Fueling the Engines: A Role for Occupational Therapy in Promoting Healthy Life Transitions

Fueling the Engines:A Role for Occupational Therapy

in Promoting Healthy Life TransitionsArie J. Schwartzman, MSOT Student

Karen Atler, MS, OTRBarb Borg, MA, OTR

Roxana C. Schwartzman

ABSTRACT. This article explores the potential role of occupationaltherapy in promoting healthy life transitions among people without ill-ness or disease, The story of Roxana, a woman who moved with her fam-ily from Mexico to the United States, is described. The many transitionsRoxana experienced are examined using the Person-Environment-Oc-cupation Model. Implications for practice focus on assessment and inter-

Arie J. Schwartzman is a Master of Science occupational therapy student, Colorado StateUniversity (E-mail: [email protected]). He received his Bachelor of Science de-gree in chemistry from San Diego State University. The idea for this article was an extensionfrom a course assignment in Occupation and the Individual.

Karen Atler is Assistant Professor, Department of Occupational Therapy, 210 Occupa-tional Therapy Building, Colorado State University, Fort Collins, CO 80523 (E-mail:[email protected]). She teaches courses related to occupation, community-basedfieldwork and neurobehavioral approaches with adults. She was the instructor for the courseOccupation and the Individual.

Barbara Borg is Assistant Professor, Department of Occupational Therapy, ColoradoState University (E-mail: [email protected]) where she teaches psychosocial coursecontent.

Roxana C. Schwartzman is a graduate student in Spanish Literature, San DiegoState University (E-mail: roxisch@[email protected]). She received her Bachelor ofArts in special education from Universidad de las Americas and certification in colorcontrol technology from Data Color International.

Occupational Therapy in Health Care, Vol. 20(1) 2006Available online at http://www.haworthpress.com/web/OTHC

© 2006 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J003v20n01_03 39

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vention strategies that can help practitioners and individuals experiencingtransitions use occupation to prevent illness and promote health. [Articlecopies available for a fee from The Haworth Document Delivery Service:1-800-HAWORTH. E-mail address: <[email protected]> Website:<http://www.HaworthPress.com> © 2006 by The Haworth Press, Inc. All rightsreserved.]

KEYWORDS. Transitions, wellness, health, person-environment-occupation model, prevention

INTRODUCTION

In this paper the story is told of a woman who experiences multiplelife changes when her family moves from Mexico to the United States.It is a story about transition. Without revealing the end of the story, wecan say that this woman did not receive occupational therapy services,but as authors we will propose that such services might have helped her,and others who experience transition, to move more smoothly throughwhat is often a difficult time.

Transition has been defined as “ . . . any event, or non-event, thatresults in changed relationships, routines, assumptions, and roles”(Schlossberg, Waters, & Goodman, 1995, p. 27). A transition could beregarded as a change of chapter in a person’s book of life. Assisting cli-ents to shift from one chapter to the next is a crucial aspect of occupa-tional therapy practice (Spencer, Davidson, & White, 1996). Multipletheoretical models have been used to examine transitions. The life spandevelopment frame of reference, for example, is a biopsychosocialframework that has been articulated for occupational therapy assess-ment and intervention (Bruce & Borg, 1987, 1993). Using this model,adult development is understood as following a predictable and sequen-tial pattern of age-related stages, which are linked by periods of transi-tion. These periods are expected to create difficulties that the adult mustnegotiate (Bruce & Borg, 1993).

The transition model (Schlossberg et al., 1995) emphasizes the ideaof individual variability in transitions and pays special attention to threemajor components: assessing where the adult is in the transition, identi-fying the resources the person has available to cope with the transition,and strengthening additional resources to further support the person intransition. Blair (2000) presents a synthesis of ideas from psychology

40 OCCUPATIONAL THERAPY IN HEALTH CARE

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and occupational science on transition. Her ideas are grounded in a re-view of the literature, interviews of people who recently experiencedtransitions, and workshop participants’ experiences. Blair addresses the“centrality of occupation” through life transitions and proposes that ex-amining the form, function, and meaning of occupations at the point oftransition help to understand the effects of transitions.

Since the seminal work by Selye (1950, 1970, 1971, 1976, 1979) andHolmes and Rahe (1967; Gunderson & Rahe, 1974), interest has grownin the social and health sciences as regards the relationship of lifechange, stress, and health. That there is an inter-relationship seems to bea conclusion shared by researchers (Manton, Singer, & Suzman, 1999;Schulenberg, Sameroff, & Cicchetti, 2004; Selder, 1989; Wadsworth,Montgomery, & Bartley, 1999; Watt, Verma, & Flynn, 1993; Whitman,Merluzzi, & White, 1999). What specifically that relationship is re-mains less clear but can be expected to have a huge bearing on future ef-forts in behalf of promoting wellness. Although occupational therapyhas made a unique and valuable contribution helping persons with dis-ease and/or disability transition or regain health, in the area of preven-tion and wellness occupational therapy intervention has been limited.Wilcock (1998) states:

Despite much current rhetoric I believe that many occupationaltherapists are still not acting on the concept of enabling occupa-tion–doing, being, and becoming–favoring instead techniques,splints and aids to daily living. Whilst these can be valuable adjunctsto what we offer, by focusing on these we have failed to include in,or have discarded from our professional repertoire, much that ispowerful in terms of people’s real lives, in terms of their health, interms of their well-being, in terms of them becoming. (p. 254)

Healthy transitions can be viewed as an integral part of that “becoming.”Wilcock echoes the sentiments expressed by former American Occupa-tional Therapy Association (AOTA) president, Dr. Jerry Johnson (1986),nearly two decades ago.

Historically, the profession has supported the ideal of prevention andhealth maintenance (Gilfoyle, 1984; Jaffe, 1986; Johnson, 1986; Reitz,1992). According to the Occupational Therapy Practice Framework: Do-main and Process (AOTA, 2002), “health and wellness,” and “preven-tion” are all potential outcomes of engagement in occupation. In thePractice Framework, health is described as a holistic state of well-being thatreflects “mental and physical balance and fitness” (AOTA, 2002, p. 628);

Schwartzman et al. 41

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wellness is described as “being in good health” and as more than the ab-sence of disease symptoms; and prevention is conceptualized as promot-ing a healthy lifestyle for an individual or individuals.

There has been seminal work by the profession to promote health andwellness among a group that copes with multiple life transitions–thisgroup is the elderly. The elderly must adapt to changes that includephysical decline, retirement, changes in residence, and loss of friendsand spouse. There has been a dramatic growth in the elderly populationand a concurrent rise in health care costs. Given this, the OccupationalTherapy and the Occupational Science Department at the University ofSouthern California (USC) conducted the well-elderly study. In thisstudy, it was demonstrated that providing occupational therapy that fo-cused on educating older adults in the role of occupation in health andfacilitating continued engagement in occupation, prevented illness andmaintained health (Clark et al., 1997). In this study, the participants re-ceiving preventive occupational therapy benefited in the areas of health,function, and quality of life when compared to a group that engaged insocial activities and to a control group that received no intervention. Afollow-up study of those who participated demonstrated that preventiveoccupational therapy for older adults living independently is cost-effec-tive and medical expenditures tend to decrease for participants receivingsuch interventions (Hay et al., 2002).

A manual summarizing information learned from this study was pub-lished in order to help occupational therapists plan and implement custom-ized Lifestyle Redesign Programs (Mandel, Jackson, Zemke, Nelson, &Clark, 1999). The manual’s guidelines are applicable not only to the elderlypopulation but to people of all ages. Based on these findings, it is the au-thors’ belief that occupational therapists would be a valuable resource forpeople experiencing difficult life transitions.

Transitions are inherent not only in aging, but also in the full spectrumof human life experience–for example, moving to a different location,marriage, divorce, change of jobs as well as careers, the “empty nest,” re-tirement, having children, and losing a loved one. As noted earlier, duringthese difficult times, the well-being of the person experiencing the transi-tion may be in jeopardy. If the person is not successful in coping with thetransition, this could mark the beginning of a health decline. In contrast, ifthe person maintains well-being in this challenging time, then the transi-tion represents the successful overcoming of a challenging situation–itrepresents a bridge between two stable life stages.

From the perspective of occupational therapy, life transitions can be un-derstood using the person-environment-occupation model (Law, Cooper,


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Strong, Stewart, Rigby, & Letts, 1996). In this model, occupational perfor-mance is defined as the “dynamic relationship between people, their occu-pations and roles, and the environments in which they live, work and play”(Law et al., 1996, p. 9). According to this model, the closer the overlap or fitof the person-environment-occupation triad, the better the occupationalperformance. In the same way, the less fit, the more diminished the occupa-tional performance. It is reasonable to think that transitions bring about achange in the relationship between the person, environment, and occupa-tion and as a result may affect occupational performance. However, if theperson pays attention to this dynamic relationship and has strategies tomaintain and/or increase the fit, then the well-being of the person will morelikely prevail. The dynamic relationship will be portrayed through Roxana’sstory.

Roxana, a 46-year-old woman, moved to the United States four yearsago. She experienced first a decline and then an increase in well-beingas a function of her participation in occupation. Major transitions inRoxana’s story will be highlighted in order to depict how these transi-tions impacted her daily occupation, and how the occupations impactedthe transition, and ultimately her identity and well-being. Following thestory, the person-environment-occupation model will be used to exam-ine Roxana’s story. The article concludes with implications for practice,with the intent of contributing to our understanding of how occupationcan promote health and wellness. For now, let us share the story of apersevering spirit in her quest for meaning and health–Roxana’s story.

THE STORY

Background

Roxana grew up in Buenos Aires, Argentina. She was the youngestof three children. Roxana attended several schools during her child-hood, and in her family doing one’s best in school was not a priority.However, values such as honesty, friendship, respect for the elderly,and unity with the family were strong priorities. Throughout her child-hood and adolescence, Roxana enjoyed reading books; sometimes shewas so intrigued with a book that she didn’t stop reading until she fin-ished. In middle school and high school, Roxana was an average studentwho enjoyed spending the weekends in La Quinta, a house in the coun-try. In La Quinta, family and friends that had grown up together gath-ered to cook parilladas [barbeques], and share relaxing times playing


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board games, enjoying the out-of-doors, listening to music, and havinglively conversations.

In her late teens, Roxana decided to go to medical school in Argen-tina, where she became a very successful student. During her studies inmedicine, school was a priority in which she invested most of her timeand energy. However, a vacation to visit her aunt in Mexico Citychanged her life. In Mexico City, Roxana met Pablo, a chemical engi-neer who had recently returned from finishing his graduate studies inthe United States. They fell in love, and subsequently married, andRoxana moved to Mexico City to live with her husband.

Once in Mexico City, Roxana changed her major to special educationand completed a bachelor’s degree in this field. She had decided tochange majors to avoid being separated from Pablo as a medical intern.Roxana worked as a special educator for several years, while beginningher family. She then chose to be a full-time mother until the youngest ofher four children was in school. At that time, she began taking computerclasses, focusing on their use in education. It was during this period thatRoxana’s husband, Pablo, was preparing to establish a new computerizedquality control department at the factory. He believed that Roxana couldhelp him in this endeavor, and he asked Roxana to take the position ashead of this new department. Roxana accepted this challenge and withinfour years was supervising a department of 14 people. In addition to this,Roxana, as the head of the quality control committee, lead the process ofcertifying the factory in one of the most prestigious quality control certifi-cations available. By her account, it was a very fulfilling period:

After working ten years in Mexico and given a lot [in the factory],and having a lot of creativity . . . I think [these] were ten extraordi-nary years of my life from the personal growth point of view be-cause of the growth of my children. Also, from the professionalpoint of view because of the growth of the factory, I realized myown potential and all I was able to contribute.

New Challenges

Roxana’s biggest transition began when she was 42 years old. At thattime she was living in Mexico City with her husband, Pablo, and theirfour children: a 20-year-old son, an 18-year-old daughter, and two 15-year-old fraternal twin girls. Because of its population and uncontrolledgrowth, Mexico City was becoming an undesirable place for the familyto live, and in the summer of 2000, Roxana and her family immigrated


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to the United States. The family decided to move to San Diego, Califor-nia where they started a new life that was unexpectedly challenging forRoxana. As she described:

I was even afraid of some things like taking care of the home. Al-though I had been married for 23 years, I was afraid because inMexico I had so much domestic help but here in the States, all theresponsibility is one’s own. Therefore, I was scared. It was a greatchallenge to see if I could get home and feed the children. I hadyears of not going to the supermarket because, although it soundsweird, in Mexico I was not responsible for going to the supermarket.As a result, it was a challenge to get home and do what a homemakershould be doing.

Throughout the first year of her new life, Roxana was busy helping allthe other members of the family to adapt to their new routines:

This kept me very occupied and made me feel that I was very use-ful. Part of my job was to be supportive and help everybody so thatthey could make positive changes and accomplish [their] objec-tives. Therefore, I was busy and felt very useful. In that moment Ididn’t consider anything else but to exercise to maintain the goodphysical condition that I had in Mexico. I didn’t consider doinganything else for myself.

All the other members of the family were settling into their new routinesin the United States except Roxana. Her husband was already becomingaccustomed to traveling back and forth to Mexico to work. Moreover, theiroldest daughter and son were both happy in their respective universitieswhile her two high school daughters were spending less time at home. Thiscaused Roxana to stop and reflect about her not “doing”:

I felt a very big emptiness because I didn’t have the work and I didn’tfeel like an executive anymore as I have felt in Mexico. As a momI didn’t feel hundred percent necessary. I started to question my-self, “What should I do about my life?”

Roxana spent about a year asking herself this question, “What should Ido about my life?” while avoiding any commitments that would makeher unavailable to Pablo and the children. Although Roxana knew thatthey were too young to retire, her dream was to spend more time with


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her husband during the day. Her husband worked during these times.However, Roxana kept waiting without “doing” so that she would beavailable if needed:

I felt that my life had become one of waiting here and waiting there. . . wait, wait.

As Roxana reflected back about this time, she realized she had beenpreparing throughout her life for this time in order to have a routine withfulfilling activities. As she said:

I had a life that I already planned so that when I reached this age . . .this is 46 years old . . . more or less when the sons and daughters flyaway and when the empty nest begins, I would be totally occupiedand that I wouldn’t be a burden for [my family]. I wanted for thistime of my life to have a sentido propio (sense of self) and it wouldbe full of positive things and with important goals.

Her plan was intended to provide a solid transition during the “emptynest” period. However, the plan was disrupted by the family’s immigra-tion to the United States. Roxana found herself in a complicated posi-tion she had never wanted:

I started to decline physically. From being able to run one hourdaily I got to the point of being able to barely exercise three times aweek. I increased my weight by 10 kilograms, which is like 20pounds. I started to feel bad in all areas of my life, meaning physi-cally as well as starting to become something I didn’t want to be: aload for everybody.

When Roxana’s son realized that his mother was dissatisfied and un-sure of what to do, he suggested some possible avenues she might pur-sue, for example, volunteering to pick up trash at the beach, or helpingto feed the elderly. These choices were not appealing to Roxana. How-ever, it was about this time that Roxana happened to hear a radio broad-cast, in which ill children were describing their experience as part of afundraising activity for the local children’s hospital:

I was very touched by a child who was saying that he was ‘verywell’ and the hospital was taking good care of him. He said that hewas treated very well but he was by himself many hours of the day


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. . . he said this made him “sad.” I identified with this child becausehe would like to have his mom and I would have liked to have mychildren, to be able to take care of them as I had done before com-ing to San Diego. However, my children were grown and didn’tneed me anymore. I made the connection and said, “Well, I cannottake care of my children but there are children who need care andattention and I have a lot of love to give.” Therefore, I went to thechildren’s hospital and said I wanted to volunteer.

Roxana liked being a volunteer at the children’s hospital. She alsotook pleasure in several other activities that she explored during thistime, including painting, cooking, and playing the piano. While she en-joyed these activities, she felt she needed something more. As she said:

I didn’t have any responsibility. I wanted to take more responsibilitybut it was not possible; it was volunteer work. After working there awhile I thought that this could be an extra, like painting or exercise,but I realized that it could not be the center of my life. I felt I was tooyoung to be dedicating myself only to volunteer work. I needed workwith more challenges and where I could develop more, where I couldhave the opportunity to keep learning things, apply what I know, usemy creativity and my knowledge–I wanted to contribute more.

Once Roxana realized that she needed to do something more chal-lenging than volunteer work, she started to consider going back toschool. Roxana thought that the most reasonable choice would be aMasters degree in special education since this was the area of her under-graduate studies. However, she was uncomfortable with the idea ofstarting over again in something she already knew. Roxana thought thatif she had continued with special education, at this time she would be inan administrative position. Roxana also considered pursuing a Mastersdegree in audiology, which she had always wanted to do but which wasnot offered in Mexico at that time. There were problems with this op-tion: it required considerable science plus the added difficulty of learn-ing in English. Another choice that Roxana considered was to obtain theteaching credentials needed for her to be a special education teacher. Afinal option, which was suggested by the mother of one of her daugh-ters’ friends, was very attractive to her. This was a Masters in Spanish.

Roxana liked the idea of studying in Spanish since this would meanhaving the advantage of being a native speaker as opposed to being dis-advantaged by having English as her second language. In addition,


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Roxana realized that reading had always been one of her passions.Therefore, she decided to explore the requirements for entry into a Mas-ters program in Spanish literature. As she was doing this, she foundherself stuck in the process:

I was anxious to do it . . . but I was not able to start up the engines.Everything was being left as a dream. I couldn’t do it. I was evenparalyzed by the idea of making an appointment at the university.

At this point, Roxana’s son encouraged Roxana to make an appoint-ment with the graduate advisor for the program in Spanish literature atSan Diego State University (SDSU). He promised her that he would ac-company her to this meeting. Together they met with the advisor who en-couraged Roxana to apply, telling her that she had a good chance of beingaccepted. He also explained that part of the prerequisites was the Gradu-ate Record Examination (GRE), in which she needed to have a combinedmath-verbal score of 750. Roxana was pleased with the meeting. How-ever, she was very frightened by the idea of taking the GRE. As she said:

I have been 23 years without studying mathematics and I didn’t re-member anything at all . . . it was my biggest fear. Sometimeswhen I thought about the GRE I felt panic because I felt it was likea mountain. What was coming after the GRE, I would be able todo. This was within the limits that a human being can do; the otherthing seemed to me like titanic homework. I thought I was not go-ing to be able to do it. Despite my always being positive and al-ways thinking that if I do my best I can do it, for me this was likeclimbing Everest.

Roxana’s son realized that Roxana would probably back out from theapplication process without some support. He discussed with Roxana aplausible day for her to take the test and registered her to take the GRE.He also tutored Roxana in mathematics to review the math basics as wellas test-taking strategies. Three weeks before the test, Roxana’s son lefthome to pursue his own graduate studies. Roxana felt sad on a personallevel but also felt she would no longer have her son’s support to completethis project. Roxana had liked the idea of being helped by her son while atthe same time feeling she was doing the work by herself. To her surprise,her son e-mailed her within three days of his departure. The e-mail con-tained a “to do” list, which included strategies to follow until the day ofthe test. This list addressed things she needed to do in preparation for the


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GRE but also suggestions for maintaining emotional and physical bal-ance. Roxana said, “I printed it out and I was very happy because this waswhat I needed. I kept the e-mail in my purse until I passed the GRE.” Withher first attempt at taking the GRE, Roxana’s score exceeded that neededto be accepted into the graduate program. To her surprise, she did muchbetter in the section she feared the most: the quantitative. Roxana latersaid, “It still seems like a miracle that I passed. I would have liked beingable to look at the score for a longer time because I was scared it was notreal and that I may have read it wrong.” During this time, Roxana was en-joying taking courses that were prerequisites for the program:

Another thing that was happening during this time was that I wasalready taking [prerequisite] classes [at SDSU] and I was enjoyingthem a lot. I liked to be “receiving” after so many years of “giving”and teaching. The fact of my receiving information . . . I reallyliked going home and doing homework, reading, and having tothink about different things. It helped relieve my tension and thenegative knot I got myself into. At these moments I thought of pos-itive things.

After taking the GRE and while still taking her prerequisites Roxanareceived the welcome news that she had been accepted into the graduateprogram in Spanish literature at SDSU. Roxana already felt independ-ent in meeting all academic responsibilities during her first semester asa graduate student. She was also taking into account different courseloads in order to determine which one would fit her needs:

I did it by myself. I registered for classes by myself. I didn’t wantto take three classes because I wanted to medirle el agual a loscamotes (in this context, to determine the implications and de-mands of a certain activity). But now I’m able to balance by myselfwhat I can do and what I can’t, but it’s not because of fear anymoreor for lack of training. I don’t want to over saturate myself and as aresult not letting this project to be successful.

RESOLUTION

Although the process of finding an occupation has been long and la-borious, Roxana now experiences her occupation as a student as a fun-damental part of her life. She has built a routine around her occupation


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as a student. For example, she starts her day with exercise and then goesto the university. In the afternoons Roxana completes her assignmentsand readings. As a result of this routine, Roxana, just as any other mem-ber of the family, has her own responsibilities and still has plenty oftime to share with Pablo and the children. Roxana is aware that there ismore adaptation still needing to be done. However, she is confident thatthe occupation she picked is helping her to live a happier life in a newand challenging environment:

There are things around me that I’m still not happy about . . . in SanDiego. However, [graduate school] is the only thing that I’m sureI’m happy about . . . it helps me a lot. It relaxes me, it gives metranquility, it makes me feel useful, and it makes me feel that I’mlearning and progressing. I like that I’m not stuck and that I’m go-ing towards an objective and me da ilusión (literally, “to give meillusion,” however, in this context meaning that something is elic-iting a positive perspective from the person and is related to beingexcited and desiring something). I haven’t got sick besides thethree colds that I had. However, they say the flu season was veryrough.

ANALYSIS OF THE STORY

The person-environment-occupation model introduced earlier (Law etal., 1996), illustrates the dynamic interaction among this triad and how itaffects the occupational performance of the person. Furthermore, thismodel takes into account the temporal dimension of this dynamic rela-tionship. The time dimension is created by the patterns and rhythms thatencompass the occupational routines in individuals over days, weeks, orlonger. Throughout time, these represent the life span of the person (Lawet al., 1996). In Roxana’s story, the dynamic changes of person, environ-ment, and occupation, and her varying levels of occupational perfor-mance are portrayed over time.

In Mexico City, Roxana was the mother of four children, wife ofPablo, the manager of a quality control department, and was proud to bea consistent client at the gym. Living in a tight-knit community, she wasable to carry out her occupations and demands within a strong supportsystem. At this point in Roxana’s story, the three main components(person, environment, and occupation) were interacting harmoniously.This interaction, however, was disrupted due to the rapidly changing


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environment–Roxana and her family did not feel that the environment(Mexico) would continue to support their occupations. Thus, the deci-sion to immigrate was made.

As Roxana and her family came to the United States, the change ingeographical environment impacted her roles–Roxana lost her role as aworker and at the same time took on new activities in her role as a home-maker. Her role as a parent was changing as well as the children grewup. Lack of established routines led to changes in other areas of her lifesuch as physical fitness. In other words, the person (Roxana) and her oc-cupation were not working harmoniously–there was a misfit amongthem. This misfit between person, environment, and occupation re-sulted in a decrease in Roxana’s occupational performance and a de-cline in her health. She stopped exercising and gained weight; even inher own estimation she was becoming “a load for everybody.”

After several attempts to find meaning through occupation–for exam-ple, volunteering, exploring the audiology program, and exploring theSpanish program–Roxana made her decision to return to school. It wasnot until Roxana became a graduate student that she started to experiencea “connection” with both, the environment and her occupation. For thefirst time in a long time she was regaining her “sense of self” as a result ofthe person-environment-occupation dynamic interaction. Roxana wasenjoying and succeeding in her role as a student. This in turn motivatedRoxana and she improved in her occupational performance as a motherand wife at home and as member of the San Diego community. Previ-ously, Roxana had anticipated spending more time with Pablo. However,this didn’t happen and illustrates a “non-event” transition, which can im-pact a life as much as the events that do happen (Schlossberg, 1989). Withher return to school, Roxana was no longer “waiting” for Pablo to finishhis work anymore, but was doing her own work and meeting with Pabloto share time together when both were free. What was happening amongthe components of the triad, in other words, is that “The closer their over-lap or fit, the more harmoniously they are assumed to be interacting”(Law et al., 1996, p. 17).

From the story we learn that the process of finding meaning throughoccupation in a life transition can be both a long and a fruitful one.Roxana initially was unsure how or where to begin. We learn from herstory that adding support in her environment, as well as breaking downthe activity of returning to school into steps, made this process of find-ing an occupation more manageable. We see that finding a meaningfuloccupation was key in her transition to restored health. In Roxana’scase, it was her family who helped her find and engage in an occupation.


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However, we can ask if the process might have been more structuredand efficient with the help of a professional? In this case, the transitionmodel could be used to analyze Roxana’s resources and how tostrengthen these (Schlossberg et al., 1995).

Roxana mentioned, “I was anxious to do it . . . but I was not able tostart up the engines,” a metaphor that speaks to her being stuck, like apiece of stalled machinery. Different professionals might hear and re-spond differently to Roxana’s need to get her “engines” going. The phy-sician, for example, might treat the physical aspects of the machineryand try to repair them. The psychologist might focus on the mental ma-chinery and try to realign her way of thinking. The spiritual expertwould consider Roxana’s spiritual life and suggest how to improve it. InRoxana’s transition, however, the physical, mental, and spiritual as-pects of her person were all at risk but not broken. There was nothing tobe “fixed” by any of these professionals. Instead, there was a more im-mediate need to address the interaction and harmony between Roxana,her environment, and her occupations to prevent ill-health from occur-ring; thus an occupational therapist could have been helpful.

It is the belief of these authors that occupational therapy interventioncould have assisted Roxana in her transition, as well as aiding otherswho have no identified disease or disability, but who are having troublestarting or keeping their “engines” going, as Roxana described. Withthe intention of promoting healthy transitions for this population, a pro-cess using occupational therapy concepts is proposed. This process usesthe insights from this story and translates them into a series of steps.These steps are intended to help the person to help herself or himself inthe process of starting or keeping his/her “engines” going before orduring a challenging transition.

IMPLICATIONS FOR OCCUPATIONALTHERAPY PRACTICE IN HEALTH AND WELLNESS

The need for occupational therapy is often clear when a person is notable to perform as effectively or efficiently as before an accident or theonset of a disease. However, when collaborating with people withoutdisease or disability, we may need to examine other issues that are lessobvious. In the case of Roxana, she was performing the activities neces-sary in her life, but that didn’t mean that she was satisfied or feelingcomfortable with herself or her life. Therefore, the occupational thera-pist would need to examine her occupational performance beyond her


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ability to engage in necessary activities. In pursuing this goal, a processconsistent with the Occupational Therapy Practice Framework can befollowed.

Evaluation

The evaluation phase begins with an occupational profile. The profileincludes information about the person’s past and present occupationalexperiences including interests, values, and needs (AOTA, 2002). Morespecifically, the therapist will want to gather information about the per-son’s roles, routines, occupational repertoire, and balance of occupa-tions. It would be important to explore with the person how the currenttransition is impacting or is expected to impact the person’s life. In thecollaborative evaluation process, the occupational therapist and personwill discover directions that will lead to finding and engaging inmeaningful occupations that could promote healthy adaptation.

The information about the person can be gathered using a formal and/orinformal interview. If using formal assessments, the therapist might choosefrom a variety of client-centered, occupation-based assessments including:the Canadian Occupational Performance Measure (Law, Baptiste, Cars-well, McColl, Polatajko, & Pollock, 1998), the Occupational PerformanceHistory II (Kielhofner et al., 1998), the Pizzi Holistic Wellness Assessment(Pizzi, 2001), the Role Change Assessment (Jackoway, Rogers, & Snow,1987), and the Self-Discovery Tapestry (Meltzer, 2001). Each of these as-sessments would contribute to gathering the individual’s occupational pro-file.

Information related to the occupational profile could also be gatheredthrough an informal interview. A list of questions to guide an informalinterview is provided in the Occupational Therapy Practice Framework(AOTA, 2002). It would be important to explore with the person his orher occupational life before, during, and following the transition. In thecase of Roxana, the occupational therapist would ask her about her lifeboth in Mexico and now here in the United States. In doing so, the occu-pational therapist would be able to identify discrepancies betweenRoxana’s activities, routines, and roles before and after the transition, aswell as satisfaction throughout this time. Whether one chooses formalor informal assessments, it is essential to establish a baseline in order todemonstrate the effectiveness of occupational therapy services.

For therapists who are less familiar with evaluating a person who doesnot have an apparent occupational dysfunction, the authors suggest thatthe person-environment-occupation model can provide an additional


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structure for gathering and interpreting information related to how theperson, environment, and occupation fit is supporting or hindering occu-pational satisfaction and performance (Strong, Rigby, Stewart, Law,Letts, & Cooper, 1999). For example, in the case of Roxana, the occupa-tional therapist would gather information about her occupations both inMexico and in the United States, as well as the physical and socioculturalcontext for her occupations. Further, the occupational therapist wouldwant to learn more about Roxana as a person–her interests, values, abili-ties and how these have or have not changed since the move. Lastly, theoccupational therapist would want to understand if or how Roxana has at-tempted to create a new “fit” between herself, her new environment andher occupations.

Bearing in mind the life span development model, we would ask our-selves, “How does Roxana function as compared to the expectations ofsociety and herself?” (Bruce & Borg, 1993). Exploring this questionwith Roxana would help to identify those skills needing to be built orstrengthened. Consistent with the transition model we would try to clar-ify with Roxana what the transition involves and how it is affecting herlife (Schlossberg et al., 1995).

Intervention

There is a fine line between the evaluation and intervention. In theevaluation process the person is already getting to know himself/herselfin an occupational context. In other words, the person is discoveringwho he/she is as an occupational being and how his/her occupations af-fect health. In the intervention process, the therapist goes a step furtherand helps the person move towards finding and engaging in occupationsthat would promote health during the transition. The OccupationalTherapy Practice Framework provides a list of various intervention ap-proaches that can be helpful when determining how to help a personreach his/her identified goal (AOTA, 2002). In the case of Roxana, thetherapist could have helped her “create/promote” opportunities to en-gage in activities that would provide Roxana opportunity to explorenew occupations, or “establish” new roles and patterns in her daily life.As we saw in Roxana’s story, taking on the role of a student enabled herto enjoy her new environment as well as her personal life.

Adolf Meyer believed that providing the individual with the opportu-nity to engage in purposeful activity promoted health (Sabonis-Chafee &Hussey, 1998). As the person finds meaning in an occupation, the occu-pational therapist may also need to assist the person in incorporating the


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occupation into a routine–that is, not only engaging in occupations butalso becoming aware of how the role of occupation and routines will al-low the person to redesign his/her life (Mandel et al., 1999).

In addition to identifying meaningful occupations, learning how tomodify the environment can support a person’s engagement in “meaning-ful doing.” Again, using the person-environment-occupation model’s as-sumptions and principles, the occupational therapist can guide the personto understand how to: (a) examine his/her own person, environment, andoccupation interactions, (b) problem solve to identify potential environ-mental changes, and (c) initiate changes in the environment to supportmeaningful doing. As we saw in Roxana’s story, taking on the role of astudent enabled her to enjoy her new environment as well as her personallife. Engaging in the occupation of education helped Roxana to interactmore harmoniously with the environment and in turn the environmentwas perceived by Roxana as an enabler rather than as a limiting factor.

Using the life span development perspective, we would expect to setintervention goals and institute an intervention process that are aimed atprevention (Bruce & Borg, 1993). In the case of Roxana, the goals–framed as positive statements–could include, for example: “Roxana willindependently engage in meaningful physical activity, three times aweek,” “Roxana and her husband will attend two social events per week,”or “Roxana will spend one hour per day using internet and printed re-sources to explore potential areas of professional interest.” Identificationof these goals would occur collaboratively with the occupational therapistprimarily using the consultation and education processes as identified inthe Occupational Therapy Practice Framework (AOTA, 2002).

After the goals are set, the therapist could help the person (Roxana) un-derstand how her occupations are related to health, monitor change, andensure that the process is leading towards the enhanced empowerment ofthe client. A powerful by-product of success in managing a transition suc-cessfully is the acquisition of knowledge and skills that are believed toenable the person to better cope with future transitions (Bruce & Borg,1993). Consistent with life span development intervention, it might bepossible to pair the person in transition with another adult who has experi-enced a similar life stage transition. The purpose would be to promotementoring, whereby the mentor plays the role of guide and serves as a re-minder that “it can be done.” Similarly, intervention could occur within agroup context if several clients were in transition.

Using the transition model, we would try to identify current and po-tential resources that a person has to cope with his or her transition andstrengthen the use of these resources through the implementation of


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new strategies (Schlossberg et al., 1995). Roxana’s main resource dur-ing the time of her transition was her family. Though her family pro-vided invaluable support, it might have been helpful to explore specificways in which her family could have participated with Roxana or con-tributed to her goal achievement. One might have explored, for exam-ple, what avenues were available for Roxana and her husband, Pablo, toparticipate together in social outings, or what might be the interest ofRoxana’s daughters in engaging along with their mother in physical orrecreational activity. When a person is transitioning, it is useful to ex-plore and help the person better understand the process by which he orshe has successfully adapted to new situations in the past–his or heradaptive repertoire (Spencer et al., 1996). In the case of Roxana, wewould explore Roxana’s adaptive repertoire and assist her in makingeffective use of it during this transition.

Outcomes

Measuring and reporting the effectiveness of occupational therapy ser-vices in health promotion areas is just as important as documenting occu-pational therapy services for people who are experiencing occupationaldysfunction. In order to demonstrate outcomes, objective baselines needto be established for those who are in transition. Although actual occupa-tional performance during observational assessments may not change,the occupational therapist can note changes in other broader outcomes ofengagement in occupation. The Occupational Therapy Practice Frame-work provides a list of some potential examples (AOTA, 2002). In thecase of Roxana, the therapist and Roxana may have identified occupa-tional outcomes related to occupational satisfaction, occupational bal-ance, and/or occupational roles. If formal assessments are used during theinitial evaluation, re-administering the assessments would assist inobjectifying and reporting the changes that have occurred.

Development of additional tools for the area of health and wellness isencouraged by these authors. In addition, an analysis of the person’s life“story” up to this point would help put the transition and the therapeuticoutcome into perspective. Taking into account the occupational time-line of the person and how transition goals fit this time-line, the clientand therapist can determine if further steps need to be taken or if thegoals have been achieved. Ultimately, the individual is the one who per-ceives when he or she is experiencing well-being during or after thetransition.


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ESTABLISHING OCCUPATIONAL THERAPY’SROLE IN PROMOTING TRANSITIONS

One might ask, “Where do I find the clients that are experiencing adifficult transition and would benefit from an occupation-based ap-proach to successfully move through the transition?” First, it is impor-tant to note that this approach is intended for the client who is willingand able to be introspective and open with the therapist. The process in-volves exploration of past experiences, present difficulties, and the pro-cess needed for a brighter and healthier future. Therefore, a certaindegree of client vulnerability to is to be expected. Moreover, in the pro-cess we have proposed, the client is an active participant and the thera-pist plays the role of a consultant and facilitator. Therefore, this approachis for the client who is willing to make a considerable effort and take re-sponsibility for his or her becoming.

It seems reasonable to suggest that virtually all people will experi-ence multiple life transitions, and that potential clients are all around us.Many of these people may currently be seeking help from a friend, fromfamily, from a psychologist or psychiatrist, from a shaman, by takingclasses, reading books, or reading horoscopes–the list could go on.However, at the present moment, despite our training and expertise inthe area of occupation, including life roles and daily routines, and ourcommitment to client-centered practice, occupational therapists are notlikely to appear in this list. If this is an area in which we as occupationaltherapists want to practice, it will be necessary for us to recognize forourselves the contribution we are able to make, and to make a commit-ment to organizing and expanding our knowledge, and our outreach.

Summary/Conclusion

Historically, using meaningful occupations to restore or maintainhealth in people with illness and disability has been the primary functionof occupational therapy. Bringing the same benefits to the well popula-tion has not been widely developed by the profession. However, thiscould be an area in which occupational therapy could flourish. Roxana’sstory was used to illustrate how occupation could be used to promote andmaintain well-being during a time of transition. The person-environ-ment-occupation model served as a helpful tool in the analysis of thestory since it provides a relatively simple and yet comprehensive pictureof the dynamic nature of occupation and its relation to the person and theenvironment.


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Fueling the Engines: A Role for Occupational Therapy in Promoting Healthy Life Transitions

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Transcript of Fueling the Engines: A Role for Occupational Therapy in Promoting Healthy Life Transitions