therapists to derive dimensions ofthe lived experience of doing occupational thera-py. Helfrich, Kielhofner and Mattingly (1994)illustrated how volition is embedded in personal

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    narratives, explaining that motivation to chooseand act results from the context and meaninguncovered. Helfrich and Kielhofner (1994)examined life experiences as they impact on themeaning derived from therapy and advised:c'occupational therapy can only transform lives ifpatients see meaning and relevance to their ownlife stories. The task of occupational therapy is tobecome an episode in the patient's narrative(p.324). Mattingly (1991), inher article on clin-ical reasoning, echoed this theme as she stated:the therapist and patient must come to share astory about the therapeutic process: they mustcome to see themselves as in the same story...anas yet unfinished story (p.1002). Accounts ofemploying narrative approaches for therapeuticpurposes are limited in the occupational therapyliterature, although some research around thetherapeutic value of life review does exist. Forexample, Froehlich and Nelson (1986) studiedthe affective meanings of l i fe review in a geriatricpopulation and reported that expression of posi-tive life events appeared to be a positive experi-ence for elderly individuals. McQuaig and Frank(1991) described a narrative process in whichmeaning was attributed by a woman with cere-bral palsy to her own personal competencethrough a series of interviews. This kind of trans-formative process is evidenced in Murphy's(1990) account of his own experience with dis-ability and the value of continued engagement inwork in maintaining a sense of meaning in hislife. It is this emphasis on discovering personalmeaning and purpose in life through narrativethat holds promise for the practice of occupa-tional therapy.

    NARRATIVE AND SPIRITU LITYThe Occupational Therapy Guidelines for

    Client-Centred Practice (CAOT, 1991) state thatt a s spiritual beings, individuals are concernedwith the nature, the meaning of life and theirpurpose and place in the universe (p.18).Subsequent Occupational Therapy Guidelines ForClient-Centred Mental Health Practice (CAOT,1993) describe spirituality as a critical element

    underpinning occupational therapy interventioand acknowledge that clients' personal knowedge and experience of living with disabilienables them to seek personal meaning and pupose (a personal sense of spirituality) (p.6). Egaand DeL aat (1994) define the spirit as our trueselves which we attempt to express in all of ouactions (p.96) and suggest that each individualspirit is expressed through engagement in everday life, that is, through occupational performance in self-care, productivity and leisurSimilarly, Urbanowski and Vargo (1994) definspirituality as the experience of meaning in everyday life activities (a here-and-now event) ancarefully distinguish this definition from tmeaning of life which, they state, is a level philosophical reflection which escapes the conscious awareness of most people. It is argued ithis paper, however, that reflection upon onelife, the path it has taken, and the road ahead an important process in meaning-making, anthe basis for a narrative approach to addressinspirituality in occupational therapy. As stated bMuldoon and King (1991): Every human beinhas a spirituality. The direction one gives to onelife, the story one tells with one's life, is itserooted in and embodies a certain way of lookinat life (pp.100-101). Through stories wattempt to clarify and understand what life iabout; we try to make sense out of life, in thsame way we try to make sense of a text when winterpret it.Drawing on previously cited conceparound spirituality which emphasize personameaning and purpose as core issues in defininthe term, the appropriateness of utilizing narrative approaches to enhance the spiritual component of the individual emerges. The power narrative in the search for personal meaning anpurpose is stated by Polkinghorne (1988Through the action of emplotment, the narrtive form constitutes human reality into wholesmanifests human values, and bestows meaninon life (p.159). The meaningfulness and sensepurpose of one's life can be reflected in one's narative identity: the unity of a person's life is exp

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    rienced and articulated in stories that express thisexperience (Widdershoven, 1993). Spiritualenrichment may oc cur through narrative as o neframes and reframes act ions and events and ret-rospectively revises, selects and orders past detailsin order to justify and find purpose in one's cur-rent life situation. Furthermore, this process mayhelp individuals in the construction of future sto-ries, projecting hopefulness and a sense of pur-pose to their futures. As stated by Polkinghorne(1988), If a person fails to project a hopefulstory about the future, he or she undergoes a cer-tain kind of unhappiness, a life without hope ...there needs to be som e co ntinuity between pastand future stories ... as narrative forms, these sto-ries draw together and configure the events ofone s life into a coherent and basictheme (p.107).

    METHOOcc upational therapists are, for the most part,highly skilled in eliciting historical and contextu-al information about a person's life. Interviews,observation, reports from significant others andrelated activities have held a prominent place inthe ongoing assessment and information-gather-ing stage of the occupational therapy process.The purpose of these activities has been to gainhistorical information to be used in planning andimplem enting appropriate occupational therapyprogramm es. In most cases, the emp hasis is onreliability of inform ation, observable behaviourand consistency between the clients ' and others'perspectives. However, a narrative approach tolooking at one's life deals with the issue of truthdifferently. Narrative analysts take the positionthat narrative constitutes reality: it is in thetelling that one makes real phenomena in thestream of co nsciousness (Young, 1 987). As statedby the Personal Narratives Group (1989):When talking about their lives, people lie

    sometimes, forget a lot, exaggerate, becom econfused, and get things wrong. Yet they arerevealing truths. These truths don't revealthe past as it actually was, aspiring to a stan-dard of objectivity. They give us instead the

    truths of our experiences...Unlike the truthof the scientific ideal, the truths of personalnarratives are neither open to proof nor self-evident. We com e to understand them onlythrough interpretation, paying carefulattention to the contexts that shape theircreation and to the wo rld views that informthem (p.261).Narratives are dynamiC, ever-changingreconstructions of life which are themselves theproducts of psychological, sociological and his-

    torical influence. The life story itself is seen as asocial construct in its own right.This view of truth as a concept separatefrom that defined by formal science, impactsupon methods employed to facilitate spiritualexploration through narrative as well as the rela-tionship between the therapist and the narrator.Narrators do not simply reproduce prefabricatedstories regardless of the interactional situation,but rather create their stories within the socialprocess of mutual orientation (Rosenthal, 1993 ,p.64) according to their perception of the inter-view situation. The narrativ e presentation is, inpart, a p roduc t of the interaction between thera-pist and client. The adoption, on the part of thetherapist, of a role of one who interacts withclients to understand their social constructions, i sconsistent with the view of reality as an ever-changing, socially constructed phenomenon.Unlike a traditional information-gathering ses-sion, the therapist will not be following a specif-ic interview format nor seeking out predeter-m ined categories. Interviews should be discov-ery-oriented (Van Ma nen, 1990, p.29), that is,they should attempt to reveal the experiences andmeanings attached to the world they explore.The therapist must be open to the unexpected,and must listen carefully, giving the narrator orclient scope to develop his or her train ofthought. Freedom to pursue topics of his or herchoice may foster the process by which a clientconstructs an identity and makes meaningthrough his or her stories. Material which may, atthe time, seem to be disconnected or irrelevantmay connect with the broader picture as the story

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    One night I was at an exam and I couldn'tconcentrate...I talked to the teacher and Itold her some of the problems I wasencountering, she said maybe we should goover to the hospital and get some help. Shestayed with me for nearly two hours in theemergency room while the doctors inter-viewed me and realized that I needed help. Iwas away from home and I was admittedthat night and I began my treatment forschizophrenia.

    In constructing his story and developinhis own personal identity Don explores the mancharacter roles he has fulfilled, one of which that of patient. It is a part of his history, and hframes it as such. He is able to do so, as it nohas its place as a piece of this single unfoldinand developing story. As stated by Sarbin (1986one may play different characters which givtemporary periods of identity during one's lispan. But these various roles - the precious chilthe good student, the fast tracker, and so on -take on meaning from the single perspective this one person, as defined by the life plot (p.17Hence we see Don's ability to use the chapterwhich his character is one of patient as a placfrom which to construct a subsequent chaptdescribing his character as worker, thereby defining further his own self and the meaning to hlife.When I got a job, I told the interviewerthen that I had a mental health problem, Itold him up front, and he said,look, as long

    as I know that you're getting treatment we'llgive it a shot...[work] occupies my time, itfocuses my mind on other things besides myillness, the thoughts that disturb the way Ithink are not as prevalent when I'm workingas when I'm unemployed... when I'm work-ing I'm in a structured environment, I amcontributing to society, I feel I'm doingsomething good not only for myself but forsociety as a whole...the job provides struc-ture to my day. It makes m e feel as if I'mimportant. I'm not just another statistic. I'mdoing something productive with my life.

    unfolds or as further reflection takes place. To theclient, such accounts may help to fit the piecestogether, to draw conclusions, and to give conti-nuity to the story so that it remains a compre-hensible whole. Hankiss (1981), a researcher whouses the life history approach in gathering data,describes this process: Human memory selects,emphasizes, rearranges and gives new colour toeverything that happened in reality; and, moreimportant, it endows certain fundamentalepisodes with symbolic meaning, often turningthem almost into myths, by locating them at afocal point of the explanatory system of the selfp.203).

    CAS STU DYDon (not his real name) is a 29 year old male,who has been involved in the mental health sys-tem for a period of ten years and who is workingfull time as a mail clerk for a large corporation.He regularly attends a community mental healthprogramme during his non-working hours andsees his psychiatrist monthly. During a lengthysession, Don told his story using a plot that con-sisted of several chapters and themes.Don's story begins at a critical time in hislife, a series of chapters describing his entry intomental illness, his changing self-perceptions, andthe subsequent struggles in his life.

    I was at university studying to be an accoun-tant, and a simple balance sheet was nolonger easy for me to do ... I had 90s goinginto university in accounting and I won astock market championship held across theprovince and my research skills were highabove anyone else at school and when Icame to university I couldn't even get a Caverage in my best subject, I became veryangry and frustrated. And instead of beingable to hit the books basically I started read-ing books on mental illness, wonderingwhat was wrong.Having set the scene, Don identifies the

    day, in fact the moment at which his identity andlife course changed:

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    It is this theme of productivity and selfefficacy that now pervades Don's reality. Carr(1985) tells us that narration is an extension andconfirm ation of the primary features of one's real-ity. He notes that everything that happens to aperson is part of his or her life; however in one'sself-stories the extraneous details are pushed intothe background through the capac ity of selection:In planning our days and our lives we are com-posing the stories or the dramas we will act outand which will determine the focus of our atten-tion and our endeavours, which will provide the

    principles for distinguishing foreground frombackground (p.117). Clearly, in telling his story,Don does not deny his status as a person with amajor mental illness, but carefully places it in thebackground, allowing other roles and capabilitiesto flourish:It's not hard for people to see that I have aphysical disability. It's harder for them toknow I have a mental disability, because it'snot as apparent...But peo ple respect me...it'snothing to be ashamed of to say you sufferfrom a mental health problem.. .peopleknow who I am and they know I put in anhonest day's work and people, not just the

    average employee but the people at the top,actually care about me. I can honestly saythat my firm has gone the extra mile for meand I continue to go the extra mile forthem...The narrative approach within psycholo-gy is often seen as a process of redefinition(Widdershoven, 1993). Through his narrative,D o n is able to redefine his own identity from one

    in need of help to one who helps others:My mother was dying of lung cancer and soI bought a car to get her to and from thehospital for chemotherapy...the increasedsalary led to being able to do things for myMom and Dad who had done literally mil-lions of things for me before...it felt verygood. My Mom was dying and here was I,her son, making the effort to help her whenshe needed it most.

    Through the narrative process Don wasable to realize how his acts of kindness broughtmeaning, a sense of purpose and fulfilment to hislife, resulting in a deepened sense of spiritualityand a strengthened identity as a productive andhumane individual.

    The process of emplotting his life enabledDon to configure the events of his life into a storywith themes around productivity, humanity, per-sonal efficacy and identity as a person other thana patient. He was able to connect with the mean-ing and purpose in his life, to enhance his ownspiritual self so that he experienced a sense of self-actualization and hope for the future.

    CONCLUSIONThis paper has discussed the use of narra-

    tive in occupational therapy as a method ofaddressing meaning and purpose in one's life,thereby exploring one's spiritual self The essenceand identity of one's self can be achieved throughnarrative, as can the process of realizing the pos-siblities in one's life. Meaning and purpose inone's life are linked to a person's life story, whichconnects up the actions into an integrating plot.The realization of self as a narrative in processserves to gather together what one has been, inorder to imagine what one will be, and to judgewhether this is what one wants to become(Polkinghorne, 1988, p.154) It is a methodwhich holds prom ise for the practice of occupa-tional therapy, as the profession embarks uponunderstanding and enhancing spiritualityamongst its clients.

    REFEREN ESBruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard

    University Press.Canadian Association of Occupational Therapists. (1991).Occupational therapy guidelines for client-centred practi ce.Toronto, ON: CA OT Publicat ions.Canadian Association of Occupational Therapists. (1993).Occupational therapy guidelines for client-centred mentalhealth practice. Toronto, ON: CAOT Publications.

    Carr, D. (1985). Life and the narrator's art. In J. Silverm an, &D. Idhe. (Eds.). Hermeneutics and Deconstruction. (pp.108-121). Albany, NY: State University of New York Press.

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    Coles, R. (1989). The call of stories. Cambridge, MA : HarvardUniversity Press.Egan, M., DeLaat, M.D. (1994). Considering spirituality inoccupational therapy practice. Canadian Journal of

    Occupational Therapy 61, 95-101.Froehlich, J., & Nelson, D .L. (1986 ). Affective meanings of lifereview through activities and discussion. American Journalof Occupational The rapy, 40, 27-33.Hankiss, A. (1981). Ontologies of the self: On the mythologicalrearranging of one's life history. In D. Bertaux (Ed)Biography and society. (pp.200-205). Beverly Hills,CA:Sage.Hasselkus, B.R., & Dickie, VA. (1994). Doing occupationaltherapy: Dimensions of satisfaction and dissatisfaction.American Journalof Occupational The rapy, 48, 145-154.Helfrich, C., & Kielhofner, G. (1994). Volitional narratives andthe meaning of therapy. merican Journal of OccupationalTherapy, 48, 319-326.Helfrich, C., Kielhofner, G., & Mattingly, C. (1994). Vo lition asnarrative: Understanding motivation in chronic illness.

    American Journalof Occupational Therapy 48, 311-317.Kleinman, A. (1988). The illness narratives: Suffering, healing andthe human condition. New York: Basic.Mattingly, C. (1991). The narrative nature of clinical reasoning.American Journalof Occupational The rapy, 45, 998-1005.McQuaig, M., & Frank, G. (1991). The able self: Adaptive pat-terns and choices in independent living for a person withcerebral palsy. American Journal of Occupational The rapy,45, 224-234.

    Muldoon, M.H., King, J.N. (1991). A spirituality for the longhaul: Response to chron ic illness. Journal of Religion andHealth , 30, 99-108.

    Murph y, R. (1990). The body silent. New Y ork: Norton.Olson, D .R. (1990). Thinking about narrative. In B.K. Britton &A.D. Pellegrini (Eds.), Narrative thought and narrative lan

    guage. (pp.99-112). Hillsdale, NJ:Erlbaum.Personal Narratives Group. (1989). Truths. In Personal NarrativGroup (Eds.), Interpreting women s lives: Feminist theory apersonal narratives.(pp. 261-264). IN: Indiana UniversiPress.

    Polkinghorne, D. (1988). Narrative knowing and the human sences. Albany, NY: State University of New York Press.

    Rosenthal, G. (1993). Reconstruction of life stories: Principlesselection in generating stories for narrative biographicreviews. In R. Josselson, & A. Lieblich (Eds.). The narratstudy of lives. (pp.59-91). Newbury Park, CA: Sage.Sarbin, T. (1986 ). The narrative as a root metapho r for psychoogy. In T. Sarbin (Ed.). Narrative psychology. New YorPraeger.Spencer, J.C. (1993). The usefulness of qualitative methods rehabilitation: Issues of meaning, of context, and change. Archives of Physical Medicine and Rehabili tat io74, 119-126.

    Townsend, E., Krefting, L., & Burwash, S. (1991). Guidelinimpact study interview and survey Halifax, NS: SchoolOcc upational Therapy, Dalhousie University.Urbanowski, R., 8c Vargo, J. (1994). Spirituality, daily practicand the occupat ional performance model. CanadiJournalof Occupational The rapy, 61, 88-94.Van Manen, M. (1990). Researching lived experience. LondoON:The A lthouse Press.

    Widdershoven, G. (1993). The story of life: Hermeneutic pespectives on the relationship between narrative and life hitory. In R. Josselson, & A. L ieblich, (Eds.). The narratstudy of lives.(pp. 1-20). Newbury Park, CA: Sage.Young, K.G. (198 7). Taleworlds and storyrealms:The phenomenoogy o f narrative. Boston: M artinus Nijhoff.

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