Sitting alone Drawing: Wendy Bryant
Conversely, an individual attending a class to improve basic literacy and numeracy skills might be assumed to be engaged in a meaningful occupation and to be socially integrated. In some instances, this might not be true, and so these assumptions have to be questioned, considering the value of the occupation(s) (Eklund and Sandlund 2013). OTs have to recognize the interpretations they impose on clients’ experiences. Collaborative work will expose the validity of these interpretations.
Content of the Occupational Therapy
Increased awareness of occupational alienation will offer a way of understanding why people appear to be bored, disengaged, or uninterested, and how to respond by adapting or creating occupational opportunities collaboratively with individuals, groups, and communities. Occupational alienation describes the combined experiences of meaninglessness, withdrawal, and boredom. In response, the OT could consider meaningfulness, belonging, and occupational choice:
Meaningfulness is a personal perspective, and often changing, reflecting subjective occupational values. Thus, there is potential for people, including OTs and other staff, to be occupationally and socially alienated in every session or setting. The meaning or symbolic value of an occupation may not be evident until after the experience (Eklund and Sandlund 2013). Recognizing this through an increased awareness of alienation can enhance collaborative work to promote engagement and recovery.
A person might find that what they are doing is meaningless because of their own mental state. In this situation, it is important to design occupational opportunities in collaboration with clients to identify what could be meaningful and what could transform their internal sense of alienation. Safety, in terms of the physical, social, and emotional environment, is vitally important to support this process.
Belonging: Clients might be withdrawn and occupationally alienated because the sessions offered are not interesting. They do not feel a connection or sense of belonging to the sessions. By focusing on what people do, it is possible to foster a sense of belonging through occupation, using shared experiences to support relationships and attitudinal changes (Fig. 55.2; Argentzell et al. 2013; Ulfseth et al. 2013). There is a risk that these experiences may not always be positive, which is why the social aspect is important to explore the challenges together. The sense of belonging can be achieved through relationships of good quality, with people accepting who you are, and equally, recognizing and accepting what you do (Argentzell et al. 2013). These issues of acceptance and recognition are important for the final issue of occupational alienation.
Shared experiences Drawing: Wendy Bryant
Making occupational choices: Being able to make realistic, informed choices requires a client-centered approach (Sumsion 2007). A dialogue should take place to facilitate this process. It could be nonverbal, expressed through the occupations performed. Locating this dialogue in a social context, for example, a group, will help clients perceive what can be achieved through occupation not only through their own participation but also through observing that of others. This promotes a sense of ownership over the process and products of their activities, reducing occupational alienation.
Living in a Glasshouse
Modernization of community mental services in the UK was driven by a concern about social exclusion, reviewing the therapeutic and supportive functions of the services (Catty et al. 2005a). As services have dispersed and specialized, research has considered continuity of care, revealing the importance of how staff are enabled to support people (Sweeney et al. 2012). This has been recognized as an organizational issue, with staff having limited power to promote social inclusion for individuals (Clifton et al. 2013).
The social environment of day centers has been valued by clients, but the extent to which social aspects are given priority over therapeutic functions depends on the organizational priorities (Catty et al. 2005a; Tjornstrand et al. 2013). Social contact and support are emphasized more in day services provided by social care and nongovernmental organizations, in contrast to the time-limited treatment offered in health-care settings. However, repeated evaluation has not distinguished significant differences for long-term clients (Carter 1981; Catty et al. 2005b; Jones 1972).
The importance of organizational priorities has implications for occupational therapy, which needs to give equal consideration to the social and occupational aspects of recovery, for which there is no agreed definition (Kartalova-O’Doherty et al. 2012; Tew et al. 2012). Notions of hope, person-centered dialogues, and empowerment (Bird et al. 2011) reflect the principles of occupational justice, which stress the importance of individual and collective capacities for engagement in occupations which promote health and well-being (Durocher et al. 2013; Townsend and Marval 2013). Occupational alienation is considered a risk factor for occupational injustice, where participation is hindered by external factors (Bryant 2008; Durocher et al. 2013).
The research that informed this approach comprises two studies. The first involved 39 mental health day clients in four focus groups (Bryant et al. 2004). Clients highlighted their experiences of feeling separate and unconnected, of being prevented from supporting each other, and of being rejected by the wider community because of their mental health problems. The metaphor of the glasshouse for day services suggested the potential for fostering vulnerability and dependency, while offering shelter from the wider world (Fig. 55.3). Within the glasshouse, what people did was restricted and highly visible from the outside. Thus, there were tensions between shelter and segregation, safety and dependency, and visibility and invisibility. These tensions resulted in organizational efforts to control occupational opportunities and the social environment. It was suggested that the concept of occupational alienation offered a way of understanding and working with these tensions, and allowing clients more control and choice. The second study (Bryant et al. 2010) used participatory action research to explore these issues in more depth, revealing the importance of a safe space (Bryant et al. 2011), sharing knowledge about community resources and the need for good support for the development of user-led day services.
Living in a glass house Drawing: Wendy Bryant
Clients have emphasized the importance of having meaningful occupational opportunities in a safe and social environment, to which they felt they belonged (Bryant et al. 2011). The importance of belonging in terms of mental health and well-being has been supported in recent research by OTs (Tjornstrand et al. 2013; Eklund and Tjornstrand 2013). The social dimension, beyond medical and psychological approaches, has been emphasized in strategies to overcome social exclusion (Tew et al. 2012). Considering occupational alienation not only incorporates the social dimension but also emphasizes the importance of what people do and the right to participate in valued occupations, not only to safeguard health and well-being but also to achieve a sense of belonging. It also raises questions about how the meaningfulness of occupations is judged and by whom, and the necessity for ongoing critical dialogue.
In the research informing this chapter, clients had some positive experiences of day services, and it is suggested that increased awareness of occupational alienation would, in many instances, confirm and illuminate good practice as well as inform service development. In particular, it would enable occupational and social aspects to be considered as equal to, if not more important than, medical and psychological aspects from the perspectives of clients and staff. Future research could explore the tension between seeking social integration and sustaining a safe place for clients to recover. It is important to develop a greater understanding of how people judge what is a meaningful occupation and what is a meaningless occupation, and who makes that judgment and with what implications. The experience of clients suggests that occupational alienation may be intrinsic to the experience of mental health problems at certain stages, especially in the context of risk management and the restriction of occupational choices for safety reasons. Reflecting on and exploring these issues in depth will enhance practice and thus the client experience.