Sue Parkinson PDF

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RECOVERY
THROUGH
ACTIVITY
I N C R EAS I N G pa rt i c i pat i o n
i n ev ery DAY li fe
Sue Parkinson
A Speechmark Book
rough activity RECOVERY through activity
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tivity RECOVERY through activity RECOVERY

COVERY through activity RECOVERY through
RECOVERY
THROUGH
ACTIVITY
tivity RECOVERY
I N C R EAS through
I N G pa rtactivity
i c i pat i o n RECOVERY
COVERY through i n activity
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OVERY through activity RECOVERY through
Sue Parkinson
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First published 2014 by Speechmark Publishing Ltd.
Published 2017 by Routledge

2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
711 Third Avenue, New York, NY 10017, USA
Routledge is an imprint of the Taylor & Francis Group, an informa business
Copyright © Sue Parkinson 2014
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British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library.
ISBN 9781909301207 (pbk)

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RECOVERY
THROUGH
ACTIVITY
Increasing participation in everyday life
I N C R E AS I N G pa rt i c i pat i o n
i n ev ery DAY li fe
Sue Parkinson
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Contents
Foreword vi
Preface viii
Acknowledgements x
Part 1 1
Introducing Recovery through Activity 3
Applying the Model of Human Occupation 9
Promoting the value of activity 13
Delivering the Recovery through Activity group programme 19
Providing one-to-one assessment and treatment-planning 23
Part 2 33
Session 1 Leisure activities 35
Session 2 Creative activities 47
Session 3 Technological activities 59
Session 4 Physical activities 71
Session 5 Outdoor activities 83
Session 6 Faith activities 95
Session 7 Self-care activities 113
Session 8 Domestic activities 125
Session 9 Caring activities 137
Session 10 Vocational activities 155
Session 11 Social activities 169
Session 12 Community activities 183
Appendix 197
Group profile 199
Group flyer 204
Activity checklist 205
Evaluation form for participants 207
Reflective log for facilitators 208
Participant outcomes 210
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Recovery through Activity
Foreword
We are delighted to provide a foreword for this ground-breaking work by Sue Parkinson, which draws on
her many years of experience in mental health clinical and leadership posts, as well as her role as a
freelance trainer. Sue has specialised in establishing occupation-focused practice in mental health
services for working-age adults and older people, and her passion has been to demonstrate the clinical
contribution of occupational therapy in these settings.
The Recovery through Activity handbook is underpinned by the conceptual framework of the Model of
Human Occupation – a model that Sue has applied for many years. In particular, she has collaborated
with the academic team at the University of Illinois in Chicago and occupational therapists in the United
Kingdom (UK) to develop and evaluate the Model of Human Occupation Screening Tool (MOHOST).
The impact of this and other assessment tools co-authored by Sue is immense. The MOHOST is now the
most extensively used evidence-based assessment in mental health occupational therapy in the UK and
has given occupational therapists a consistent approach to assessing occupational participation and
evaluating occupational outcomes.
The aim of the Recovery through Activity programme is to enable service users to recognise the
long-term benefits of occupational participation by exploring the value of a range of activities. At a time
when the focus of occupational therapy practice in mental health is hotly debated, and occupational
therapists in community mental health teams are struggling to balance their generic roles with
occupation-specific working (Pettican and Bryant, 2007; Fox, 2013), the programme answers the call to
focus occupational therapy intervention on activity.
Enhancing participation in everyday life should be a core focus of occupational therapy and this
handbook provides occupational therapists with a valuable tool to support the use of their core skills.
It also provides comprehensive evidence regarding the value of activity, along with a wealth of
resources to support the implementation of an occupation-focused intervention.
As occupational therapists, we recognise that reducing isolation and building supportive social networks
and relationships promotes a sense of purpose, good mental health and recovery, and prevents mental
health problems. Participation in meaningful activity is associated with improved self-esteem and
wellbeing but time-use studies have identified that people with mental health problems are often
underoccupied and engage in passive leisure pursuits (Shimitras et al, 2003; Bejerholm, 2010). The fact
remains, however, that adults with a diagnosed mental health problem form one of the most socially
excluded groups in the UK (Social Exclusion Unit, 2004). Occupational therapists now have to
demonstrate that they have a key role in combating this situation.
vi
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Foreword
The evaluation and publication of the clinical and cost-effectiveness of occupational therapy
interventions is a vital step in building the evidence base and demonstrating value. Very few studies
have been conducted within occupational therapy using standardised intervention manuals and outcome
measures, and there are few occupational therapy manuals in practice (Blanche et al, 2011) –
particularly in the mental health field. The introduction of this treatment handbook will provide an
invaluable tool to practitioners and create a platform for research. We are privileged to be working on a
pilot study to test a manualised version of this intervention with people who have long-term mental
health problems and who need support to identify and access community resources.
We are confident that this handbook will be of interest to occupational therapy practitioners and
students as well as occupational therapy managers who are seeking to introduce time-limited,
occupation-focused interventions into clinical pathways. We believe that Recovery through Activity
meets real practice needs and can help to refocus the practice of occupational therapy in mental health
on occupation – supporting occupational therapy practitioners to engage in their core skills and
enhancing the quality of service user care in mental health.
Dr Mary Morley Mary Birken

Director of Therapies Occupational Therapist, Researcher
South West London and Institute of Psychiatry
St George’s Mental Health Trust King’s College London
References
Bejerholm U (2010) ‘Occupational balance in people with schizophrenia’, Occupational Therapy in Mental Health, 26 (1),
pp1–17.
Blanche EI, Fogelberg D, Diaz J, Carlson M & Clark F (2011) ‘Manualization of Occupational Therapy interventions:
illustrations from the pressure ulcer prevention research program’, American Journal of Occupational Therapy, 65 (6),
pp711–19.
Fox V (2013) ‘Professional roles in community mental health practice: generalist versus specialist’, Occupational Therapy in
Mental Health, 29 (1), pp3–9.
Pettican A & Bryant W (2007) ‘Sustaining a focus on occupation in Community Mental Health Teams’, British Journal of
Occupational Therapy, 70 (4), pp140–6.
Shimitras L, Fossey E & Harvey C (2003) ‘Time use of people living with schizophrenia in a North London catchment area’,
British Journal of Occupational Therapy, 66 (2), pp46–54.
Social Exclusion Unit (2004) Mental Health and Social Exclusion: Social Exclusion Unit Report, Office of the Deputy Prime
Minister, London.
vii
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Preface
Writing the Recovery through Activity programme has been an incredible experience and has taken time
that I could never have afforded when working as a practising occupational therapist. More than ever,
it made me appreciate why so many promising occupational therapy interventions are not published in a
format that can be readily shared with others. I believe this waste of potential, and the hours of clinical
practice spent ‘reinventing the wheel’, should be prevented if at all possible. My hope is that the
Recovery through Activity handbook will provide a flexible resource that will scaffold occupation-
focused interventions in a range of adult mental health settings, and provide a platform for promoting
the enduring value of occupational participation for recovery and wellbeing.
The task of communicating the benefits of occupational participation might seem relatively
straightforward. Surely, the importance of inclusion and integration are well understood by now.
However, the challenge of enabling people to recognise the beneficial impact that occupational and
social participation can play in their own lives is not easy, especially when people have first-hand
experience of being marginalised and excluded. The sheer audacity of this undertaking became apparent
to me when working with occupational therapy undergraduates to generate ideas for an early version of
Recovery through Activity. Their enthusiasm and their skills as researchers were not in doubt, but there
was still a tendency for them to assume that facilitating participation in an activity would be sufficient
to convince people of its inherent benefits.
It’s important to recognise that engaging people in activities requires skilled facilitation but also that
people must be supported to integrate activities into long-term occupations. This is crucial if progress is
to be sustained.The trick lies in being sufficiently open, direct and overt in our encouragement, while
still allowing people to reflect on their own experiences and reach their own conclusions. It is my belief
that the Model of Human Occupation (MOHO) (Kielhofner, 2008) can support this process by promoting
occupation-focused, holistic, evidence-based and person-centred practice, and by providing tools
capable of enhancing professional intervention.
I have benefited hugely from several superb resources, including the user’s manual for The Remotivation
Process (de las Heras et al, 2003) and the textbook for The Intentional Relationship (therapeutic use of
self; Taylor, 2008). In their different ways, these describe approaches required by occupational therapists
when studying how to facilitate participation. Meanwhile, Recovery through Activity centres on the
various activities that might be facilitated. In other words: what people can participate in. It aims to
provide multiple options for opening up discussion and initiating a meaningful dialogue with
participants. MOHO remains central to progressing the discussion by providing a framework for
occupational therapists to ask the right questions, set measurable goals and evaluate change.
viii
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Preface
Originally, I had intended to include six topics in Recovery through Activity, but this grew to twelve
when I started to review the literature. The more research I did, the more I was reminded that there are
pros and cons to many activities. For instance, there are advantages to having passive leisure pursuits
as well as disadvantages, and social activities can provide pain as well as pleasure. Likewise,
establishing a vocational role does not provide the solution for everyone’s problems, while domestic and
caring activities can both be viewed as chores and yet still provide deep sources of meaning.
I was struck by the evidence that occupational therapists can so easily miss opportunities to broach the
value of particular activities – perhaps because they are not technologically minded, or because they are
unsure about how to initiate discussions about faith, or because the issue of self-care is perceived as
being too sensitive. Moreover, activities requiring physical exercise or involving community integration
seem to be easier to promote than others, while the value of creative activity and outdoor activity can
be harder to articulate.
I hope that occupational therapists will be able to build a tailor-made programme to suit the needs of
participants by incorporating a balance of leisure, self-care and productive activities in their Recovery
through Activity programmes. With this in mind, an ‘Activity checklist’ is included in the Appendix to
help identify the relevant topics to include. ‘Key messages’ have also been provided for each topic, to
help reinforce the value of each activity. Ultimately, however, this handbook should be viewed only as a
foundation for practice; practitioners can add to the topics, or find new ways of facilitating the activities,
over time.
As a clinician, I had the privilege of working with many talented occupational therapists. We learned to
develop our own programmes of intervention and had to work hard to retain our occupational focus.
For all its limitations, I would have loved a handbook like this!
References
de las Heras CG, Llerena V & Kielhofner G (2003) A User’s Manual for Remotivation Process: Progressive Intervention for
Individuals with Severe Volitional Challenges. Version 1.0, University of Illinois, Chicago, IL.
Kielhofner G (ed) (2008) Model of Human Occupation: Theory and Application, 4th edn, Lippincott, Williams & Wilkins,
Baltimore, MD.
Taylor RR (2008) The Intentional Relationship: Occupational Therapy and Use of Self, FA Davis, Philadelphia, PA.
ix
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Acknowledgements
I am indebted to Mary Morley (Director of Therapies, South West London and St George’s Mental Health
Trust) for her boundless enthusiasm, her tireless commitment and her unwavering belief in the potential
of Recovery through Activity.
In addition, my warmest thanks go to my past colleagues who piloted the earliest draft, attracting
positive feedback from service users:
• Sarah Carter who facilitated an eight-week programme to match the needs of service users in a
community mental health setting and who suggested the title, Recovery through Activity
• Miriam Rowe and Deborah Mitchell who delivered the programme in a rehabilitation setting and
who effectively introduced service users to a wide range of local resources
• Kalwran Sangha who combined discussion topics with experiential activities in single sessions, and
used Recovery through Activity as the basis for open groups in an acute setting.
I would also like to express my appreciation for all the interest that occupational therapists have shown
in the development of the Recovery through Activity programme and for past colleagues who have
helped to shape my ideas. Especially:
• Rachel Humphries and Sara Bains, who helped set up a project with occupational therapy students
from the University of Derby to investigate the original Recovery through Activity topics
• Karen Wheeler, for promoting the role of occupational therapy in health promotion and coordinating
funding for the student project and pilot groups from NHS Derbyshire County Public Health as part of
the ‘Choosing Health – Mental Health’ programme.
Furthermore, I am proud to acknowledge that the Model of Human Occupation (MOHO) has guided my
professional reasoning for many years and provides the framework for Recovery through Activity. I am
deeply grateful for the generous support and warm encouragement shown to me by the model’s author,
Gary Kielhofner, and for the continued support of Renée Taylor who leads the MOHO Clearing House at
the University of Illinois, Chicago. The chapter explaining MOHO theory, descriptions of assessments
based on MOHO, and reference to levels of change and support strategies identified by the model have
been included in Recovery through Activity with the kind permission of the MOHO Clearing House.
My understanding of MOHO owes a great deal to a scholarship of practice that I was fortunate to be
involved in, between the occupational therapy service where I worked as the Practice Development
Adviser and the UK Centre for Outcomes, Research and Education (UKCORE). UKCORE is facilitated by
Professor Kirsty Forsyth and it has been my privilege to work with Kirsty for many years. I have benefited
immensely from her supervision, coaching and direction. In particular, my thinking about how to
x
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Acknowledgements
structure measurable goals has been transformed and this knowledge has shaped the explanation of
treatment-planning in Recovery through Activity. I am also much obliged to Kirsty for teaching me the
importance of writing comprehensive group profiles, and I have included a sample group profile for
Recovery through Activity in the Appendix.
Thanks, too, to Peter Bates at the National Development Team for Inclusion, for allowing me to outline
the Inclusion Web, and to use the social inclusion traffic light system in an exercise that considers the
degree to which community venues are socially inclusive.
Finally, the completion of this Recovery through Activity handbook would not have been possible
without the loving support of my partner, Peter Gray, and his steadfast trust in me.
xi
Introducing Recovery through Activity
Applying the Model of Human Occupation
Promoting the value of activity
Delivering a Recovery through Activity group programme
Providing one-to-one assessment and treatment-planning

Introducing Recovery
through Activity
Current occupational therapy practice
The evidence suggests that retaining a unique professional identity has become more difficult for
occupational therapists in current healthcare services (Farnworth, 2003). While some occupational
therapists are activity or occupation-focused, others are required to fulfil a host of generic clinical and
support roles (Lloyd et al, 2002). In addition, many occupational therapists have chosen to offer
intervention programmes that ostensibly focus on symptom reduction, such as anxiety management
(Meeson, 1998). The risk is that occupational therapists could find themselves teaching coping
strategies for occupational participation without reinforcing the value of the occupations themselves or
increasing occupational participation. Indeed, concerns have been raised that occupational therapists
may become so alienated from their original role that they cannot articulate their unique contribution to
health promotion (Tremblay and Brousseau, 2011). For this reason, occupational therapists have been
reminded to identify and pursue health-promoting activities in their everyday practice (College of
Occupational Therapists, 2008). In addition, Pierce (2001) has urged occupational therapists to develop
highly sophisticated design skills to ensure that activities match the participants’ goals.
Several occupational programmes have already been designed, to help occupational therapists
implement their understanding regarding the value of activities and the need for balanced participation.
Most notable are the Lifestyle Redesign programme (Mandel et al, 1999) and the Lifestyle Matters
programme (Craig and Mountain, 2007), which are both designed for use with older adults. The original
Lifestyle Redesign programme was developed in the United States of America (USA) and reinforced the
importance of embedding healthy occupations in lifestyle change. Its effectiveness was researched in a
randomised controlled trial which proved that it was highly successful in enhancing the physical and
mental health of well elderly people (Jackson et al, 1998). So much so that, when all the participants in
the study were re-evaluated six months after the intervention, approximately 90 per cent of the
therapeutic gain had been sustained (Clark et al, 2001). In addition, the programme was found to be
cost-effective, with the post-intervention healthcare costs being lower than in the control groups
(Hay et al, 2002) – a finding that was replicated in a further study (Clark et al, 2012). Meanwhile, the
Lifestyle Matters programme was developed in the UK and researchers have carried out a successful
feasibility study in community settings (Mountain et al, 2008).
P This page may be photocopied for instructional use only. © Sue Parkinson 3
Other lifestyle programmes have been designed over the years, including the Wellness and Lifestyle
Renewal manual (Rosenfeld, 1993), based on the Model of Human Occupation (Kielhofner, 1985). This
model has provided a framework for analysing occupational life for more than 30 years (Kielhofner and
Burke, 1980; Kielhofner, 1985, 1995, 2002, 2008). It provides a framework for analysing occupational life
according to a person’s volition, roles and routines, performance and environment (Kielhofner, 2008) and
it has been used extensively to guide occupational therapy interventions (de las Heras de Pablo, 2011).
The target population for these interventions spans older adults (Yamada et al, 2010) and adults in acute
in-patient care (Melton et al, 2008), ‘worried well’ people (Rosenfeld,1993, piii), rehabilitation
(de las Heras et al, 1993) and secure psychiatric settings (Lee and Harris, 2010).
Recovery through Activity – purpose and content

Recovery through Activity shares the aims of the Japanese wellness programme for older people based
on the Model of Human Occupation, which is paraphrased below.
Aims:
• To provide a forum for participants with mental health problems to reflect on their occupational
lives and the impact on their general health
• To discuss and practise lifestyle choices that can better meet the participants’ occupational and
health needs
(Yamada et al, 2010)
It is also hoped that the programme will enable participants to experience some of the benefits that
participants ascribed to a lifestyle programme in Sweden: increased awareness of their situation;
changes to daily life; improved health; and a more equal relationship with the facilitators
(Forsberg et al, 2011).
Recovery through Activity differs from the programmes mentioned above in that it has been designed to
engage adults who are accessing mental health services, whether these are hospital-based or
community-based. MOHO has guided the design of the whole intervention, but it is most evident in the
one-to-one assessment and treatment-planning element of the programme. Meanwhile, the group
aspect of the programme focuses on encouraging participants to increase their participation in a range
of leisure activities, self-care activities and vocational activities.
The intention in creating this handbook was to describe a flexible intervention that is suitable for adults
who are of working age, based on widely recognised categories of occupational participation. The
resulting programme combines discussion-based sessions with opportunities to experience activities at
4 P This page may be photocopied for instructional use only. © Sue Parkinson
first hand or to explore topics in greater depth. Group sessions are complemented by one-to-one
assessment and treatment planning and they can be delivered by occupational therapists in a range of
mental health settings. Facilitators should note that the emphasis of group discussion is on recognising
the benefits of activity and reflecting on personal strengths, rather than dwelling on barriers and
personal limitations.
This handbook includes:
• a question-and-answer section for facilitators of a Recovery through Activity group programme
• options for formal and informal one-to-one (1:1) assessment to be offered in conjunction with the
group programme
suggestions for formal assessments
informal assessment questions to help examine the needs of individual participants
guidelines for setting measurable goals with individual participants
• an appendix including
a group protocol for the Recovery through Activity programme, a sample flyer and suggestions for
a pre-group interview and post-group evaluations.
• The core of this handbook is divided into 12 sections, each one detailing a separate category of
activity which can be used as the topic for group interventions. These categories of activity are:
1 Leisure activities
– identifying the difference between passive and active leisure pursuits
2 Creative activities
– realising that creativity involves risk-taking and problem-solving
3 Technological activities
– weighing up positive and negative outcomes
4 Physical activities
– acknowledging the benefits for physical and mental health
5 Outdoor activities
– comprehending the power of the natural environment for restoring a sense of wellbeing
6 Faith activities
– discovering the ways in which spiritual and religious beliefs can shape everyday life
7 Self-care activities
– appreciating that self-care involves managing health conditions, looking after our bodies, and
taking care of how we look
8 Domestic activities
– understanding the cultural importance placed on domestic identity and home-making
9 Caring activities
– distinguishing between caring about others, caring for others, looking after others, and receiving
care from others
10 Vocational activities
– reflecting on the benefits of paid work, volunteering and study
11 Social activities
– recognising the value of social interaction for building social networks
12 Community activities
– thinking about how to extend community involvement.
Each section includes:
• key messages to share with participants

• background information on the value of each activity
• suggestions for facilitating reflection and discussion, including
discussion starters
group exercises
handouts for photocopying
• ideas for practical follow-up activities to develop further awareness of each activity.
• references
References
Clark F, Azen SP, Carlson M, Mandel D, LaBree L, Hay J, Zemke R, Jackson J & Lipson L (2001) ‘Embedding health-
promoting changes into the daily lives of independent-living older adults: long-term follow-up of occupational therapy
intervention’, The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 56 (1), ppP60–P63.
Clark F, Jackson J, Carlson M, Chou C-P, Cherry BJ, Jordan-Marsh M, Knight BG, Mandel D, Blanchard J,
Granger DA, Wilcox RR, Lai MY, White B, Hay J, Lam C, Marterella S & Azen SP (2012) ‘Effectiveness of a lifestyle
intervention in promoting the well-being of independently living older people: results of the Well Elderly 2 Randomised
Controlled Trial’, Journal of Epidemiology and Community Health, 66 (9), pp782–90.
College of Occupational Therapists (2008) Health Promotion in Occupational Therapy, College of Occupational
Therapists, London.
Craig C & Mountain G (2007) Lifestyle Matters: An Occupational Approach to Healthy Aging, Speechmark Publishing,
Milton Keynes.
de las Heras CG, Dion GL & Walsh D (1993) ‘Application of rehabilitation models in a state psychiatric hospital’,
Occupational Therapy in Mental Health, 12 (3), pp1–32.
de las Heras de Pablo, CG (2011) ‘Promotion of occupational participation: integration of the Model of Human Occupation
in practice’, Israeli Journal of Occupational Therapy, 20 (3), ppE67–E88.
Farnworth L (2003) ‘Time use, tempo and temporality: occupational therapy’s core business or someone else’s business?’,
Australian Occupational Therapy Journal, 50 (3), pp116–26.
Forsberg, KA, Lindqvist O, Bjorkman TN, Sandlund M & Sandman PO (2011) ‘Meanings of participating in a lifestyle
programme for persons with psychiatric disabilities’, Scandinavian Journal of Caring Sciences, 25 (2), pp357–64.
Hay J, LaBree L, Luo R, Clark F, Carlson M, Mandel D, Zemke R, Jackson J & Azen SP (2002) ‘Cost-effectiveness of
preventive occupational therapy for independent-living older adults’, Journal of the American Geriatrics Society, 50 (8),
pp1381–8.
Jackson J, Carlson M, Mandel D, Zemke R & Clark F (1998) ‘Occupation in Lifestyle Redesign: the well elderly study
occupational therapy program’, American Journal of Occupational Therapy, 52 (5), pp326–36.
Kielhofner G (ed) (1985) Model of Human Occupation: Theory and Application, 1st edn, Lippincott, Williams and Wilkins,
Baltimore, MD.
Kielhofner G (ed) (1995) Model of Human Occupation: Theory and Application, 2nd edn, Williams and Wilkins,
Baltimore, MD.
Kielhofner G (ed) (2002) Model of Human Occupation: Theory and Application, 3rd edn, Lippincott, Williams and Wilkins,
Baltimore, MD.
Kielhofner G (ed) (2008) Model of Human Occupation: Theory and Application, 4th edn, Williams and Wilkins,
Baltimore, MD.
Kielhofner G & Burke J (1980) ‘A model of human occupation, part 1: conceptual framework and content’, American
Journal of Occupational Therapy, 34 (9), pp572–81.
Lee S & Harris M (2010) ‘The development of an effective occupational therapy assessment and treatment pathway for
women with a diagnosis of borderline personality disorder in an inpatient setting: implementing the Model of Human
Occupation’, British Journal of Occupational Therapy, 73 (11), pp559–63.
Lloyd C, King R & Bassett H (2002) ‘A survey of Australian mental health occupational therapists’, British Journal of
Mandel DR, Jackson JM, Zemke R, Nelson L & Clark FA (1999) Lifestyle Redesign: Implementing the Well Elderly
Program, The American Occupational Therapy Association, Inc., Bethesda, MD.
Meeson B (1998) ‘Occupational therapy in community mental health, part 1: intervention choice’, British Journal of
Melton J, Forsyth K, Metherall A, Robinson J, Hill J & Quick L (2008) ‘Program redesign based on the model of human
occupation: inpatient services for people experiencing acute mental illness in the UK’, Occupational Therapy in Health Care,
22 (2–3), pp37–50.
Mountain G, Mozley C, Craig C & Ball L (2008) ‘Occupational therapy led health promotion for older people: feasibility of
the lifestyle matters programme’, British Journal of Occupational Therapy, 71 (10), pp406–13.
Pierce D (2001) ‘Occupation by design: dimensions, therapeutic power, and creative process’, American Journal of
Rosenfeld MS (1993) Wellness and Lifestyle Renewal: Manual for Personal Change, The American Occupational Therapy
Association, Bethesda, MD.
Tremblay MM & Brousseau M (2011) ‘Theoretical perspectives on health education and record-keeping’, Canadian
Yamada T, Kawamata H, Kobayashi N, Kielhofner G & Taylor RR (2010) ‘A randomised clinical trial of a wellness
programme for healthy older people’, British Journal of Occupational Therapy, 73 (11), pp540–8.
Applying the Model of

Human Occupation
Overview of MOHO theory
The Model of Human Occupation (Figure 1) is based on the belief that occupational participation is a
central force in health, wellbeing and development. It views people as dynamic, self-organising beings,
who are continuously responding to changes and instigating changes. This self-organisation stems from
a person’s occupational behaviour. In other words, we can maintain, reinforce and build our capacities,
beliefs and characters as we engage in leisure, self-care and work-related tasks.
Environment
Person
Figure 1 The Model of Human Occupation (Source: Parkinson et al, 2006)
How we participate in occupation and adapt to our occupational circumstances is shaped by the
interplay of our individual characteristics and by conditions within the environment.
• Individual characteristics comprise volition, habituation and performance capacity.
Volition – the universal need to act is uniquely expressed in each person’s occupational
performance according to the person’s volition. Volition has three main constituents: personal
causation, interests and values. That is, how effective we think we are; what we find enjoyable
and satisfying; and what we hold as being important.
Habituation – the process of acquiring and repeating recurring patterns of occupational

performance that make up much of our everyday lives and are regulated by our roles
and routines.
Performance capacity – the complex interaction of musculoskeletal, neurological, perceptual

and cognitive phenomena.
• The environment influences occupational participation by: (a) providing opportunities and
resources and (b) creating conditions that constrain and make demands on a person.
Reduced capacity alone does not prevent us from participating in occupation. Instead, our underlying
capacities combine with other personal and environmental factors, allowing us to continue to
participate in occupation if we can make volitional choices, have supportive roles and routines, and can
access adequate environmental supports.
Occupational participation refers to a person’s involvement in life roles and is underpinned by a person’s
occupational performance and skills, so that together they constitute three ‘levels of doing’.
• Participation is the broadest term and describes engaging in meaningful occupations that are
significant socially and personally.
• Performance is more specific and is used to denote the various individual activities that are carried
out as part of a larger occupation. For instance, participation in daily personal activities necessitates
the performance of a range of tasks, including brushing teeth, washing hands and face, bathing and
toileting, etc.
• Skills are the goal-directed actions that are required for each activity.
Communication and interaction skills, including a person’s non-verbal skills, conversation, vocal
expression and relationship skills.
Process skills, including a person’s knowledge of activities, use of objects, utilisation of time and
space, and problem-solving skills.
Motor skills, including a person’s posture and mobility, coordination, strength and effort,
and energy.
Participation leads to adaptation, which is defined as a state of wellbeing that is achieved when we
respond effectively to the challenges in our lives. Occupational adaptation is viewed as arising from two
component parts: occupational identity and occupational competence.
• Occupational identity is essentially a sense of self, of who we are and want to become,
combining elements of volition and habituation and perceptions of the environment.
Applying the Model of Human Occupation
• Occupational competence is the degree to which we sustain a pattern of occupational

participation that reflects identity. Competence concerns putting our identity into action and having
lifestyles and skills that support our identity. Whereas occupational identity is subjective,
occupational competence is the objective manifestation of whether a person can organise life to
meet his or her responsibilities and obligations.
A person’s sense of their identity and competence develops over time, flowing from exploration into
competence and achievement, according to the person’s developmental age and their relative
experience of different occupations and environments.
• Exploration is the first stage of change when we try out new things and learn about our capacities,
preferences and values.
• Competence is the next stage when we begin to integrate new ways of doing things and are more
concerned with improving standards relating to greater efficacy and efficiency.
• Achievement is the final stage when we have sufficient skills and habits to participate fully in the
occupation in question.
MOHO and Recovery through Activity

The stages of change should be borne in mind when facilitating Recovery through Activity. Essentially,
the group programme needs to focus on exploration while the 1:1 element is more focused on building
competence. This means that the aim of the group sessions is to reinforce the participants’ view of
themselves as occupational beings – to shore up their occupational identities and allow them to explore
their interests, values and beliefs.
The facilitators’ role is to provide the structure for participants to experience a range of occupations, to
validate their experience and to encourage anticipation of future participation in activities. (Note: this
fits in with stage 4 of the Remotivation Process: ‘Pleasure and Efficacy in Action’; de las Heras et al,
2003.) Meanwhile, the time spent 1:1 takes things a stage further by helping individuals to organise
their roles and routines. The facilitators will continue to provide structure, validation and encouragement
on a 1:1 basis. They will also be working to identify specific issues that can facilitate occupational
participation and to negotiate personal goals, as well as providing specific feedback, targeted advice,
individual coaching and, if necessary, physical support to access new occupations and environments.
In this way, they may help participants to address any skill limitations and performance limitations,
with the overall aim of increasing occupational participation. (Note: this fits in with stages 5 and 6 of
the Remotivation Process: ‘Internalised Sense of Efficacy’ and ‘Living and Telling One’s Story’;
de las Heras et al, 2003.)
The table below summarises the differences between a group programme and 1:1 work.
Differentiating between the Recovery through Activity group programme and

1:1 work using concepts from MOHO
Characteristic Group programme 1:1 work

Targeting: exploration level competence level
to build: occupational identity occupational competence
through: discussion and reflection analysis and practice
Focusing on: volition habituation
• interests • roles
• values • routines
• personal causation performance capacity
environmental opportunities skills, performance and participation
Using key strategies: structuring identifying

validating negotiating
encouraging giving feedback
advising
coaching
providing physical support
(Source: Forsyth & Kielhofner, 2008)
References
de las Heras CG, Llerena V & Kielhofner G (2003) A User’s Manual for Remotivation Process: Progressive Intervention for
Individuals with Severe Volitional Challenges. Version 1.0, University of Illinois, Chicago, IL.
Forsyth K & Kielhofner G (2008) ‘Therapeutic strategies for enabling change’, Kielhofner G (ed), Model of Human
Occupation: Theory and Application, 4th edn, Lippincott, Williams & Wilkins, Baltimore, MD, pp185–203.
Baltimore, MD.
Parkinson S, Forsyth K & Kielhofner G (2006) User’s Manual for the Model of Human Occupation Screening
Tool (MOHOST) (version 2.0), University of Illinois, Chicago, IL.
Promoting the value

of activity
Activity and occupation
Activity fills our days and action characterises our very existence. As human beings, we all need
occupation to survive and flourish (Wilcock, 1993). Our lives revolve around the things we need to do or
want to do, whether they are self-care tasks to meet our personal and domestic needs, leisure pursuits
or work-related responsibilities. When describing all that this entails, the terms ‘activity’ and
‘occupation’ are often used interchangeably (Royeen, 2002). However, the two terms are subtly, yet
fundamentally, different.
• Activity describes a ‘culturally shared idea about a category of action’ (Pierce, 2001a) and, as such,
is a useful starting point. The three main categories include activities done for their own sake (play
or leisure), activities necessary for self-care, and productive activities which provide services to
other people (Kielhofner, 2008). Wellbeing comes from having a balance in everyday life (Håkansson
et al, 2006) – a balance between those ‘must do’ activities and the ‘would like to do activities’
(Majnemer, 2010).
• Occupation is a broader and more individualised concept. By engaging in a cluster of related

activities we come to develop a series of personally constructed occupations (Hinojosa and Kramer,
1997), which are moulded by our specific circumstances (Pierce, 2001a). By participating in these
occupations, we can form long-term roles and relationships, giving a sense of belonging,
commitment and permanence that inevitably shapes our values and the way we define ourselves
(Kielhofner, 2008).
In Kielhofner’s book The Model of Human Occupation: Theory and Application (2008), activity and
occupation are both described as forms of action or ‘doing’ that allow us to have an impact on our
environment and help us to pass the time. It is noted that time weighs heavily upon us if we do not
engage in action, so we are all moved to fill or occupy our time and we mark the passing of time
according to what we have been doing (mealtimes, the working week, etc.). In this way, what we do fills
our present and we anticipate the future according to what we have planned to do.
Whereas activity choices are short-term decisions that require only brief deliberation, occupational
choices require greater thought because they imply greater permanence and sustained performance
over a longer period of time. They involve taking on new roles and establishing routines, and they
demand greater commitment.
The Recovery through Activity programme is concerned with helping individuals to reflect on their
occupational lives but, undeniably, ‘activity’ is the more familiar term (Craig and Mountain, 2007) and
therefore is used throughout this handbook.
Activity and mental health

Enduring mental illness has a major impact on occupational participation and leads to people being less
social and less active (Law, 2002). The reasons for this reduction in activity are many and various: for
example, people may fear a relapse of their condition, or they may experience various socio-economic
constraints (Nagle et al, 2002), or the symptoms of mental ill health may themselves present barriers
(Leufstadius and Eklund, 2008).
Institutional environments can also hinder participation in valued activities (Farnworth et al, 2004),
although living in the community is not without its problems. Shimitras et al (2003) found that people
with schizophrenia in North London spent most of their time engaged in sleeping, personal care or
passive leisure and little time engaged in vocational or active leisure pursuits.
People who experience mental illness are not all affected in the same way. On the whole, women will
spend more time engaged in domestic activities than men (Shimitras et al, 2003). This was confirmed by
Leufstadius and Eklund (2008), who found that women and individuals living with children spent more
time on self-care or self-maintenance. Meanwhile, when compared with other groups, older people
have better daily rhythms in that they are more likely to engage in certain activities on a more regular
basis (Leufstadius and Eklund, 2008), while young people spend more time in social occupations
(Shimitras et al, 2003).
Increased activity, whether social or domestic, is associated with recovery from mental illness.
Aubin et al (1999) found that perceived competence in daily activities and pleasure in vocational and
leisure activities were both linked with a higher subjective quality of life in people with severe mental
illness. Similarly, Kelly et al (2001) studied the relationship between involvement in activities and quality
of life for people with severe and enduring mental illness. They found that while involvement in
activities was linked to self-reported quality of life, a stronger link existed when participants were
satisfied with their involvement. Meanwhile, Eklund et al (2001) found that people with schizophrenia
reported greater wellbeing when satisfied with their employment status, and that satisfaction with their
participation in daily occupations as a whole was even more important. To be satisfying, activities must
be perceived as facilitating self-identity and supporting normality and social interaction (Hvalsøe and
Josephsson, 2003), as well as engendering a sense of usefulness (Legarth et al, 2005).
Activity and the occupational therapy process

Occupational therapists believe not only that occupational participation can influence health and
wellbeing (Kielhofner, 2008) but also that by using activity, occupational therapy has a unique role to
play in enabling people to lead fulfilling lives (Law, 2002). The entire occupational therapy profession is
founded on the
magnificent hypothes[i]s … That man, through the use of his hands as

they are energised by mind and will, can influence the state of his
own health.’
(Reilly, 1962, p2)
In other words, we can set about improving our health by purposefully choosing to engage in activities.
The term purposeful activity is used in occupational therapy to describe the activities that are used in
therapeutic settings (Golledge, 1998) but, to be truly therapeutic, the activities must also be meaningful.
It is meaningfulness that motivates performance (Trombly, 1995), so occupational therapists must first
understand what is important to their clients and then initiate purposeful activities that reflect these
values. They must also match the use of any group activities with individualised goal-setting, to build
and restore the participants’ specific occupations. In this way, the ultimate focus, or endpoint, of
occupational therapy remains fixed on the sustainability of valued occupations, with activity simply
being the tool through which change is initiated.
The transformation from activity to occupation and from ill health to wellbeing involves a dynamic
process that is characterised by doing, being and becoming (Wilcock, 1998). Doing the activities will
enable participants to practise their skills and abilities (Fidler and Fidler, 1978) and needs to be balanced
with time for being (Wilcock, 1998), so that there can be time for reflection and evaluation. By taking
time to review people’s experience, it becomes apparent that activities will mean different things to
different people. For some people leisure will be a matter of pleasure; for others it will have a
productive focus; and for some it will be restorative in nature (Pierce, 2001b). Consequently, the
outcome of therapy is not merely that people will engage in various categories of activity, but that they
will fulfil their varied occupational needs, including accomplishment, affirmation, companionship and
pleasure (Doble and Santha, 2008). This will allow them ‘to connect the past and present to a hopeful
future’ (Hammell, 2009, p107).
The value of activity – key messages

• Action helps us to have an impact on our environment and helps time to pass.
Without action, time weighs heavily upon us, so we are all moved to fill or occupy our time.
We mark the passing of time according to what we have been doing (mealtimes, the
working week, etc.).
What we do fills our present.
We anticipate the future according to what we have planned to do.
• Wellbeing comes from having a balance in three types of activity:

activities of daily living or self-care
leisure or play
work or productivity.
• Wellbeing can be maintained when we establish roles and routines to incorporate the activities
in long-term ‘occupations’ based on our values and interests:
occupations are more permanent and require commitment
occupations help us to develop relationships and give us a sense of belonging.
• Because occupations describe who we are, they change how we feel about ourselves:
What we choose to do changes how we feel and has the power to change our lives.
References
Aubin G, Hachey R & Mercier C (1999) ‘Meaning of daily activities and subjective quality of life in people with severe
mental illness’, Scandinavian Journal of Occupational Therapy, 6 (2), pp53–62.
Craig C & Mountain G (2007) Lifestyle Matters: An Occupational Approach to Healthy Aging, Speechmark Publishing,
Milton Keynes.
Doble SE & Santha JC (2008) ‘Occupational well-being: rethinking occupational therapy outcomes’, Canadian Journal of
Eklund M, Hansson L & Bejerholm U (2001) ‘Relationships between satisfaction with occupational factors and health-
related variables in schizophrenia outpatients’, Social Psychiatry and Psychiatric Epidemiology, 36 (2), pp79–85.
Farnworth L, Nikitin L & Fossey E (2004) ‘Being in a secure forensic psychiatric unit: every day is the same, killing time or
making the most of it’, British Journal of Occupational Therapy, 67 (10), pp430–8.
Fidler G & Fidler J (1978) ‘Doing and becoming: purposeful action and self-actualisation’, American Journal of
Golledge, J (1998) ‘Distinguishing between occupation, purposeful activity and activity, part 1: review and explanation’,
Håkansson C, Dahlin Ivanoff S & Sonn U (2006) ‘Achieving balance in everyday life’, Journal of Occupational Science,
13 (1), pp74–82.
Hammell KW (2009) ‘Self-care, productivity, and leisure, or dimensions of occupational experience? Rethinking occupational
“categories”‘, Canadian Journal of Occupational Therapy, 76 (2), pp107–14.
Hinojosa J & Kramer P (1997) ‘Statement: fundamental concepts of occupational therapy: occupation, purposeful activity,
and function’, American Journal of Occupational Therapy, 51 (10), pp864–6.
Hvalsøe B & Josephsson S (2003) ‘Characteristics of meaningful occupations from the perspective of mentally ill people’,
Scandinavian Journal of Occupational Therapy, 10 (2), pp61–71.
Kelly S, McKenna H, Parahoo K & Dusoir A (2001) ‘The relationship between involvement in activities and quality of life
for people with severe and enduring mental illness’, Journal of Psychiatric and Mental Health Nursing, 8 (2), pp139–46.
Kielhofner G (ed) (2008) The Model of Human Occupation: Theory and Application, 4th edn, Lippincott, Williams & Wilkins,
Baltimore, MD.
Law M (2002) ‘Participation in the occupations of everyday life’, American Journal of Occupational Therapy, 56 (6), pp640–9.
Legarth KH, Ryan S & Avlund K (2005) ‘The most important activity and the reasons for that experience reported by a
Danish population at age 75 years’, British Journal of Occupational Therapy, 68 (11), pp501–8.
Leufstadius C & Eklund M (2008) ‘Time use among individuals with persistent mental illness: identifying risk factors for
imbalance in daily activities’, Scandinavian Journal of Occupational Therapy,15 (1), pp23–33.
Majnemer A (2010) ‘Balancing the boat: enabling an ocean of possibilities’, Canadian Journal of Occupational Therapy,
77 (4), pp198–205.
Nagle S, Cook JV & Polatajko HJ (2002) ‘I’m doing as much as I can: occupational choices of persons with a severe and
persistent mental illness’, Journal of Occupational Science, 9 (2), pp72–81.
Pierce D (2001a) ‘Untangling occupation and activity’, American Journal of Occupational Therapy, 55 (2), pp138–46.
Pierce D (2001b) ‘Occupation by design: dimensions, therapeutic power, and creative process’, American Journal of
Reilly M (1962) ‘The 1961 Eleanor Clarke Slagle lecture: Occupational therapy can be one of the great ideas of 20th century
medicine’, American Journal of Occupational Therapy, 16 (1), pp1–9.
Royeen CB (2002) ‘Occupation reconsidered’, Occupational Therapy International, 9 (2), pp111–20.
Shimitras L, Fossey E & Harvey C (2003) ‘Time use of people living with schizophrenia in a North London catchment area’,
Trombly CA (1995) ‘The 1995 Eleanor Clarke Slagle lecture: Occupation: purposefulness and meaningfulness as therapeutic
mechanisms’, American Journal of Occupational Therapy, 49 (10), pp960–72.
Wilcock A (1993) ‘A theory of the human need for occupation’, Journal of Occupational Science, 1 (1), pp17–24.
Wilcock AA (1998) ‘Reflections on doing, being and becoming’, Canadian Journal of Occupational Therapy, 65 (5),
pp248–57.
Delivering the Recovery through

Activity group programme
Questions and answers
The materials in this handbook can be used flexibly to respond to the individual needs of participants.
Each course will therefore evolve differently and skilled facilitation is required to tailor the session plans.
Facilitators should consider the following questions when planning a Recovery through Activity
programme.
How often should the sessions be held?

This depends on the remit of the service and the expected timeframes for intervention. The discussion-
based sessions could be offered on a weekly, fortnightly or monthly basis. Having more time between
each session will give increased opportunities for follow-up activities to explore the topic further,
including 1:1 assessment and coaching or supplementary sessions, but this may make the programme
too lengthy. Compromises may be needed to meet the demands of local resources.
Should group membership be closed or open?

It can be either, depending on the setting:
• in an acute hospital setting, the programme is more likely to be run as an open group
• in the community, the programme is more likely to be run as a closed group.
Who should attend?

A group profile is provided in the Appendix. Participants should meet the referral criteria and if group
membership is closed, the facilitators should gather together participants with like needs and interests.
The following chapter describes a range of occupational assessments that can assist with this task.
How many people should attend?

The optimum number of participants per session is usually six to eight people. Some facilitators may
choose to start a closed group with ten participants if it is thought that attendance might fluctuate
during the programme.
Should all the session topics be included in a single programme?

No – programmes should be tailored to meet the needs of the participants and the setting:
• in an acute hospital setting where group membership is open, the topic might be decided each week
according to the needs of the participants
• in a long-term rehabilitation setting, all of the topics might be covered in a systematic fashion
• in the community, it is more likely that the occupational therapists will build a programme using a
reduced number of topics that have been tailored to meet the needs of the participants. For
instance, the programme might be themed:
to focus on ‘leisure interests’ and include:
– leisure activities, social activities, creative activities and physical activities
to focus on ‘keeping active’ and include:
– physical activities, outdoor activities, vocational activities and community activities
to focus on ‘looking after oneself’ and include:
– self-care activities, domestic activities, faith activities and outdoor activities
or the programme might be an eclectic mix of topics, reflecting the identified needs and
interests of the participants.
Can activities from different topics be merged together?

Yes, for example:
• Several of the topics are closely related. When sessions have not been included in the programme,
facilitators may still choose to include some of the activities from these sessions.
• Some of the sessions cover topics that could be combined. For instance:
the physical activities session might include some of the content from the outdoor activities
session
the leisure activities session might include some of the content from the social activities session
the social activities session might include some of the content from the community
activities session
the creative activities session might include some of the content from the technological
activities session
the domestic activities session might include some of the content from the caring
activities session
Delivering the Recovery through Activity group programme
some of the content from the vocational activities session might be combined with some from
the community activities session, to focus particularly on volunteering activities
some of the content from the self-care activities session might be combined with some from the
domestic activities session to focus more broadly on activities of daily living.
How many activities should be included in a single session?

The listed activities are suggestions only. It is not intended that all of them be used in any one session
and the facilitators may well have their own ideas for activities to explore the topics. Activities can be
chosen to create a balanced agenda that matches the abilities and interests of the participants, ensuring
that plenty of time is allowed for discussion.
• In acute in-patient settings, facilitators might combine discussion-based topics and experiential
follow-up activities in a single session.
• In forensic settings, less time might be spent investigating local resources.
• If participants find discussion difficult, several discussion starters might be used as quick-fire
questions, without expecting detailed discussion.
• In general, facilitators should endeavour to include:
a short warm-up activity
an activity that introduces the key issues in the topic
a main activity – whether practical or discussion-based
a reflective activity to end with.
Do the activities need to be presented exactly as described in the handbook?

No, for example:
• the facilitators can arrange for participants to work individually, in pairs, in small groups or as a
whole group
• they could photocopy the worksheets in the handbook, or copy them onto flipchart paper, or
facilitate discussion without recourse to any written information
• they might generate ideas by giving individuals time to collect their thoughts before going round
asking each person in turn, asking pairs or groups to feed back their discussions, or inviting the
group to call out their ideas at random
• they could reinforce the key messages by making a formal presentation and providing handouts, or
informally introducing themes into the conversation one by one. They could also ask the participants
to reflect on each topic and produce their own summary of the key learning points.
Is it necessary to follow up the sessions with additional activities?

The sessions are designed to allow participants to explore the importance of activity to their recovery.
Additional 1:1 work is required to support individual goal-setting and to allow participants to experience
and reflect on the benefits of activity, but this can be achieved with or without the addition of
supplementary sessions for the whole group.
• Facilitators may choose to include a practical, experiential activity in the discussion-based session.
• Where access to resources is challenging, facilitators may also choose to arrange follow-up
activities to some, but not all, sessions.
What background reading would be useful?

It is recommended that facilitators read the introductory chapter for each session. The references may
provide a useful starting point for further reading but will inevitably become dated over time. It is
therefore recommended that facilitators conduct rudimentary literature searches before facilitating the
programme, in order to acquaint themselves with current thinking, get fresh ideas, and recommend the
latest websites to participants.
How can the programme be promoted?

The Appendix includes a prototype A5 flyer for participants, as well as a group profile, to explain the
purpose of the group to the wider team and referring agencies. In addition, the key messages for The
Value of Activity (page 16) should be discussed widely, and facilitators may want to consider making
posters to advertise the programme, using information from this handbook.
How can the programme be evaluated?

There is an evaluation form for participants and a reflective log for facilitators in the Appendix, but the
service may have its own format for gathering feedback. Occupational therapists may also consider
using assessments based on the Model of Human Occupation as outcome measures. Descriptions of
these can be found in the next chapter.
Can professionals other than occupational therapists facilitate the programme?

It is envisaged that occupational therapists will be the primary facilitators of Recovery through Activity,
although other people may co-facilitate the programme. Occupational therapists are deemed to have the
expertise required to assess the participants’ occupational needs and to provide the necessary follow-up
interventions to maximise occupational participation. In addition, the programme relies on facilitators
having sufficient training and experience in therapeutic groupwork, to coordinate the programme and
choose the most appropriate exercises for each cohort of service users.
Although this handbook is an effective tool for those who have the right combination of skills, it does
not provide the detailed guidance that would enable everyone to undertake essential 1:1 coaching and
facilitate a comprehensive Recovery through Activity programme.
Providing one-to-one assessment

and treatment-planning
In addition to facilitating the group programme, occupational therapists must also provide individual
support to the participants in order to:
• assess their particular occupational needs
• negotiate individual treatment plans with measurable goals
• provide one-to-one (1:1) therapy.
Assessing occupational needs

To enhance occupational performance, occupational therapists need assessment tools that will reflect
their unique focus and gather information about a person’s everyday life and their reasons for doing
what they do (Law, 2005). They should become as proficient as possible in their professional language
(Loftus and Higgs, 2008). It is also recommended that they adopt an occupation-focused, conceptual
model of practice capable of providing a framework for constructing their reasoning, and providing the
necessary technical terms to articulate the occupational needs of participants (Melton et al, 2009).
The author recommends assessments based on the Model of Human Occupation, which provides a
structure for minimum, yet comprehensive, assessment (Kielhofner, 2008) by systematically identifying
the personal and environmental factors influencing a person’s occupational adaptation (Kramer et al,
2008). The model enables client-centred measurement (Law, 2005) by providing a range of assessments
to suit different situations which have been tested to ensure reliability and clinical utility (Kramer et al, 2008).
Formal assessments to use pre- and post-intervention

The five assessments in this section are all self-assessments which could be offered to prospective
participants in order to:
• initiate discussion about occupational needs
• identify areas of occupational need that might be addressed in a Recovery through Activity
programme.
Activity Checklist (see the Appendix)

The activity checklist has been specially created for Recovery through Activity. It is based on the UK
version of the Interest Checklist (Heasman and Salhotra, 2008) which gathers information on a client’s
strength of interest and engagement in activities in the past, currently, and in the future. The main focus
of the Interest Checklist is on leisure interests, while the Activity Checklist has been adapted to mirror
the full range of activities in Recovery through Activity. As such, it could be used to assist the selection
of topics in a Recovery through Activity programme. Alternatively, the interest checklist has been used
successfully during the leisure activities session, to stimulate discussion about participants’ interests.
Occupational Self Assessment (OSA) Version 2.2 (Baron et al, 2006)

Reflecting the uniqueness of each person’s values and needs, the OSA is a tool that facilitates person-
centred therapy. The self-report assists individuals to recognise their occupational needs, articulate the
level of satisfaction that they experience currently, and establish priorities for change. It could be used
to help plan the group programme and to inform 1:1 support. It could also be repeated as an outcome
measure to evaluate progress at the end of the programme.
The Inclusion Web (Bates, 2010)

The Inclusion Web is based on Social Role Valorisation (Wolfensberger, 2011), rather than the Model of
Human Occupation (Kielhofner, 2008). It helps people to think about the places in which they experience
various occupations and the people associated with those places. As such, it could be used both before
and after the Recovery through Activity programme to help plan the sessions and evaluate change.
Role Checklist Version 2 (Scott et al, 2014)

The Role Checklist Version 1 (Oakley et al, 1986) was designed to gather information about clients’
perceptions of 10 occupational roles. It also asked clients to rank the value they placed on these roles.
Patricia Scott, from Indiana University has modified the checklist to measure ‘Quality of Performance’,
allowing individuals to rate their satisfaction with their performance of the same ten roles. It could be
used in conjunction with the Activity Checklist to identify relevant session topics to include in a
Recovery through Activity programme and to monitor outcomes.
Occupational Questionnaire (Smith et al, 1986)

The Occupational Questionnaire documents an individual’s participation in occupations during half-hour
intervals throughout the day. The questionnaire might be used in 1:1 sessions to help participants reflect
on their occupational participation and the changes that they would like to make.
Additional formal assessments

The following assessments would not be used with all participants, but they could be used at various
points in the Recovery through Activity programme, to provide more detailed information about an
individual’s occupational participation.
The Volitional Questionnaire (VQ) Version 4.1 (de las Heras et al, 2007)
This is an observational assessment that evaluates a person‘s volition, including motivation, values,
interests and the impact of the environment. The VQ provides insight into a person’s inner motives and
information about how the environment affects volition by systematically capturing how a person reacts
to, and acts within, his or her environment. The assessment is made through observation, making it an
effective tool for occupational therapists to evaluate a person’s responses when engaging in
experiential activities, in order to confirm which activities are most meaningful. It could be used to
reflect on participants’ responses to experiential activities in the Recovery through Activity programme.
The Assessment of Communication and Interaction Skills (ACIS) Version 4.0

(Forsyth et al, 1998)
The ACIS is an observational assessment that gathers data on communication and interaction skills
necessary for accomplishing daily tasks. Three domains – non-verbal communication, verbal
communication and ability to relate to others – are used to describe different aspects of communication
and interaction. If problems are identified engaging in social activities or community-based activities in
the Recovery through Activity programme, occupational therapists could use this assessment to identify
issues to be addressed.
The Assessment of Motor and Process Skills (AMPS) (Fisher and Jones, 2010)
The AMPS is an observational assessment which was originally based on the Model of Human
Occupation and requires assessors to successfully complete a formal training programme. It is used to
measure the quality of a person’s performance of domestic activities or self-care activities.
If participants experience problems with these particular activities in the Recovery though Activity
programme, or if their motor and process skills affect their ability to participate in any of the other
activities, this assessment could be used to identify the particular issues and suggest possible solutions.
Worker Role Interview (WRI) Version 10.0 (Braveman et al, 2005) and Work Environment Impact
Scale (WEIS) Version 2.0 (Moore-Corner et al, 1998)
These semi-structured interviews gather information about a person’s vocational needs and could be
used as part of the Recovery through Activity programme, to help address psychosocial and
environmental factors that hinder participation in vocational activities.
Informal assessment
Facilitators should constantly seek to understand the person’s particular strengths and challenges in
relation to the various activities included in the Recovery through Activity programme. In addition to any
formal assessments, they will need to ask questions about the person’s motivation to participate in each
activity, how each activity can be integrated into the person’s life, whether the person has the necessary
skills for the activity, and how their environment will support them.
Concepts from the Model of Human Occupation (Kielhofner, 2008) can be used to guide the facilitators’
reasoning and might lead to them asking the following questions.
• Does the person expect to be able to do the activity? (personal causation)
• Does the person enjoy the activity? (interests)
• How important is the activity to the person? (values)
• Do the person’s responsibilities support or interfere with their ability to participate in the activity?
(roles)
• How can the activity be integrated into the person’s routines? (habits)
• Does any impairment affect the person’s ability to participate in the activity? (performance capacity)
• Does the person have adequate motor, process and communication and interaction skills to perform
the activity? (skills)
• Where can the person participate in the activity? (physical space)
• Are there sufficient resources for the person to participate in the activity? (physical objects)
• Who could support the person to participate in the activity? (social environment)
Negotiating treatment plans

Negotiating treatment goals leads to improved outcomes in practice (Scott and Haggerty, 1984;
Annesi, 2002; Arnetz et al, 2004; Parkinson et al, 2011) by:
• increasing ownership of goals and the meaningfulness of interventions, thereby enhancing

motivation and adherence (Randall and McEwan, 2000; Law et al, 2004; Armstrong, 2008)
• informing individualised treatment and enhancing the quality of feedback provided (Law et al, 2004;
Park, 2009)
• ensuring that time and resources are used more effectively (Park, 2009), leading to better outcomes
(Levack et al, 2006)
• providing a clearer focus for the team (Armstrong, 2008) and improving the continuity of care
(Scott and Haggerty, 1984)
• meeting legislative requirements to measure outcomes (Levack et al, 2006)
• enabling greater client autonomy (Levack et al, 2006) and ability to set own goals in the future
(Annesi, 2002).
The more specific the goals, the better the results (Law et al, 2004), so goals should be measurable,
achievable and person-centred (Levack et al, 2006; Wilson and Dobson, 2008), with specified
timeframes and conditions (Webb and Glueckauf, 1994) which can be broken down to form smaller goals
(Annesi, 2002).
When these principles are embedded in practice, Parkinson et al (2011) found that service users
appreciated the support to stay focused. They were also more able to celebrate their achievements
once their goals had been reached. Meanwhile, team members noticed that their clients responded
well to having goals. The goals were viewed as being empowering because they were both meaningful
and manageable.
Components of each goal

According to Forsyth and Kielhofner (2008), each occupational goal should include the following
components: an action, a setting, the degree of dependence or support, and a timeframe. Recovery
through Activity recommends the following:
• a timeframe
• a level of occupational engagement
• an occupation (activity)
• an occupational setting (if this cannot be inferred from the occupation)
• an indication of the level of independence or support required.
Levels of change
The Model of Human Occupation identifies various levels of engagement (Kielhofner and Forsyth,
2008a). Using the levels of change, we can ensure that the goal remains focused on an active change
that can be made by the participant. Although the exact words can be adjusted, the taxonomy in the
MOHO textbook provides an excellent starting place:
• choosing
• committing
• exploring
• identifying
• negotiating
• planning
• practising
• re-examining
• sustaining.
Support strategies
The Model of Human Occupation also identifies various strategies for enabling change (Kielhofner and
Forsyth, 2008b). These describe the types of support that occupational therapists regularly provide:
• validating
• identifying
• giving feedback
• advising
• negotiating
• structuring
• coaching
• encouraging
• providing physical support.
By stipulating the nature of the support that will be provided, the occupational therapist is better able to:
• negotiate their role in enabling the individual to achieve her or his goals
• explain how carers and other members of the multidisciplinary team could support the individual
• demonstrate the breadth of their role.
Once more, the actual words are not exclusive, but they provide a good starting point.
Example goals indicating level of change and strategies for change

The following are possible goals using the above taxonomies.
• Within 2 weeks, Anna will choose a leisure activity to pursue at home, with advice from her
occupational therapist.
• Within 4 weeks, Ben will commit to increasing his participation in social activities, with coaching
from his occupational therapist.
• Within 3 weeks, Chloe will examine options for engaging in creative activities at home, with
encouragement from her occupational therapist.
• Within 3 weeks, David will independently identify the opportunities for engaging in physical
activities in adult education.
• Within 2 weeks, Emily will negotiate a routine with her carers to meet her self-care needs at home,
with advice from her occupational therapist.
• Within 2 weeks, Frances will plan how to manage her domestic activities at home with help to
identify solutions from her occupational therapist.
• Over the next 6 weeks, George will practise the skills necessary for employment, with feedback
from his occupational therapist.
• Over the next 4 weeks, Holly will re-examine her progress in a college course, with validation from
her course tutor.
• Over the next 8 weeks, Isabella will sustain her participation in her faith activities, with her support
worker providing physical support to enable her to attend church.
The timeframe for each goal would be negotiated with the participants and specific occupations
(eg gardening, voluntary work at an animal rescue centre) might be substituted for the general activities
if specific occupations have been chosen. Then, once these initial goals have been met, new goals
would be negotiated by extending the level of engagement, increasing the occupational settings or
reducing the degree of support. For example:
• Within 2 weeks, Anna will identify the resources she needs to pursue her chosen leisure activity,
with advice from her occupational therapist.
• Within 2 weeks, Ben will choose to participate in a social activity within the Secure Unit, with
encouragement and prompting from his occupational therapist.
• Within 2 weeks, Chloe will negotiate the resources to engage in card-making, with practical support
from her parents.
• For the next 4 weeks, David will commit to going swimming once a week, accompanied by his
support worker.
• Over the next 3 weeks, Emily will practise her identified self-care routine, with encouragement and
feedback from her parents.
• Over the next 3 weeks, Frances will sustain her routine of domestic responsibilities, with coaching
from the occupational therapy team.
• Within 4 weeks, George will have explored the options for voluntary work, with advice from the
Volunteer Bureau.
• Within 2 weeks, Holly will independently plan a homework routine.
• Over the next 2 weeks, Isabella will re-examine her participation in faith activities, with validation
from her parish priest.
It is unlikely that participants will develop long-term goals for each topic covered in their Recovery
through Activity programme. However, they might explore various options, and identify the associated
benefits and challenges before they choose certain activities and use their experiences to re-examine
their performance or negotiate particular roles. Eventually, it is hoped that the participants will plan two
or three activities to practise and then sustain. This process may last longer than the Recovery through
Activity group programme and so, if practicable, individual support could be extended for several weeks
after the programme finishes.
References
Annesi JJ (2002) ‘Goal-setting protocol in adherence to exercise by Italian adults’, Perceptual and Motor Skills, 94 (2),
pp453–8.
Armstrong J (2008) ‘The benefits and challenges of interdisciplinary, client-centred goal setting in rehabilitation’,
New Zealand Journal of Occupational Therapy, 55 (1), pp20–25.
Arnetz JE, Almin I, Bergström K, Franzén Y & Nilsson H (2004) ‘Active patient involvement in the establishment of
physical therapy goals: effects on treatment outcome and quality of care’, Advances in Physiotherapy, 6 (2), pp50–69.
Baron K, Kielhofner G, Lyenger A, Goldhammer V & Wolenski J (2006) A User’s Manual for the Occupational Self
Assessment (OSA). Version 2.2, University of Illinois, Chicago, IL.
Bates P (2010) Inclusion Web Resource Pack, National Development Team for Inclusion, Bath.
Braveman B, Robson M, Velozo C, Kielhofner G, Fisher G, Forsyth K & Kerschbaum J (2005) A User’s Guide to the
Worker Role Interview (WRI). Version 10.0, University of Illinois, Chicago, IL.
de las Heras CG, Geist R, Kielhofner G & Li Y (2007) A User’s Manual for the Volitional Questionnaire. Version 4.1,
University of Illinois, Chicago, IL.
Fisher AG & Jones KB (2010) Assessment of Motor and Process Skills, Vol. 2: User Manual, 7th edn, Three Star Press,
Fort Collins, CO.
Forsyth K & Kielhofner G (2008) ‘Communication and documentation’, Kielhofner G (ed), Model of Human Occupation:
Theory and Application, 4th edn, Lippincott, Williams & Wilkins, Baltimore, MD, pp407–41.
Forsyth K, Salamy M, Simon S & Kielhofner G (1998) A User’s Guide to the Assessment of Communication and
Interaction Skills (ACIS). Version 4.0, University of Illinois, Chicago, IL.
Heasman D & Salhotra G (2008) Interest Checklist UK: Guidance Notes, University of Illinois, Chicago, IL.
Baltimore, MD.
Kielhofner G & Forsyth K (2008a) ‘Occupational engagement: how clients achieve change’, Kielhofner G (ed), Model of
Human Occupation: Theory and Application, 4th edn, Lippincott, Williams & Wilkins, Baltimore, MD, pp171–84.
Kielhofner G & Forsyth K (2008b) ‘Therapeutic strategies for enabling change’, Kielhofner G (ed), Model of Human
Occupation: Theory and Application, 4th edn, Lippincott, Williams & Wilkins, Baltimore, MD, pp185–203.
Kramer J, Kielhofner G & Forsyth K (2008) ‘Assessments used with the Model of Human Occupation’, Hemphill-Pearson
BJ (ed), Assessments in Occupational Therapy Mental Health, Slack Incorporated, Thorofare, NJ, pp159–84.
Law M (2005) ‘Measurement in occupational therapy’, Law M, Baum C & Dunn W (eds), Measuring Occupational
Performance, 2nd edn, Slack Incorporated, Thorofare, NJ, pp3–20.
Law M, Pollock N & Stewart D (2004) ‘Evidence-based occupational therapy: concepts and strategies’, New Zealand
Levack WMM, Taylor K, Siegert RJ, Dean SG, McPherson KM & Weatherall M (2006) ‘Is goal-planning in
rehabilitation effective? A systematic review’, Clinical Rehabilitation, 20 (9), pp739–55.
Loftus S & Higgs J (2008) ‘Learning the language of clinical reasoning’, Higgs J, Jones M, Loftus S & Christensen N (eds),
Clinical Reasoning in the Health Professions, 3rd edn, Butterworth Heinemann, Oxford, pp339–48.
Melton J, Forsyth K & Freeth D (2009) ‘Using theory in practice’, Duncan EAS (ed), Skills for Practice in Occupational
Therapy, Churchill Livingstone, Edinburgh, pp9–23.
Moore-Corner RA, Kielhofner G & Olsen L (1998) A User’s Manual for Work Environment Impact Scale (WEIS).
Version 2.0, University of Illinois, Chicago, IL.
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reliability. Occupational Therapy Journal of Research, 6(3), pp157–69..
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Occupational Therapy, Churchill Livingstone, Edinburgh, pp105–22.
Parkinson S, Shenfield M, Reece K & Elliott J (2011) ‘Enhancing clinical reasoning through the use of evidence-based
assessments, robust case formulations and measurable goals’, British Journal of Occupational Therapy, 74 (3), pp148–52.
Randall KE & McEwan IR (2000) ‘Writing patient-centred functional goals’, Physical Therapy, 80 (12), pp1197–1203.
Scott AH & Haggerty EJ (1984) ‘Structuring goals via goal attainment scaling in occupational therapy groups in a partial
hospitalisation setting’, Occupational Therapy in Mental Health, 4 (2), pp39–58.
Scott PJ, McFadden R, Yates K, Baker S & McSoley S (2014). The Role Checklist V2: QP: Establishment of reliability and
validation of electronic administration. The British Journal of Occupational Therapy, 77(2), pp96–102.
Smith NR, Kielhofner G & Watts JH (1986) Occupational Questionnaire, University of Illinois, Chicago, IL.
Webb PM & Glueckauf RL (1994) ‘The effects of direct involvement in goal setting on rehabilitation outcome for persons
with traumatic brain injuries’, Rehabilitation Psychology, 39 (3), pp179–88.
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Management Association, New York.
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Developmental Disabilities, 49 (6), pp435–40.
For details of how to access assessments based on the Model of Human Occupation, please visit the Model of
Human Occupation website at: www.uic.edu/moho/products.aspx
For details of how to access the Inclusion Web, please visit the website for the National Development Team for
Inclusion at: www.ndti.org.uk
1 Leisure activities
3 Technological activities
5 Outdoor activities
6 Faith activities
7 Self-care activities
8 Domestic activities
9 Caring activities
10 Vocational activities
11 Social activities
12 Community activities
Leisure activities 1
Key messages
• A balanced lifestyle includes:
leisure activities
work-related activities
self-care activities.
• Leisure involves:
the use of free time
freedom of choice
freedom from everyday pressures.
• Leisure provides enjoyment and satisfaction and often includes:
increased social contact
a chance to improve skills.
• Leisure can restore balance in life because it can be relaxing or challenging:
it can be passive (when looking at things) or active (when doing things)
too much passive activity is not satisfying and is not good for our mental health.
• Leisure activities can take many forms but they must be meaningful for the individual.
The value of leisure activities
Introduction
Self-care, work and leisure are all essential aspects of a balanced lifestyle (Majnemer, 2010) and one of
the defining features of leisure is the lack of pressure (Craik and Pieris, 2006). Along with work, leisure
is more closely linked with high levels of life satisfaction than daily living tasks or rest (Smith et al,
1986) and the role of leisure has always been particularly valued by occupational therapists in mental
health settings (Turner et al, 2000; Specht et al, 2002).
The impact of leisure is recognised by staff and service users alike (Hutcheson et al, 2010). Mental
health systems around the world have come to recognise its importance in active living – a concept that
is much broader than pure physical exercise and should encompass leisure experiences in general
(Iwasaki et al, 2010). Indeed, a review of the literature reveals that there is:
empirical evidence that leisure can contribute to physical, social,

emotional and cognitive health through prevention, coping
(adjustment, remediation, diversion), and transcendence
(Caldwell, 2005, p7)
Furthermore, when Lloyd et al (2007) examined the relationship between motivation to engage in leisure
and perceptions of recovery, they found a statistically significant association when activities met
intellectual and social needs, and the need for competence or mastery.
Passive and active leisure

Certain activities are described as being more passive than others if they involve sitting still on our own
and observing others engage in activity, rather than being actively involved – watching life instead of
living it. Typically, these activities include watching television, browsing the web or reading. Such
pursuits are not totally without value and we all experience the need to ‘chill out’ or have time to
ourselves when life is busy, but a balance is required to maintain health and wellbeing (Westhorp, 2003).
Leisure can restore balance by satisfying those needs that would otherwise be unmet. It has been found
that it helps combat work stress precisely because it can be more passive and recuperative, or more
active and challenging, than a person’s usual work tasks (Trenberth and Dewe, 2002).
Leisure activities
Certain activities are better fitted for meeting our different needs, whether they are educational,
physical, social or aesthetic needs. However, it is generally acknowledged that passively watching
television is a poorly satisfying activity (Di Bona, 2000). The same might also be said of any leisure
pursuit where the sole motivation is to escape from life’s demands. This is not perceived as supporting
recovery (Lloyd et al, 2007).
Unfortunately, people with severe mental health problems are known to spend a disproportionate
amount of time in passive leisure (Krupa et al, 2003) or simply ‘doing nothing’ (Scanlan et al, 2011).
They also experience multiple barriers to participating in leisure pursuits (Hodgson et al, 2001),
including physical limitations, lack of finance and lack of transport (Pieris and Craik, 2004). These issues
are exacerbated still further if they live on their own (Harvey et al, 2006).
Meaningfulness
Active leisure does not necessarily require intense physical activity, and sedentary activity that does not
require exercise is better than no activity at all. What matters is whether the participants enjoy the
experience or find it satisfying, as pleasure and relaxation are key motivators (Ball et al, 2007).
Indeed, Fine (2001, p45) found that:
Individuals who engaged in leisure activity, whether it was physical

exercise or more sedentary activity such as card games, were less
depressed than individuals who did not engage in leisure activity.
Perhaps this is because all activity can induce an experience of flow – a rewarding psychological state
that comes when we are fully immersed in an activity (Csikszentmihalyi, 1995; Emerson, 1998).
The fact that positive subjective experiences rely on activities being meaningful to the people involved
(Pereira and Stagnitti, 2008) has implications for occupational therapy. Occupational therapists must
ensure that chosen leisure activities are imbued with personal meaning, which involves establishing a
person’s valued goals to enable particular needs to be met (Blacker et al, 2008). Occupational therapists
can provide individual support to enable any barriers to be overcome (Heasman and Atwal, 2004). They
also need to be aware that adequate social support is the most important factor for sustaining leisure
interests (Pieris and Craik, 2004).
Sample activities
Introduction
This session is designed to be a useful starting place in any Recovery through Activity programme.
Facilitators should reinforce the need for a balanced lifestyle, and the difference between activity and
occupation, referring to the key messages that relate to leisure activities (p35). They should also take
the opportunity to remind the participants of topics that have been chosen for subsequent sessions and
the times and dates for the programme.
Ideas for exercises and discussion

Childhood leisure interests
Ask the participants to think about the activities they enjoyed as children – for example, climbing trees,
making dens, playing with favourite toys, playing ‘make-believe’. Suggest that they discuss their
experience in pairs before feeding back to the group. Encourage pleasurable reminiscence about the
importance of play.
Activity checklists
Review the activity checklists that were completed before the Recovery through Activity programme.
Ask the participants to share one of their previous hobbies or interests and one that they would like to
pursue in the future.
Ask:
• Have people’s interests changed over time?
• What are the possible reasons for this – eg wanting a new challenge, discovering a new interest,
changes to circumstances, losing interest?
What do our interests do for us? (worksheet page 41)

Discuss what happens to time when we are busy.
In particular, what happens to symptoms when we are absorbed in something? Discuss the symptoms of
physical health as well as mental health – eg an itch or a tickly cough as well as the symptoms of anxiety.
Session 1 Leisure activities
What does leisure mean to you? (worksheet page 42)

Discuss the difference between leisure, self-care and work and the idea that some activities can vary
according to the context – eg cooking, shopping. Introduce the concept of flow.
Ask:
• How can we define ‘leisure’? What does it mean?
• If ‘All work and no play makes Jack a dull boy’, would a life that was all play be any better?
• Is it possible for an activity to be enjoyable but not satisfying?
Passive or active? (worksheet page 43)

This exercise works best as a group activity, with the chart drawn on a large piece of paper. Take time to
remind the participants of the difference between passive and active leisure pursuits.
Ask:
• Is it better to do something rather than nothing?
• What proportion of our leisure time is spent in passive leisure?
What did our grandparents do?

Ask people to reflect on what people did before television and computers were invented – eg parlour
games such as charades, card games, music-making.
Ask:
• Does everyone have a television?
• Would they cope without television?
• Are television and computing necessarily bad for you?
• How could you make watching the television more fulfilling? For example:
invite some friends round to watch a film together
watch a cooking programme and then try out the recipe
try to answer the questions on a television quiz
watch specific programmes rather than ‘channel-hop’.
What sorts of activity do you do to pass the time? (worksheet page 44)
This exercise can be a useful adjunct to the activity checklist, especially if future sessions are
concentrating on social activities, creative activities and physical activities.
If money was no object

Ask participants to share the leisure activities they would like to pursue if money was no object –
eg travel, expensive sports, pampering.
Plan any follow-up activities

Investigating local options
• Visit the local library to find out about local groups.
• Check out the ‘What’s on’ section of a local newspaper or magazine.
• Review the groups available for mental health service users.
Sharing experiences
Arrange for participants or staff members to give mini presentations about their favourite interests.
Alternative nights in
Play a game together, as an alternative to watching television, eg:
• parlour games
• board games
• card games.
Active experience
If the topics relating to creative, physical or outdoor activities are not being explored later in the
Recovery through Activity programme, arrange a taster session for one of these activities. Encourage
the participants to reflect on their experience.
Plan follow-up activities for the rest of the programme

Depending on which topics have already been agreed for the rest of the Recovery through Activity
programme, finalise the choice of experiential sessions to match particular topics.
What do our interests do for us?

✐
WORKSHEET
Think of an interest that you have, or that you had in the past, and circle the
statements below that fit with your experience.
I lose track I relax It’s fun

of time
I get a buzz
It’s an escape Time slows down out
of it
It’s fascinating It’s healthy Time flies by
It fits with all It’s stimulating

I lose myself my skills
It fits with my It’s absorbing It’s challenging

values
What does leisure mean to you?

✐
WORKSHEET
Mark each of the statements below True or False, according to your beliefs.
True False
1 A chance to rest or recharge my batteries
2 Being away from the outside world
3 Being really interested in something
4 Doing something that I enjoy
5 Doing something different from my usual routine
6 Freedom from rules, regulations and obligations
7 Having a sense of control or flexibility regarding the amount of

time and the pace of an activity
8 Having a varied lifestyle with lots of interests
9 Having enough money to do things and go places
10 Having time and space to myself
11 Not having any challenges
12 Something that adds quality to life
13 Something that is healthy for me
14 Taking part in a hobby or sport
15 Taking part in organised activities
16 The opposite of work
17 Time to be myself and to develop myself
Passive or active?
✐
WORKSHEET
What are the positive and negative aspects of passive leisure pursuits such as:
• reading
• watching television
• browsing the web?
What are the positive and negative aspects of active leisure pursuits that involve:
• creativity
• social activity
• physical activity?
Positives Negatives
Passive leisure pursuits
Active leisure pursuits
What sorts of activity do you do to pass the time?

✐
WORKSHEET
When thinking about activities that you do to pass the time, do not include activities
that you need to do or that are arranged for you by the health service. Think about
things that you do independently, as pastimes.
Write down the things you do as

pastimes in the column below and
(eg going to see things, enjoying eating)

(eg listening to music, bird-watching)
(eg sewing, photography, art, music)

tick your main reason for doing the
(eg visiting friends, going to the pub)

(eg watching TV, browsing the web)
7 To enjoy sensory experiences

activity.
(eg crosswords, puzzles, quizzes)

3 To keep my brain active
Although examples of activities are
given for each category, there is no right
4 To be with others
(eg exercise, sports)

1 To pass the time
or wrong answer. Some people do some
5 To be creative
activities to relax, while other people do
6 To keep fit
them to pass the time or to be with
2 To relax
others.
Activity
How much do you take part in the following categories of activity and how much
do you like these activities?
I do this I like this
never sometimes often a lot not at all a bit quite a lot a lot
1 Activities to pass the time

2 Relaxing activities
3 ‘Brain’ activities
4 Social activities
7 Sensory activities
Which activities would you like to do more? Or less?
References
Ball V, Corr S, Knight J & Lowis M (2007) ‘An investigation into the leisure occupations of older adults’, British Journal of
Blacker D, Broadhurst L & Teixeira L (2008) ‘The role of occupational therapy in leisure adaptation with complex
neurological disability: a discussion using two case study examples’, NeuroRehabilitation, 23 (4), pp313–19.
Caldwell LL (2005) ‘Leisure and health: why is leisure therapeutic?’, British Journal of Guidance & Counselling,
33 (1), pp7–26.
Craik C & Pieris Y (2006) ‘Without leisure … “it wouldn’t be much of a life”: the meaning of leisure for people with mental
health problems’, British Journal of Occupational Therapy, 69 (5), pp209–16.
Csikszentmihalyi M (1995) Beyond Boredom and Anxiety: Experiencing Flow in Work and Play, Jossey-Bass, San Francisco.
Di Bona L (2000) ‘What are the benefits of leisure? An exploration using the Leisure Satisfaction Scale’, British Journal of
Emerson H (1998) ‘Flow and occupation: a review of the literature’, Canadian Journal of Occupational Therapy,
65 (1), pp37–43.
Fine J (2001) ‘The effect of leisure activity on depression in the elderly: implications for the field of occupational therapy’,
Occupational Therapy in Health Care, 13 (1), pp45–59.
Harvey C, Fossey E, Jackson H & Shimitras L (2006) ‘Time use of people with schizophrenia living in North London:
predictors of participation in occupations and their implications for improving social inclusion’, Journal of Mental Health,
15 (1), pp43–55.
Heasman D & Atwal A (2004) ‘The Active Advice pilot project: leisure enhancement and social inclusion for people with
severe mental health problems’, British Journal of Occupational Therapy, 67 (11), pp511–14.
Hodgson S, Lloyd C & Schmid T (2001) ‘The leisure participation of clients with a dual diagnosis’, British Journal of
Hutcheson C, Ferguson H, Nish G & Gill L (2010) ‘Promoting mental wellbeing through activity in a mental health
hospital’, British Journal of Occupational Therapy, 73 (3), pp121–8.
Iwasaki Y, Coyle CP & Shank JW (2010) ‘Leisure as a context for active living, recovery, health and life quality for persons
with mental illness in a global context’, Health Promotion International, 25 (4), pp483–94.
Krupa T, McLean H, Eastabrook S, Bonham A & Baksh L (2003) ‘Daily time use as a measure of community adjustment
for persons served by Assertive Community Treatment Teams’, American Journal of Occupational Therapy, 57(5), pp558–65.
Lloyd C, King R, McCarthy M & Scanlan M (2007) ‘The association between leisure motivation and recovery: a pilot
study’, Australian Occupational Therapy Journal, 54 (1), pp33–41.
Majnemer A (2010) ‘Balancing the boat: enabling an ocean of possibilities’, Canadian Journal of Occupational Therapy,
77 (4), pp198–208.
Pereira RB & Stagnitti K (2008) ‘The meaning of leisure for well-elderly Italians in an Australian community: implications
for occupational therapy’, Australian Occupational Therapy Journal, 55 (1), pp39–46.
Pieris Y & Craik C (2004) ‘Factors enabling and hindering participation in leisure for people with mental health problems’,
Scanlan JN, Bundy AC & Matthews LR (2011) ‘Promoting wellbeing in young unemployed adults: the importance of
identifying meaningful patterns of time use’, Australian Occupational Therapy Journal, 58 (2), pp111–19.
Smith NR, Kielhofner G & Watts JH (1986) ‘The relationships between volition, activity pattern, and life satisfaction in the
elderly’, American Journal of Occupational Therapy, 40 (4), pp278–83.
Specht J, King G, Brown E & Foris C (2002) ‘The importance of leisure in the lives of persons with congenital physical
disabilities’, American Journal of Occupational Therapy, 56 (4), pp436–45.
Trenberth L & Dewe P (2002) ‘The importance of leisure as a means of coping with work related stress: an exploratory
study’, Counselling Psychology Quarterly, 15 (1), pp59–72.
Turner H, Chapman S, McSherry A, Krishnagiri S & Watts J (2000) ‘Leisure assessment in occupational therapy:
an exploratory study’, Occupational Therapy in Health Care, 12 (2–3), pp73–85.
Westhorp P (2003) ‘Exploring balance as a concept in Occupational Science’, Journal of Occupational Science,
10 (2), pp99–106.
Creative activities 2
Key messages
• Creativity underpins all human achievements and is part of everyday life.
• Creativity is important for learning and development:

it requires imagination and inventiveness
it involves problem-solving and risk-taking
it allows us to change our environment.
• By changing the things around us, we can change our inner thoughts and feelings.
Creative activities:
tap into our creative potential
provide us with coping mechanisms
allow us to recognise our skills.
• Creative activity is important for our health because it:
transforms chaos into order and provides hope
involves learning to let go and make mistakes
provides a sense of purpose and a form of self-expression
draws attention away from stresses and anxiety.
• Creative activities can be adapted to match:
our interests, skills and experience
the time available.
The value of creative activities
Introduction
Creative activity provides occupational therapists with a significant tool for helping people to find
alternative ways to handle the challenges in their lives (la Cour et al, 2007) and offers ‘a vehicle for
choice and engagement’ (Griffiths, 2008, p49). Its therapeutic application stems from the fact that
creativity is a part of everyday life involving risk-taking (Schmid, 2004) and problem-solving, and
therefore has the power to foster autonomy and competence (Schmid, 2005).
In other words, creative activities foster creativity, which can be defined as:
an innate capacity to think and act in original ways, to be inventive,

to be imaginative and to find new and original solutions to needs,
problems and forms of expression. It can be used in all activities.
Its processes and outcomes are meaningful to its user and generate
positive feelings.
(Schmid, 2005, p6)
Creativity requires a supportive environment (Schmid, 2004). It is not just an attribute that resides within
activity; it is also a personal attribute that can be used consciously by service users and therapists alike,
so that the therapeutic process itself is creative (Atkinson and Wells, 2000). The versatility of creative
activity allows it to be used effectively in 1:1 and group interventions (Griffiths and Corr, 2007) and as an
alternative to verbal therapies (Körlin et al, 2000; Odell-Miller et al, 2006). It can also be used to help
occupational therapists assess functional performance (Mitchell and Neish, 2007). However, if service
users are truly to benefit from its life-changing properties, therapists must promote the value of creative
activity with them (Schmid, 2005).
Craft as a therapeutic occupation

According to Harris (2008, p133), ‘craft was the first therapeutic occupation of occupational therapy’.
Since that time, however, a decline in the use of creative activities by occupational therapists led
Thompson and Blair (1998) to question whether this therapeutic role was ‘ancient history or
contemporary practice’ (p48). They were joined by Perrin (2001) in making an impassioned plea for the
importance of creativity in therapy to be appreciated once more and for the promotion and retention of
creative arts in the profession.
Session 2 Creative activities
A survey of UK occupational therapists published in 1998 revealed that the use of creative activities had
not been abandoned as a therapeutic medium and that they still formed one of the most frequently used
interventions (Craik et al, 1998). Indeed, a later cross-sectional survey of this professional group found
that 82 per cent reported using creative activities (Griffiths and Corr, 2007).
More recently, a Swedish study of occupational therapists working in both physical and mental health
services reported that 44 per cent used creative activities, with arts and crafts used most frequently,
followed by gardening (Müllersdorf and Ivarsson, 2012). Furthermore, the use of art materials, music and
creative writing is still strong in Chinese and Japanese health care (Crawford and Paterson, 2007).
Evidence base
Unfortunately, the research base supporting the use of creative activities in occupational therapy has
not been strong (Lloyd and Papas, 1999; Hacking et al, 2006; Griffiths, 2008). Much has been based on
speculation about a possible link between creative expression and mental health, with a plethora of
well-known artists and authors known to experience mental ill health (Crawford and Paterson, 2007).
However, in 2012 a ground-breaking study was published, investigating the impact of attending a
creative activity group in an in-patient mental health setting. Four measurement tools were used to
assess the mental health outcomes for 403 patients over a five-year period and a positive correlation
was found, linking participation in creative activity with improved mental health (Caddy et al, 2012).
Before the quantitative study described above, numerous studies were published detailing the quality of
people’s subjective experiences when participating in creative activities. Positive experiences were
noted in a variety of settings: working with homeless people (Thomas et al, 2011); in long-term illness
(Reynolds, 2004; Reynolds et al, 2008); with older people (Howie et al, 2004; la Cour et al, 2005);
and in cancer care (Reynolds and Prior, 2006; Daykin et al, 2007).
These studies have added to our theoretical understanding of the nature of creative activity and shown
that it contributes to the recovery process (Lloyd et al, 2007) by providing optimal experiences of flow
(Reynolds and Prior, 2006; Griffiths, 2008), fostering hope, creating meaning and purpose, and allowing
people to develop new coping mechanisms and rebuild their identities (Spandler et al, 2007). Many of
these studies have been examined in a literature review by Perruzza and Kinsella (2010) covering
23 peer-reviewed articles. They summarise the key benefits for health and wellbeing as:
• enhanced perceived control

• building a sense of self
• expression
• transforming the illness experience

• gaining a sense of purpose
• building social support.
So, who chooses to engage in creative activity? When attempting to answer this question, occupational
therapists are indebted to Frances Reynolds for her extensive investigations about the meaning of arts
and crafts. Whereas Spandler et al (2007) state that arts activities ‘may not necessarily be appropriate
for all service users’ (p791), Reynolds has found that participants do not have to view themselves as
being artistic or creative (Reynolds, 2004, 2009). Instead, people choose to engage in creative activities
because they tend to be familiar with craft skills (Reynolds et al, 2008) and may even have been
encouraged to participate by family members (Reynolds, 2009). They then discover that creative
activities can be adapted to suit the time available (Reynolds, 2000) and are manageable despite the
constraints of ill health (Reynolds et al, 2008).
In fact, service users who experience depression were found to be intuitively aware of the potential
therapeutic benefits to be gained from participating in creative activity (Reynolds, 2000). In one study,
Reynolds and Prior (2003) found that about half of those interviewed had taken up a creative pursuit
since they first became ill.
It seems, then, that people who experience mental ill health will continue to appreciate the rewards of
engaging in creative activities, regardless of whether the exact benefits can be proved conclusively.
Sample activities
Introduction
In addition to introducing the key messages for this session, facilitators may want to emphasise that
creative activities need not mean craft-based activities. For example, cooking, gardening and drumming
can all be creative activities.

Thinking creatively
Ask participants to imagine they are marooned on a desert island. Ask how many creative ideas can
they think of for how to use some rope? (For example, a tether for a wild goat, a belt, a fly whisk, a
hammock – if it was long enough!) Go round the group and ask each person to make one suggestion
until there are no more ideas to share.
Looking at things afresh

Introduce the idea that creativity requires us to be mindful of the environment and our actions.
• Think about how children explore everything. Has anyone got an example of a child who was
amazed by something quite ordinary?
• Can looking through the lens of a camera help you to see things differently?
Defining creativity
Facilitate discussion about what creativity means by asking the following questions.
• What is creativity? For example, making something new, thinking ‘outside the box’, being artistic,
working things out, using your hands.
• What does ‘being creative’ make you think of? For example, it’s therapeutic, it takes time, it can’t be
done to order, being a hippy, having energy, making things beautiful, making do.
• What is the difference between ‘doing something’ and ‘doing something creative’?
Creativity and mental health (worksheet page 53)

This activity helps lead into a discussion about the value of creative activity as a therapy and the
importance of flow.
• Share the things that you enjoy about being creative.
• Why do you think creative activities are considered to be therapeutic?
• Is creativity linked to mental illness? Are people aware of any celebrities who are known to
experience the symptoms of mental illness?
What kind of creative things could I do? (worksheet page 54)

This exercise was inspired by the examples of creative activities categorised by Griffiths and Corr
(2007). In addition to discussing participants’ interests and the reasons for their choices, the group could
go on to discuss the skills, time and materials required.
• Which creative activities have you tried in the past and which ones are you most proud of?
• Are all technical activities creative? For example, is gardening creative or computer programming?
What would make them more creative?
Creativity = problem-solving (worksheet page 55)

This activity requires participants to have an ability to reflect on their experience.
• What helps you to feel creative?
• Do you need to be artistic to be creative?
Creative influences
Did your parents or grandparents do anything creative?
• Is craft as common as it used to be?
• Who is the most creative person you know?

Check out the creative activities that are available in adult education classes.
• Visit a local gallery or a paint-a-pot studio.
• Arrange to go to a local theatre or music venue.
Active experience
Organise a taster session for participants to try something new and reflect on their experience:
eg digital photography, felting, glass-painting, candle-making, card-making, transient natural art.
Creativity and mental health

✐
WORKSHEET
Below are some of the positive outcomes that happen when people take part in
creative activities.
Tick all of the outcomes that you have experienced when doing something creative.
Circle all of the outcomes that you would like to experience.
increased sense of opportunities to be

maintaining a healthy
appreciated and self-image
self-control praised
increased sense of a way of

confidence in control over the communicating
achievements environment without words
transforming negative
making a contribution emotions into feelings of power
to others positive ones
time to reflect on our allowing others to see increased ability to

experiences us as being capable deal with mistakes
a chance to making feelings real

feelings of freedom re-evaluate our lives
increased ability to increased confidence feelings of release

take risks in expressing self
rediscovering the gaining a sense of

people we were sharing with others purpose
before illness
What kind of creative things could I do?

✐
WORKSHEET
Think about the creative activities that you have tried in the past, the creative activities that
you still do, and the ones that you would like to try in the future.
Fill in the chart below and make a plan to do at least one creative activity in the next fortnight.
I used to I do this I’d like to

do this do this in
now
the future
art-based
(eg painting, artwork, drawing, colouring, collage, framing)
paper-based
(eg card-making, papercraft, papier mâché, printing)
fabric-based
(eg sewing, embroidery, dress-making, patchwork, knitting)
modelling-based
(eg pottery, salt dough, fimo, sculpture, model-making)
technical-based
(eg woodwork, metalwork, photography)
word-based
(eg drama, creative writing, play reading, writing poetry,
calligraphy)
music-based
(eg dance, music-making, music appreciation, singing)
craft-based
(eg flower-arranging, jewellery-making, mosaics,
candle-making, glass-painting, engraving)
food-based
(eg baking, sugarcraft)
Plan of Action
Within the next 2 weeks I will ………………………………………………………………..
In order to do this I will need to prepare by ………………..………..………..………..………..…
Creativity = problem-solving
✐
WORKSHEET
Think of something creative that you have done and write down some answers to the
following questions.
(If you can’t think of anything, interview someone who can.)
Afterwards, discuss the creative process in the group.
1 What did you do and why did you decide to do that activity?
2 What did you decide you had to do first?
3 How did you know when to finish the activity?
4 Is there a best way to do this activity?
5 Did you need any help to complete the activity?
6 How could you improve what you did?
7 Did the finished creation turn out as it should?
8 Did you like what you created?
9 Do you think other people would like/liked what you did?
References
Atkinson K & Wells C (2000) Creative Therapies: A Psychodynamic Approach within Occupational Therapy,
Stanley Thornes, Cheltenham.
Caddy L, Crawford F & Page AC (2012) ‘“Painting a path to wellness”: correlations between participating in a creative
activity group and improved measured mental health outcome’, Journal of Psychiatric and Mental Health Nursing,
19 (4), pp327–33.
Craik C, Chacksfield JD & Richards G (1998) ‘A survey of occupational therapy practitioners in mental health’,
Crawford MJ & Paterson S (2007) ‘Arts therapies for people with schizophrenia: an emerging evidence base’,
Evidence-Based Mental Health, 10 (3), pp69–70.
Daykin N, McClean S & Bunt L (2007) ‘Creativity, identity and healing: participants’ accounts of music therapy in cancer
care’, Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, 11 (3), pp349–70.
Griffiths S (2008) ‘The experience of creative activity as a treatment medium’, Journal of Mental Health, 17 (1), pp49–63.
Griffiths S & Corr S (2007) ‘The use of creative activities with people with mental health problems: a survey of occupational
therapists’, British Journal of Occupational Therapy, 70 (3), pp107–14.
Hacking S, Secker J, Kent L, Shenton J & Spandler H (2006) ‘Mental health and arts participation: the state of art in
England’, Journal of the Royal Society for the Promotion of Health, 126 (3), pp121–7.
Harris E (2008) ‘The meanings of craft to an occupational therapist’, Australian Occupational Therapy Journal,
55 (2), pp133–42.
Howie L, Coulter M & Feldman S (2004) ‘Crafting the self: older persons’ narratives of occupational identity’, American
Körlin D, Nybäck H & Goldberg FS (2000) ‘Creative arts groups in psychiatric care: development and evaluation of a
therapeutic alternative’, Nordic Journal of Psychiatry, 54 (5), pp333–40.
la Cour K, Josephsson S & Luborsky M (2005) ‘Creating connections to life during life-threatening illness: creative
activity experienced by elderly people and occupational therapists’, Scandinavian Journal of Occupational Therapy,
12 (3), pp98–109.
la Cour K, Josephsson S, Tishelman C & Nygård L (2007) ‘Experiences of engagement in creative activity at a palliative
care facility’, Palliative & Supportive Care, 5 (3), pp241–50.
Lloyd C & Papas V (1999) ‘Art as therapy within occupational therapy in mental health settings: a review of the literature’,
Lloyd C, Wong SR & Petchkovsky L (2007) ‘Art and recovery in mental health: a qualitative investigation’, British Journal
of Occupational Therapy, 70 (5), pp207–14.
Mitchell R & Neish J (2007) ‘The use of a ward-based art group to assess the occupational participation of adult acute
mental health clients’, British Journal of Occupational Therapy, 70 (5), pp215–17.
Müllersdorf M & Ivarsson AB (2012) ‘Use of creative activities in Occupational Therapy practice in Sweden’, Occupational
Therapy International, 19 (3), pp127–34.
Odell-Miller H, Hughes P & Westacott M (2006) ‘An investigation into the effectiveness of the arts therapies for adults
with continuing mental health problems’, Psychotherapy Research, 16 (1), pp122–39.
Perrin T (2001) ‘Don’t despise the fluffy bunny: a reflection from practice’, British Journal of Occupational Therapy, 64 (3),
pp129–34.
Perruzza N & Kinsella EA (2010) ‘Creative arts occupations in therapeutic practice: a review of the literature’, British
Journal of Occupational Therapy, 73(6), pp261–8.
Reynolds F (2000) ‘Managing depression through needlecraft creative activities: a qualitative study’, The Arts in
Psychotherapy, 27 (2), pp107–14.
Reynolds F (2004) ‘Textile art promoting well being in long term illness: some general and specific influences’, Journal of
Occupational Science, 11 (2), pp58–67.
Reynolds F (2009) ‘Taking up arts and crafts in later life: a qualitative study of the experiential factors that encourage
participation in creative activities’, British Journal of Occupational Therapy, 72 (9), pp393–400.
Reynolds F & Prior S (2003) ‘“A lifestyle coat-hanger”: a phenomenological study of the meanings of artwork for women
coping with chronic illness and disability’, Disability and Rehabilitation, 25 (14), pp785–94.
Reynolds F & Prior S (2006) ‘Creative adventures and flow in art-making: a qualitative study of women living with cancer’,
Reynolds F, Vivat B & Prior S (2008) ‘Women’s experiences of increasing subjective well-being in CFS/ME through
leisure-based arts and crafts activities: a qualitative study’, Disability and Rehabilitation, 30 (17), pp1279–88.
Schmid T (2004) ‘Meanings of creativity within occupational therapy practice’, Australian Occupational Therapy Journal,
51(2), pp80–88.
Schmid T (ed) (2005) Promoting Health through Creativity for Professionals in Healthcare Arts and Education,
Whurr, London.
Spandler H, Secker J, Kent L, Hacking S & Shenton J (2007) ‘Catching life: the contribution of arts initiatives to
recovery approaches in mental health’, Journal of Psychiatric and Mental Health Nursing, 14 (8), pp791–9.
Thomas Y, Gray M, McGinty S & Ebringer S (2011) ‘Homeless adults’ engagement in art: first steps towards identity,
recovery and social inclusion’, Australian Occupational Therapy Journal, 58 (6), pp429–36.
Thompson M & Blair SE (1998) ‘Creative arts in occupational therapy: ancient history or contemporary practice?’,
Occupational Therapy International, 5 (1), pp48–64.
Technological activities 3
Key messages
• Technological activities play an increasing part in everyday life and have changed how people
engage in:
leisure activities (eg video-gaming and social networking)
domestic activities (eg shopping online)
work activities (eg using email to work from home).
• Technological advances have been linked with several concerns, for example:
cyber-bullying
internet addiction
less face-to-face contact and increased loneliness.
• However, technology can provide real benefits:

enabling people to maintain social contact
providing access to information
freeing up time to spend on leisure activities
providing fun, challenging and relaxing leisure opportunities
helping people to feel in control of their lives.
• Technology can lead to positive or negative outcomes according to how it is used.

As technology develops, we need to consider how best to use it and consider:
– information control and privacy issues
– balancing ‘virtual reality’ with real life.
The value of technological activities
Introduction
In recent years, incredible advances have been made in media technology, with a corresponding
escalation of the role that it plays in our lives. There has been a lifestyle shift, with children in some
parts of the world spending more than five and a half hours every day looking at screens of one sort
another, whether television screens, computer monitors or mobile phone screens (Nayar et al, 2012).
In fact, technology has changed the way in which we engage with many of our traditional leisure
pursuits as we read books on digital devices, download music, play video games (Nayar et al, 2012),
take digital photos and write emails instead of letters (Chard, 2007).
Moreover, as the population becomes ever more comfortable with technology (Gillen and Watkins,
2011), the range of activities is expanding. Digital gaming is increasingly popular (Wang et al, 2008;
Boyle et al, 2012) with virtual reality providing new forums for exercise (Bacon et al, 2012) and
increased opportunities for communication (Earl, 2011).
Not only have our leisure activities been transformed but also, as the use of the internet has grown
(Teng and Huang, 2012), it has changed how people conduct every aspect of their daily lives
(Khvorostianov et al, 2012). People are now more able to work from home (Nie and Erbring, 2000);
they can buy their groceries online (Morganosky and Cude, 2000); they have new opportunities for social
networking (Nayar et al, 2012); and they can be assisted by electronic gadgetry in their own homes
(Verdonck et al, 2011). They even have online access to education (Takacs, 2005), health information
(Christensen and Griffiths, 2000) and discussion forums (Kummervold et al, 2002).
A cause for concern or celebration?

Over recent years, several concerns have been linked to the increased use of technology. These include
worries about obesity and fears of cyber-bullying (Nayar et al, 2012), disquiet regarding the quality of
information available on the internet (Christensen and Griffiths, 2000), fear that less time spent reading
will have a detrimental effect on schooling (Wiecha et al, 2001), and alarm about internet addiction
(Hall and Parsons, 2001).
Indeed, a survey published in 2000 by Nie and Erbring indicated that people were more likely to lose
contact with their social group, the more time they spent online. Moreover, a systematic review by
Earl (2011) found that spending more time ‘chatting’ online can exacerbate feelings of loneliness when
people are already experiencing social exclusion.
Session 3 Technological activities
Yet, as Bell (2007, p445) states:
The internet is typically discussed as if it were a set of activities

when it is actually a medium upon which various activities can occur.
It is, therefore, neither ’good’ nor ‘bad’ for mental health, although
specific activities may have an influence.
In general, it seems that ‘the concept of “internet addiction” is increasingly invalid, although depressed
or isolated individuals are perhaps more likely to focus on certain activities to excess’ (Bell, 2007, p445).
Bearing this in mind, many commentators would now argue that technology is a positive force
(Salonius-Pasternak and Gelfond, 2005). It provides a modern format for ‘satisfying basic human needs
within the conditions of modern society’ (Demetrovics et al, 2011).
For instance, working from home and shopping online mean that less time is spent commuting (Nie and
Erbring, 2000), allowing people to spend more time on activities that are important to them, and
enabling people to overcome any physical constraints that might have prevented their participation
(Morganosky and Cude, 2000). Meanwhile, video-gaming is viewed as ‘socially captivating, fun,
challenging but relaxing’, providing entertainment value even when people lose the game (Hoffman and
Nadelson, 2010). This may be because videos have the power to transport people into narrative worlds
in which viewers can connect with the characters (Green et al, 2004) in much the same way as if they
were reading a book.
The following benefits have been noted for older people who embrace modern technology.
• White et al (1999) realised that when people living in a retirement community were provided with
internet access, they became less isolated.
• Aguilar et al (2010) found that older people attributed ‘feeling in control’ to computer use, stating
that it enabled them to keep their brains active and relate to other people. It was viewed as both
challenging and rewarding, and an important part of their daily life.
• Khvorostianov et al (2012) discovered that older migrants relied on the internet to manage their
health, nurture their professional interests, maintain and extend their social networks, appreciate
the past, and enjoy leisure opportunities. Usage was associated with improved self-worth and a
better quality of life.
Meanwhile, social networking sites appear to be the preserve of young people and, while these have
been criticised for reducing time spent in face-to-face interaction, their benefits should also be
acknowledged (Earl, 2011). Many people enjoy the sense of freedom that they offer. Not only do online
forums make it easier for people to discuss problems (Kummervold et al, 2002), they also cancel out
many of the gender differences that are evident in face-to-face conversation (Lipinski-Harten and
Tafarodi, 2012). These benefits, while liberating, may make it harder to transfer online relationships into
the real world and it is perhaps not surprising that social networking sites are not commonly used to
develop new relationships (Earl, 2011).
However, there is evidence that the internet is frequently used by people who are already known to each
other, to help them stay connected (Ellison et al, 2007) and maintain their relationships (Ledbetter and
Kuznekoff, 2012). In the same way, multiplayer online game use cannot replace face-to-face
communication, but it can complement social interaction (Shen and Williams, 2011).
Whether the use of technology has negative or positive outcomes seems to depend on the ‘purposes,
contexts, and individual characteristics of users’ (White et al, 1999, p358). Mobile phone use can help to
maintain friendships, yet if people call others too frequently, this can lead to overdependence and
feelings of pressure, entrapment and guilt (Hall and Baym, 2012).
Likewise, online gaming might be motivated by ‘harmonious passion’ that is balanced by other interests
or ‘obsessive passion’ that is more akin to a craving that can never be sated (Stoeber et al, 2011). The
success of a computer game will also depend on the skill level of the user because repetitive challenges
are linked to feelings of boredom (Teng and Huang, 2012).
As technology develops, new etiquettes are evolving too, although some critics would say that they are
not developing fast enough (Furgang, 2011). It is recognised that particular care needs to be taken with
online messaging, which is known to result in communications that are less sequential and have greater
self-focus than face-to-face interaction (Lipinski-Harten and Tafarodi, 2012).
Information control and privacy are emerging issues and it seems that social network users are
concerned about protecting their own information and yet continue to push the boundaries of what is
acceptable in order to find out about other people (Raynes-Goldie, 2010). They also disclose more
information about themselves than might be warranted, in a bid to be popular, and are less able to
negotiate the tricky matter of information control if their self-esteem is not robust (Christofides et al, 2009).
Use of technology in therapy

Nayar et al (2012, p96) state that:
because new media technologies are so integrated in young people’s

lives, they are also valuable resources to promote mental health;
to develop distinct identity; to give opportunities for social
networking; and to provide scaffolds for constructing new forms of
self-directed interest-driven activities, peer-based communication,
learning and support.
The media provides ‘a constant stream of messages about families, peers, relationships, gender roles,
sex, violence, food, values, clothes, and an abundance of other topics too long to list’ (Rideout et al,
2010, p1) which could be harnessed to improve mental health information (Bell, 2007). Technology could
also be used to provide online therapy (Bell, 2007), including exposure to anxiety-provoking situations in
graded virtual environments (Lear, 1997). Alternatively, video games could be used for assessment and
training purposes to facilitate social interaction (Wilkinson et al, 2008).
Technology is already being used in several therapeutic settings. For example, a DVD has been created
to teach emotion-recognition to people with autistic-spectrum disorder (Baron-Cohen et al, 2007), and
art therapists are experimenting with options for generating computer art (Parker-Bell, 2011), films and
photography (Malchiodi and Johnson, 2013). Occupational therapists are also making forays into the
technological world and have used animation as a purposeful activity (Mason, 2009) and electronic
assistive technology to promote independence. They have used Wii video games to good effect in
physical rehabilitation (Halton, 2007) and psychiatric services (Liao et al, 2009). The Wii Fit has the
potential to be particularly useful in promoting weight loss (Jacobs et al, 2011). It has enabled service
users in a secure mental health setting to regard exercise as fun and challenging (Bacon et al, 2012).
In conclusion:
Occupational therapy must ensure that it not only understands changes in

occupational engagement but also is willing to use [technological
activities] as part of the intervention choices it
offers to service users.
(Gillen and Watkins, 2011, p92)
Recovery through Activity aims to assist this process by supporting occupational therapists to promote
the value and safe use of technological activities.
Sample activities
Introduction
Technology provides new media for engaging in traditional activities. Participants in the Recovery
through Activity programme are encouraged to consider how they might harness technology to maximise
the potential benefits.

Gadgetry
Ask whether people consider themselves to be ‘gadget people’.
Discuss the types of gadgets that people own or would like to own:
• in the kitchen
• in the home in general.
Media use (worksheet page 67)

Before sharing this worksheet, ask people to produce their own list of all the various types of media that
they use.
• Discuss how frequently people use the various media and whether they regard themselves as
computer-literate or not.
• Check whether people know what the various media are.
• Ask whether people abbreviate language when texting or not.
Emoticon quiz ☺
Create a range of emoticon flashcards using your email system and ask people to guess their meaning.
• Do people use emoticons?
• Why, or why not?
Media preferences
Which do people prefer:
• books or e-books
• television or iPlayer
• landline or mobile phone?
Screen time
Question: How much time do you think children in the USA spend using media on a typical day
(including listening to music and reading printed materials outside school, as well as
watching television and playing video games)?
Answer: They spend an average of 7 hours 38 minutes (29 per cent of the time multitasking).
(Source: Rideout et al, 2010)
Ask:
• How much time do people spend looking at screens?
• How much technology do people use compared with older or younger people?
A cause for concern or celebration?

Facilitate a discussion regarding the benefits and challenges of media use.
Ask:
• What do people like about computer games and social networking? (Discuss favourite games
and websites.)
• Has technology changed how we live our lives?
• Can television be bad for you? Or using a mobile phone?
• Do people interact differently when online? Yes or No? (Answer = Yes)
Ground rules for techno-etiquette

Review guidelines for online etiquette on the web and work with the group to create a list of guidelines
to control information, maintain privacy, establish boundaries, show courtesy, enable a balanced
lifestyle, etc.

Training session
Arrange a computer training session to explore a specific aspect of:
• word-processing
• email
• browsing the web
• using a social network
etc.
Get creative
Arrange a session to try out:
• digital photography
• digital animation
• or create a poster or a presentation to share the techno-etiquette ground rules that the group has
put together.
Computer games
Organise a games session or arrange for people to share their favourite games if this is appropriate.
Media use
✐
WORKSHEET
Which of the following media or media applications do you use?
Yes No
Computer
email
instant messaging
office applications, eg PowerPoint, Excel, Publisher
online gaming
online grocery shopping
other online shopping
photo-shopping and sharing
social networking, eg Facebook
word-processing
YouTube
Mobile phone
texting
hands-free
smartphone applications
Music
CD
mp3 player or iTunes
radio
Television
live television
DVDs
Blu-ray
iPlayer
on-demand viewing
Video games
PlayStation
Wii
Xbox
References
Aguilar A, Boerema C & Harrison J (2010) ‘Meanings attributed by older adults to computer use’, Journal of Occupational
Science, 17 (1), pp27–33.
Bacon N, Farnworth L & Boyd R (2012) ‘The use of the Wii Fit in forensic mental health: exercise for people at risk of
obesity’, British Journal of Occupational Therapy, 75 (2), pp61–68.
Baron-Cohen S, Golan O, Chapman E & Granader Y (2007) ‘Transported to a world of emotion’, The Psychologist,
20 (2), pp76–77.
Bell V (2007) ‘Online information, extreme communities and internet therapy: Is the internet good for our mental
health?’, Journal of Mental Health, 16 (4), pp445–7.
Boyle EA, Connolly TM, Hainey T & Boyle JM (2012) ‘Engagement in digital entertainment games: a systematic review’,
Computers in Human Behavior, 28 (3), pp771–80.
Chard G (2007) ‘Computer games and karate: the arts and crafts of today’, British Journal of Occupational Therapy,
70 (8), p329.
Christensen H & Griffiths K (2000) ‘The internet and mental health literacy’, Australian and New Zealand Journal of
Psychiatry, 34 (6), pp975–9.
Christofides E, Muise A & Desmarais S (2009) ‘Information disclosure and control on Facebook: are they two sides of the
same coin or two different processes?’, CyberPsychology and Behavior, 12 (3), pp341–5.
Demetrovics Z, Urbán R, Nagygyörgy K, Farkas J, Zilahy D, Mervó B, Reindl A, Ágoston C, Kertész A & Harmath E
(2011) ‘Why do you play? The development of the Motives for Online Gaming Questionnaire (MOGQ)’, Behavior Research
Methods, 43 (3), pp814–25.
Earl R (2011) The Impact of Online Social Participation on Social Capital and Mental Health Outcomes of Young Adults:
A Systematic Review. Participation and quality of life of young adults living in Western Australia: research report,
Edith Cowan University Theses Collections, Perth, Australia.
Ellison NB, Steinfield C & Lampe C (2007) ‘The benefits of Facebook “friends”: social capital and college students’ use of
online social network sites’, Journal of Computer-Mediated Communication, 12 (4), pp1143–68.
Furgang K (2011) Netiquette: A Student’s Guide to Digital Etiquette, Rosen Publishing Group, New York.
Gillen A & Watkins J (2011) ‘Where is the evidence base to help occupational therapists select technological occupations
for current and future service users?’, British Journal of Occupational Therapy, 74 (2), pp92–94.
Green MC, Brock TC & Kaufman GF (2004) ‘Understanding media enjoyment: the role of transportation into narrative
worlds’, Communication Theory, 14 (4), pp311–27.
Hall AS & Parsons J (2001) ‘Internet addiction: college student case study using best practices in cognitive behavior
therapy’, Journal of Mental Health Counseling, 23 (4), pp312–27.
Hall JA & Baym NK (2012) ‘Calling and texting (too much): mobile maintenance expectations, (over)dependence,
entrapment and friendship satisfaction’, New Media and Society, 14 (2), pp316–31.
Halton J (2007) ‘Virtual rehabilitation with video games: a new frontier for occupational therapy’, Occupational Therapy
Now, 9 (6), pp12–14.
Hoffman B & Nadelson L (2010) ‘Motivational engagement and video gaming: a mixed methods study’, Educational
Technology Research and Development, 58 (3), pp245–70.
Jacobs K, Zhu L, Dawes M, Franco J, Huggins A, Igari C, Ranta B & Umez-Eronini A (2011) ‘Wii health: a preliminary
study of the health and wellness benefits of Wii Fit on university students’, British Journal of Occupational Therapy,
74 (6), pp262–8.
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Physical activities 4
Key messages
• Guidelines recommend 30 minutes of moderate activity, five days a week:
activity can be completed in 10-minute bursts.
• Physical activity can include housework, gardening and dancing as well as sporting activities
and structured exercise.
• Even small increases in activity will lead to health benefits.
• Physical activity is known to be good for our physical health, for example:
reducing weight
protecting against heart disease and diabetes.
• Physical activity is also good for our mental health because it contributes to:
improvements in mood, concentration and sleep
reduced symptoms
improved quality of life related to increased social interaction and meaningful use of time.
• Sustaining physical activity requires us to change our routines.
• Motivation can be strengthened by:
understanding the benefits of exercise
being able to access appropriate facilities
having support from other people.
The value of physical activities
Introduction
Previous guidelines for physical activity in the UK and the USA have both recommended 30 minutes of
moderate activity, five days a week (Department of Health, 2004; Haskell et al, 2007). It is now
recognised that this can be completed in 10-minute bursts and can include activities such as housework,
home improvements, gardening and dancing, as well as sporting activities and structured exercise
(Chief Medical Officers [CMO], 2011). Indeed, there is evidence that walking has an important role to
play in improving physical health (Bauman, 2004).
Recommendations for physical exercise were originally motivated by the desire to protect people
against physical ill health such as coronary heart disease and diabetes (World Health Organization
[WHO], 2010), the role of physical activity in promoting mental health receiving less attention (Bauman,
2004). Yet the physical benefits alone would be sufficient to prioritise the inclusion of physical activity in
routine mental health care because people with severe mental illness have lower levels of physical
activity than the general population and higher levels of obesity (Northey and Barnett, 2012). The
problem is so great that it contributes to people with severe mental illness dying up to 15 years earlier
than people in the general population (Richardson et al, 2005).
Exercise and mental health

It is now accepted that physical activity is linked directly to mental wellbeing (CMO, 2011) and that
physical activity is associated with a better quality of life (Penedo and Dahn, 2005). In particular, studies
have shown that there is an inverse association between physical inactivity and mental health (Galper
et al, 2006) and that an increase in leisure-time physical activity is associated with increased scores for
quality of life (Tessier et al, 2007). Therefore, physical activity can be said to improve the lives of people
with serious mental illness in two ways: by reducing physical ill health and by improving wellbeing and
functioning (Jones and O’Beney, 2004; Richardson et al, 2005).
Habitual exercise does not prevent the onset of depression (Paluska and Schwenk, 2000), but there is a
growing body of evidence that exercise benefits people who have mild to moderate depression and
anxiety (Martinsen, 2008). The impact of exercise on severe depression is less clear. Babyak et al (2000)
reported significant benefits when people sustained an exercise programme but Bonsaksen and Lerdal
(2012) did not find a relationship between physical activity and quality of life. They attributed this to the
severity of illness in their in-patient population.
Session 4 Physical activities
The Cochrane Database includes a systematic review of research investigating the benefit of exercise
for treating depression (Mead et al, 2009) and recommends that more methodologically robust trials are
required. Similarly, the database includes a systematic review of exercise therapy for schizophrenia
(Gorczynski and Faulkner, 2010) which emphasises the need for larger randomised studies. The apparent
benefits for this population are nevertheless acknowledged, echoing the findings from other reviews of
exercise interventions as an adjunct therapy for psychosis (Ellis et al, 2007) and the impact of physical
activity on psychological wellbeing for people with schizophrenia (Holley et al, 2011). In particular, it is
noted that mild to moderate aerobic exercise can decrease psychiatric symptoms and increase quality of
life (Acil et al, 2008) and yoga therapy might be even more effective than physical exercise
(Duraiswamy et al, 2007).
Physical activity and occupational therapy

Unsurprisingly, occupational therapists are keenly interested in how to support people to integrate
physical activity into their lives, whether this involves joining a fitness centre, playing squash, practising
golf or hiking (Jones, 2008). This professional interest resulted in a special issue of the British Journal of
Occupational Therapy being dedicated to the importance of promoting physical activity to enhance
quality of life (Baxter and Porter-Armstrong, 2012). It includes articles describing the value of dancing
(Borges da Costa, 2012; Froggett and Little, 2012), walking (Wensley and Slade, 2012) and using the
Wii Fit (Bacon et al, 2012), along with a critical review highlighting the benefits of exercise for people
with severe mental illness:
The findings show that exercise can contribute to improvements in

symptoms including mood, alertness, concentration, sleep patterns
and psychotic symptoms. Exercise can also contribute to improved
quality of life through social interaction, meaningful use of time,
purposeful activity and empowerment.
(Alexandratos et al, 2012, p48)
Handcock and Tattersall (2012) regret that many guidelines focus largely on physical health outcomes
and urge caution in the rush to implement physical activity guidelines. They remind occupational
therapists that care is needed to ensure that good intentions are converted into lasting habits, and
attention must be paid to the psychosocial adjustments people make when accommodating an exercise
routine. In other words, if we are to promote increased activity, the process must involve more than
mere fitness testing and exercise prescription (advocated by Meyer and Broocks, 2000).
Yet the two approaches are not mutually exclusive and the most recent guidelines, such as those by the
CMO (2011), refer to the physical and psychosocial benefits of activity, as well as recognising the need
to incorporate activity into everyday life (Cole, 2012).
Even small increases in activity will bring some health benefits in the
early stages and it is important to set achievable goals that provide
success, build confidence and increase motivation.
(O’Donovan et al, 2010, p573)
Cole (2010) conceptualises participation in physical activity using MOHO and recognises that volitional
factors are particularly influential. She describes how physical activity is used in the initial stages of
treatment as an adjunct to other treatments and comes into its own as mental health issues begin to be
resolved. At this point, when it comes to people sustaining long-term physical activity, the importance of
optimal social support and accessible physical environments cannot be underestimated (Owen et al,
2000; Crone et al, 2005).
To conclude, therefore, occupational therapists need to develop educational interventions where barriers
to activity can be explored (Reynolds, 2001) and participants can consolidate their appreciation of the
social and psychological benefits of participation (Pentecost and Taket, 2010).
Sample activities
Introduction
Throughout this session, facilitators need to reinforce the message that any increase in physical activity,
however small, is good.

Does physical health affect our mental health?
Check out the participants’ understanding at the beginning of the session and encourage them to share
their knowledge. Share the quotation by Alexandratos et al (2012) in ‘The value of physical activities’ at
the beginning of this section.
How energetic are you?

• What is the most energetic thing you have ever done? For example, moving house, running for a bus,
going to an exercise class, climbing a mountain, or having children!
• What is the furthest distance you have ever walked (or run)? For example, a sponsored walk,
walking to the shops and back, a ‘fun run’, walking to school, hiking.
Warm-up exercises
• Try out some simple exercises and stretches which the participants can easily accomplish.
• Teach the participants to take their pulse before and after exercise:
take advice about how to calculate a healthy pulse rate, at rest and during exercise.
• Ask whether anyone has ever used a pedometer. Show them how a pedometer works and find out
how many steps a person takes during the warm-up.
Average time sitting down per day

Question: How long do you think the average British person spends sitting down every day?
Answer: 14 hours!
(Source: www.telegraph.co.uk/health/healthnews/7738663/Britons-spend-more-than-14-hours-a-day-sitting-down.html)
• Try to work out how long you spend sitting down every day.
• Include time spent:
at a table (eg at mealtimes)
behind a desk (eg at a computer)

in a car or on public transport
in an armchair (eg watching television).
Activity alphabet
Below there is a list of physical activities from A to Z. Read out the list, from left to right, one by one,
and ask participants to raise their hand if they have ever tried the activity. Alternatively, involve the
participants in creating their own list. Go through each letter of the alphabet and ask them to call out
activities that start with each letter and write them on a flipchart before asking which activities they
have ever tried.
• archery • bowling • climbing

• disco-dancing • egg-and-spoon race • fencing
• golf • horse-riding • ice-skating
• jogging • kayaking • line-dancing
• martial arts • netball • orienteering
• parcours • quoits • rugby
• squash • table-tennis • ultimate Frisbee
• volleyball • Xbox game • water polo
• yoga • Zumba
If you use the above list, remember to check that everyone knows what all the activities are!
Lost calories (worksheet page 79)

When completing this worksheet, remind the participants that the answers assume that a person would
be carrying out the activities continuously for half an hour. Ask the participants to complete the
worksheet on their own before discussing their answers in pairs and making any revisions.
Answers: average number of calories used by 10 stone (63.5 kg) person in half an hour when:
1 watching television 32
2 reading (sitting down) 41
3 playing cards 48
4 doing deskwork 57
5 singing (standing up) 64
6 ironing 73
7 changing bed linen 79

8 fishing from a riverbank 111
9 gardening 127
10 playing badminton (non-competitive) 143
11 tap-dancing 152
12 doing aerobics (low impact) 159
13 jogging 222
14 carrying objects upstairs 286
If the participants are not familiar with the activities on the worksheet, alternative lists can be found on
the web.
Incorporating exercise into daily routine

• What stops you being active?
• When did you last do any of the following?

gardening running for the bus
dog-walking running upstairs
housework walking to the shops
dancing cycling
• How can you increase the number of steps you take each day?
Use stairs not lifts
Walk don’t drive
Park further away
Exercise ideas
Ask the participants to describe any fitness exercises that they can do using just their body weight – for
example, ladders, steps, lunges, push-ups, tricep dips, plank, hip hikes.
• When is the best time for you to do some exercise? For example, early morning or before your
evening meal.
• How much exercise should we do per week?
150 minutes of moderate exercise, ie 30 minutes five times a week, or 10 minutes three times a
day with two days of rest.

Expert opinion
• Invite a physiotherapist to talk about the benefits of physical exercise.

• Visit a sports centre and arrange for a gym induction.
• Visit a green gym – working outdoors with other people to improve green spaces and do physical
exercise at the same time.
Active experience
• Organise a taster session – eg t’ai chi, salsa dancing, archery.
• Join a Walking for Health session – a free scheme that organises short guided walks in
communities across England.
Lost calories
✐
WORKSHEET
Assuming that a person does the following activities for half an hour each, rank them
in order from 1 to 14.
Scale: 1 = fewest calories used; 14 = most calories used.
Rank
aerobics (low impact)
changing bed linen
playing badminton (non-competitive)
carrying objects upstairs
playing cards
tap-dancing
deskwork
fishing from a riverbank
gardening
ironing
jogging
reading (sitting down)
singing (standing up)
watching television
References
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schizophrenia’, Journal of Psychiatric and Mental Health Nursing, 15 (10), pp808–15.
Alexandratos K, Barnett F & Thomas Y (2012) ‘The impact of exercise on the mental health and quality of life of people
with severe mental illness: a critical review’, British Journal of Occupational Therapy, 75 (2), pp48–60.
Babyak M, Blumenthal JA, Herman S, Khatri P, Doraiswamy M, Moore K, Craighead WE, Baldewicz TT
& Krishnan KR (2000) ‘Exercise treatment for major depression: maintenance of therapeutic benefit at
10 months’, Psychosomatic Medicine, 62 (5), pp633–8.
Bacon N, Farnworth L & Boyd R (2012) ‘The use of the Wii Fit in forensic mental health: exercise for people at risk of
obesity’, British Journal of Occupational Therapy, 75 (2), pp61–68.
Bauman AE (2004) ‘Updating the evidence that physical activity is good for health: an epidemiological review
2000–2003’, Journal of Science and Medicine in Sport, 7 (1), pp6–19.
Baxter GD & Porter-Armstrong A (2012) ‘Special issue: promoting physical activity to enhance quality of life’, British
Journal of Occupational Therapy, 75 (2), p47.
Bonsaksen T & Lerdal A (2012) ‘Relationships between physical activity, symptoms and quality of life among inpatients
with severe mental illness’, British Journal of Occupational Therapy, 75 (2), pp69–75.
Borges da Costa AL (2012) ‘Circle dance, occupational therapy and wellbeing: the need for research’, British Journal of
Chief Medical Officers of England, Scotland, Wales and Northern Ireland (CMO) (2011) Start Active, Stay Active:
A Report on Physical Activity from the Four Home Countries’ Chief Medical Officers, Department of Health, London.
Cole F (2010) ‘Physical activity for its mental health benefits: conceptualising participation within the Model of Human
Occupation’, British Journal of Occupational Therapy, 73 (12), pp607–15.
Cole F (2012) ‘Physical activity guidelines’, British Journal of Occupational Therapy, 75 (4), p205.
Crone D, Smith A & Gough B (2005) ‘“I feel totally at one, totally alive and totally happy”: a psycho-social explanation of
the physical activity and mental health relationship’, Health Education Research, 20 (5), pp600–11.
Department of Health (DH) (2004) At Least Five a Week: evidence on the impact of physical activity and its relationship to
health, DH, London.
Duraiswamy G, Thirthalli J, Nagendra HR & Gangadhar BN (2007) ‘Yoga therapy as an add-on treatment in the
management of patients with schizophrenia – a randomized controlled trial’, Acta Psychiatrica Scandinavica, 116 (3),
pp226–32.
Ellis N, Crone D, Davey R & Grogan S (2007) Exercise interventions as an adjunct therapy for psychosis: a critical
review’, British Journal of Clinical Psychology, 46 (1), pp95–111.
Froggett L & Little R (2012) ‘Dance as a complex intervention in an acute mental health setting: a place “in-between”‘,
Galper D, Trivedi MH, Barlow CE, Dunn AL & Kampert JB (2006) ‘Inverse association between physical inactivity and
mental health in men and women’, Medicine & Science in Sports & Exercise, 38 (1), pp173–8.
Gorczynski P & Faulkner G (2010) ‘Exercise therapy for schizophrenia’, Cochrane Database of Systematic Reviews,
Issue 5.
Handcock P & Tattersall K (2012) ‘Occupational therapists beware: physical activity guidelines can mislead’, British
Haskell WL, Lee I-M, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD &
Bauman A (2007) ‘Physical activity and public health: updated recommendation for adults from the American College of
Sports Medicine and the American Heart Association’, Medicine & Science in Sports & Exercise, 39(8), pp1423–34.
Holley J, Crone D, Tyson P & Lovell G (2011) ‘The effects of physical activity on psychological well-being for those with
schizophrenia: a systematic review’, British Journal of Clinical Psychology, 50 (1), pp84–105.
Jones L (2008) ‘Promoting physical activity in acute mental health’, British Journal of Occupational Therapy, 71 (11),
pp499–502.
Jones M & O’Beney C (2004) ‘Promoting mental health through physical activity: examples from practice’, Journal of Public
Martinsen EW (2008) ‘Physical activity in the prevention and treatment of anxiety and depression’, Nordic Journal of
Mead GE, Morley W, Campbell P, Greig CA, McMurdo M & Lawlor DA (2009) ‘Exercise for depression’, Cochrane
Database of Systematic Reviews, Issue 3.
Meyer T & Broocks A (2000) ‘Therapeutic impact of exercise on psychiatric diseases: guidelines for exercise testing and
prescription’, Sports Medicine, 30 (4), pp269–79.
Northey A & Barnett F (2012) ‘Physical health parameters: comparison of people with severe mental illness with the
general population’, British Journal of Occupational Therapy, 75 (2), pp100–5.
O’Donovan G, Blazevich AJ, Boreham C, Cooper AR, Crank H, Ekelund U, Fox KR, Gately P, Giles-Corti B,
Gill JMR, Hamer M, McDermott I, Murphy M, Mutrie N, Reilly JR, Saxton JM & Stamatakis E (2010) ‘The ABC of
Physical Activity for Health: a consensus statement from the British Association of Sport and Exercise Sciences’, Journal of
Sports Sciences, 28 (6), pp573–91.
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behavior’, Exercise and Sport Sciences Reviews, 28 (4), pp153–8.
Paluska SA & Schwenk TL (2000) ‘Physical activity and mental health: current concepts’, Sports Medicine, 29 (3),
pp167–80.
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physical activity’, Current Opinion in Psychiatry, 18 (2), pp189–93.
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model demonstrating the importance of exercise identity, benefits of attending and support’, Health Education Research,
26 (5), pp908–22.
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into mental health services for persons with serious mental illness’, Psychiatric Services, 56 (3), pp324–31.
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(2007) ‘Association between leisure-time physical activity and health-related quality of life changes over time’, Preventive
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World Health Organization (WHO) (2010) Global Recommendations on Physical Activity for Health, WHO, Geneva.
Outdoor activities 5
Key messages
• Human beings appear to be attracted to the natural world:
animals and birds
plants
landscapes.
• Green spaces in our towns and cities contribute to health and wellbeing because:
they encourage people to exercise more
exercising outdoors is linked with increased enjoyment and motivation
stress is reduced just by looking at natural environments
– patients get better more quickly when hospitals have attractive views from the
windows
– people exercising in gyms feel better about themselves if the gym shows images of
pleasant scenes (whether of towns or the countryside).
• Ordinarily, we spend a lot of time concentrating on what we need to do, but the endless
fascination we have for the natural world is undemanding and helps us to ‘recharge our
batteries’.
It helps us to regain a sense of perspective.
Watching the world around us gives us a sense of connection with the age-old human
pursuits needed for survival.
• Outdoor activities include:
adventurous pursuits in the wild that require responsibility and teamwork
gentler pursuits, such as gardening, which provide opportunities for social participation.
The value of outdoor activities

Green environments
The value of outdoor activities appears to be instinctive and has led to the concept of ‘biophilia’ (Kellert
and Wilson, 1993). That is, the idea that human beings are drawn towards nature and the various
aspects of the natural world, including ‘animals, plants, landscapes and wilderness’ (Frumkin, 2001,
p234). Since the term ‘biophilia’ was coined, numerous studies have concluded that green environments,
particularly those including water, improve mood and self-esteem (Barton and Pretty, 2010).
It is now widely recognised that urban green spaces contribute to health and wellbeing (Morris, 2003),
and that access to gardens and other green areas near to where we live is associated with reduced
stress and obesity (Nielsen and Hansen, 2007; Sugiyama and Thompson, 2007). This may be because
they allow us to walk more (Sugiyama and Thompson, 2007) and engage in more outdoor activities
(Nielsen and Hansen, 2007) but, interestingly, ‘the number of visits cannot explain the effects of green
areas on … health indicators’ (Nielsen and Hansen, 2007, p839).
Morris (2003) provides compelling evidence that exposure to green environments – even if it is passive
rather than active – is associated with a wide range of social and health benefits. Her literature review
cites a range of studies demonstrating that recuperation is enhanced when patients can view natural
environments, either through a window or depicted on a mural (Morris, 2003). Kaplan (1995) argues that
this is because our ordinary lives require us to expend a great deal of effort in focusing our attention,
while nature harnesses our involuntary attention. He suggests that natural environments are rich in
restorative experiences that combat fatigue by enabling us to get away from our usual contexts, be
drawn into effortless fascination, and regain a sense of perspective and connectedness.
Furthermore, the natural world calls on people to engage in age-old human pursuits that meet natural
inclinations for survival (eg building fires and shelters, hunting and fishing, domesticating animals, and
growing vegetables) and fulfil inbuilt needs to observe wildlife (eg bird-watching and whale-watching)
and roam the countryside (eg hiking and sailing) (Kaplan, 1995).
Nature-assisted therapy and green exercise

In 2010, Barton and Pretty published a multiple-study analysis showing that green environments
improved self-esteem for men and women alike, with people who were mentally ill showing the
greatest improvement. Then, in 2011, Annerstedt and Währborg published a systematic review detailing
significant improvements that ‘nature-assisted therapy’ has achieved for a range of conditions, including
Session 5 Outdoor activities
schizophrenia. In the same year, Thompson Coon et al published a systematic review that specifically
looked at the impact of combining physical activity with outdoor environments.
Although some of the trials were of poor methodological quality, the results were promising:
Compared with exercising indoors, exercising in natural

environments was associated with greater feelings of revitalization
and positive engagement, decreases in tension, confusion, anger, and
depression, and increased energy. However, the results suggested
that feelings of calmness may be decreased following outdoor
exercise. Participants reported greater enjoyment and satisfaction
with outdoor activity and declared a greater intent to repeat the
activity at a later date.
(Thompson Coon et al, 2011, p1761)
Such findings support the importance of outdoor recreation being used in occupational therapy to
improve the quality of life for people with enduring mental health problems. This can be walking or
cycling or more adventurous pursuits such as climbing and kayaking (Frances, 2006), horse-riding
(Bizub et al, 2003; Burgon, 2003), or other activities on Outward Bound programmes (Neill and Dias,
2001). The more adventurous pursuits, involving real or perceived risk, may even have enhanced benefits
in terms of social outcomes (requiring teamwork to overcome challenges) and psychological outcomes
(requiring increased responsibility and achievement) (Ewart et al, 2001).
All too often, institutions provide very little support for outdoor recreation. Indeed, Farnworth et al
(2004) found that just two per cent of recreation and leisure time in a forensic psychiatric unit was spent
in sport and outdoor activities. They reinforced the importance of finding out about people’s unique
occupational histories, skills and interests in order to engage them in relevant occupations.
Occupational therapists also need to consider the availability of resources and cultural influences. This
will determine whether the identified occupations include: ‘surfing, beach volleyball and bushwalking’
(Lloyd et al, 2000, describing rehabilitation programmes in Australia); participating in a ‘Green Gym’
(Birch, 2005, describing a British conservation scheme); or activities in a forest environment (Nordh
et al, 2009, describing a Swedish rehabilitation project).
Alternatively, occupational therapists might introduce natural images into indoor gyms. For example,
Pretty et al (2005) projected a series of scenes onto a wall while participants exercised on a treadmill.
They found that pleasant scenes (whether rural or urban) increased the impact of exercise on
self-esteem while unpleasant scenes (especially unpleasant rural scenes) reduced this impact.
Gardening and wellbeing

Gardening deserves a special mention in this section to reflect the wealth of literature that has been
devoted to analysing its benefits for health and wellbeing (York and Wiseman, 2012). Studies have
shown how gardening:
• provides a coping strategy for people diagnosed with cancer (Unruh, 2004)
• provides opportunities for functional improvement and social participation when people have brain
damage (Söderback et al, 2004)
• improves the psychological wellbeing of older people (Heliker et al, 2000)
• enables fathers to develop stronger relationships with their children (Mason and Conneeley, 2012).
For a person who feels marginalised from mainstream society, gardening can provide a sustainable way
of maintaining social citizenship (Parr, 2007). Allotments, for instance, can provide opportunities for
mental health clients to rebuild a destigmatised sense of their identity and engage in highly valued
social networks (Fieldhouse, 2003), while conservation activities can provide opportunities for
volunteering (O’Brien et al, 2010).
Equally, gardening has a positive impact on underlying mental health conditions. Immediate positive
effects on quality of life have been found when people with chronic mental illness participated in a
group-based horticultural experience (Perrins-Margalis et al, 2000) and depression continued to be
alleviated, three months after a therapeutic horticultural intervention (Gonzalez et al, 2009).
The growing support for the use of social and therapeutic horticulture (Sempik et al, 2003) has led to
care farms being established, particularly in the Netherlands (Hassink et al, 2010). These are now
emerging in the UK, where there are calls to expand their work (Hine et al, 2008).
Care farms typically enable people to care for animals as well as plants (Elings and Hassink, 2008),
with associated benefits for mental health in terms of decreased anxiety and an increased sense of
self-efficacy (Berget et al, 2007). Moreover, the benefits are twofold because, while the participants are
benefiting from increased links to nature, the environment is benefiting too. In fact, many of the
activities pursued in green spaces encourage engagement in sustainable living while supporting the
management of limited ecological resources. This is an important consideration, and one that
occupational therapists should endeavour to promote (Hudson and Aoyama, 2008).
Sample activities
Introduction
This topic could be combined with the physical activities session to extend discussions about physical
activity. It might also appeal to participants who are less interested in physical activity but have an
interest in nature conservation or travel. When facilitating the session, occupational therapists should
demonstrate an awareness of local resources and the opportunities that participants have to access
outdoor environments.

Current access
Before discussing the value of outdoor activities, encourage the participants to reflect on their current
experiences.
Ask:
• Where is the nearest green space to you?
• How often do you walk around your neighbourhood? Where do you go to?
• When did you last visit the countryside? Or the beach?
Favourites
Ask the participants about the type of places and things they like.
Ask:
• What is your favourite place in this country? Tell us about it.
• If you could go anywhere in the world, where would you go? Why?
• Does anyone have a favourite:
wild animal or bird?
season, weather or time of day?
plant, tree, flower or type of garden?
The importance of being outdoors

Before sharing the key messages for the session, the facilitators should read the information at the start
of this section, and lead an open discussion about the value of outdoor activities.
Ask:
• Does being outdoors make a difference to health and wellbeing?
• Why might it make a difference to health and wellbeing?
True or false?
Arrange for the participants to work in pairs and think of an answer to the following questions.
Question: Does it make a difference if:
• patients in hospital have attractive views from their hospital beds? (Answer: True)
• people going to a gym are shown pleasant images while they are exercising? (Answer: True)
• housing estates are built with access to green spaces? (Answer: True)
Preferences
Ask the participants to vote for the places they are most attracted to and keep a record of their ‘votes’
on a flipchart.
• Urban landscapes or natural landscapes?
• Wild countryside or ‘tamed’ countryside (eg fields, gardens and managed woodland)?
• Quiet places or noisy places?
• Places where you can be on your own or places where there are lots of other people?
Check whether everyone is attracted to the same type of place.
There are no right or wrong answers and, as the group starts to discuss their preferences, it may
become apparent that their preferences will depend on their mood and what they want to do at any
particular time. If participants express a definite preference, they could be asked, ‘Are there any
circumstances when you might prefer the opposite?’
Nature appreciation
Collect some images of beautiful landscapes: pictures from magazines or images that can be projected
onto a screen. For example, a relaxation video showing images of the natural world would be ideal.
Try to include a large variety of images, such as: the sky at night and sunsets; clouds and rainbows;
mountains and woodland; streams, waterfalls, lakes and coastline; urban landscapes and gardens;
plants and animals, etc. Share the images and ask participants to choose their favourite ones and
explain what attracts them to those images.
Feelings (worksheet page 91)

Ask the participants to think about how beautiful environments affect them. Be aware that sometimes
people may feel insignificant and less connected with the world when they are in beautiful
surroundings. Allow them to express these feelings before helping them tap into times in the past when
they experienced more positive feelings.
Outdoor opportunities (worksheet page 92)

Encourage the participants to think of even more ideas for outdoor activities – especially any activities
that are free or cost very little.
Barriers and stepping stones

Give the group a short amount of time to share some of the things that stop them from going outdoors.
Then allow twice as long for them to think of ideas for increasing the amount of time they spend
outdoors. Go round the group and ask everyone to contribute one idea and then encourage each
participant to make a resolution.

Active experience
Organise a session to try out one of the simpler activities on the ‘Outdoor opportunities list’,
eg a walk, gardening or kite-flying.
Guest speaker
Arrange for someone to talk about one of the activities on the ‘Outdoor opportunities list’,
eg bird-watching or fishing, star-gazing.
Rainbow walk
If it is spring or summer, organise a walk through a meadow or woodland, or anywhere where there is
some greenery. Give the participants a small piece of cartridge paper each. The aim is to rub natural
materials (grasses, petals, lichen, berries, etc) onto the paper to create a palette of colours and to see
who can find the widest palette. The participants should not pick wild flowers that are not abundant and
they should be careful to wash their hands afterwards.
Scavenger hunt
Spend time outside and give the participants a list of things to find that will all fit into a small bag.
For example:
• a variegated leaf
• a feather
• a smooth pebble
• a piece of litter
• a seed head
• a flower petal
• a clover leaf
• a pine cone, an acorn or a conker
• a small piece of moss
• something red.
Town walk
Arrange for a town walk with a local historian, or one where the participants have to find the location of
various landmarks (having first been given photographs of the landmarks, eg unusual doors, chimneys,
or statues).
Mindfulness exercise
Take the group somewhere outdoors where they can be still and listen.
Ask:
• What can they hear?
• What can they smell?
• How does the air feel on their skin?
• Can they tell what the ground is like just by taking a few steps?
• What physical sensations can they feel?
• Can they see any birds, animals or insects?
• Looking up at the sky, how many colours are there? Are they shades of blue or are there other
colours?
• Looking around, is there a bright green? A dark green? An olive green? A blue-green? A grey-green?
Feelings
✐
WORKSHEET
How do we feel when we are in beautiful surroundings?
• Circle any of the feelings listed below which you have felt in the past.
• Share an occasion when being outdoors made you feel really good.
peaceful fascinated energised
healthy small awestruck
lucky refreshed happy
at one
enchanted riveted
with nature
sad uplifted strong
Outdoor opportunities
✐
WORKSHEET
• Tick all of the activities listed below that you have you tried in the past.
• Circle any activities that you would like to do in the future.
• a walk in the park • having a barbeque
• badger-watching • having a picnic
• bat-watching • helping on a farm
• bird-watching • hiking
• blackberry-picking • horse-riding
• camping • jogging
• climbing • kayaking
• conservation work • kite-flying
• croquet • making a sandcastle
• crown green bowling • orienteering
• cycling • paddling in the sea
• dog-walking • parcours (urban gym)
• feeding ducks • photography
• fishing • pond-dipping
• fossil-hunting • quad-biking
• gardening • sight-seeing
• going on a boat trip • skimming stones
• going on a safari • star-gazing
• going on a scavenger hunt • train-spotting
• golf • visiting a nature reserve
• having a bonfire • whale-watching
References
Annerstedt M & Währborg P (2011) ‘Nature-assisted therapy: systematic review of controlled and observational
studies’, Scandinavian Journal of Public Health, 39 (4), pp371–88.
Barton J & Pretty J (2010) ‘What is the best dose of nature and green exercise for improving mental health? A multi-study
analysis’, Environmental Science and Technology, 44 (10), pp3947–55.
Berget B, Skarsaune I, Ekeberg Ø & Braastad BO (2007) ‘Humans with mental disorders working with farm animals:
a behavioral study’, Occupational Therapy in Mental Health, 23 (2), pp101–17.
Birch M (2005) ‘Cultivating wildness: three conservation volunteers’ experiences of participation in the Green Gym Scheme’,
Bizub AL, Joy A & Davidson L (2003) ‘“It’s like being in another world”: demonstrating the benefits of therapeutic
horseback riding for individuals with psychiatric disability’, Psychiatric Rehabilitation Journal, 26 (4), pp377–84.
Burgon H (2003) ‘Case studies of adults receiving horse-riding therapy’, Anthrozoos: A Multidisciplinary Journal of the
Interactions of People and Animals, 16 (3), pp263–76.
Elings M & Hassink J (2008) ‘Green care farms: a safe community between illness or addiction and the wider society’,
Therapeutic Communities: the International Journal for Therapeutic Communities, 29 (3), pp310–22.
Ewart AW, McCormick BP & Voight AE (2001) ‘Outdoor experiential therapy: implications for TR practice’, Therapeutic
Recreation Journal, 35 (2), pp107–22.
Farnworth L, Nikitin L & Fossey E (2004) ‘Being in a secure forensic psychiatric unit: every day is the same, killing time or
making the most of it’, British Journal of Occupational Therapy, 67 (10), pp430–8.
Fieldhouse J (2003) ‘The impact of an allotment group on mental health clients’ health, wellbeing and social
networking’, British Journal of Occupational Therapy, 66 (7), pp286–96.
Frances K (2006) ‘Outdoor recreation as an occupation to improve quality of life for people with enduring mental health
problems’, British Journal of Occupational Therapy, 69 (4), pp182–6.
Frumkin H (2001) ‘Beyond toxicity: human health and the natural environment’, American Journal of Preventive Medicine,
20 (3), pp234–40.
Gonzalez MT, Hartig T, Patil GG, Martinsen EW & Kirkevold M (2009) ‘Therapeutic horticulture in clinical depression:
a prospective study’, Research and Theory for Nursing Practice, 23 (4), pp312–28.
Hassink, J, Elings M, Zweekhorst M, van den Nieuwenhuizen N & Smit A (2010) ‘Care farms in the Netherlands:
attractive empowerment-oriented and strengths-based practices in the community’, Health and Place, 16 (3), pp423–30.
Heliker D, Chadwick A & O’Connell T (2000) ‘The meaning of gardening and the effects on perceived well being of a
gardening project on diverse populations of elders’, Activities, Adaptation and Aging, 24 (3), pp35–56.
Hine R, Peacock J & Pretty J (2008) ‘Care farming in the UK: contexts, benefits and links with therapeutic
communities’, Therapeutic Communities: the International Journal for Therapeutic Communities, 29 (3), pp245–60.
Hudson MJ & Aoyama M (2008) ‘Occupational therapy and the current ecological crisis’, British Journal of Occupational
Therapy, 71 (12), pp545–8.
Kaplan S (1995) ‘The restorative benefits of nature: toward an integrative framework’, Journal of Environmental Psychology,
15 (3), pp169–82.
Kellert SR & Wilson EO (eds) (1993) The Biophilia Hypothesis, Island Press, Washington, DC.
Lloyd C, Bassett J & Samra P (2000) ‘Rehabilitation programmes for early psychosis’, British Journal of Occupational
Therapy, 63 (2), pp76–82.
Mason J & Conneeley L (2012) ‘The meaning of participation in an allotment project for fathers of preschool children’,
Morris N (2003) Health, Well-being and Open Space: Literature Review, OPENSpace Research Centre, Edinburgh.
Neill JT & Dias KL (2001) ‘Adventure education and resilience: the double-edged sword’, Journal of Adventure Education
and Outdoor Learning, 1 (2), pp35–42.
Nielsen TS & Hansen KB (2007) ‘Do green areas affect health? Results from a Danish survey on the use of green areas and
health indicators’, Health & Place, 13 (4), pp839–50.
Nordh H, Grahn P & Währborg P (2009) ‘Meaningful activities in the forest: a way back from exhaustion and long-term
sick leave’, Urban Forestry & Urban Greening, 8 (3), pp207–19.
O’Brien L, Townsend M & Ebden M (2010) ‘“Doing something positive”: volunteers’ experiences of the well-being
benefits derived from practical conservation activities in nature’, VOLUNTAS: International Journal of Voluntary and
Nonprofit Organizations, 21 (4), pp525–45.
Parr H (2007) ‘Mental health, nature work, and social inclusion’, Environment and Planning D: Society and Space,
25 (3), pp537–61.
Perrins-Margalis NM, Rugletic J, Schepis NM, Stepanski HR & Walsh MA (2000) ‘The immediate effects of a
group-based horticulture experience on the quality of life of persons with chronic mental illness’, Occupational Therapy in
Pretty J, Peacock J, Sellens M & Griffin M (2005) ‘The mental and physical health outcomes of green exercise’
International Journal of Environmental Health Research, 15 (5), pp319–37.
Sempik J, Aldridge J & Becker S (2003) Social and Therapeutic Horticulture: Evidence and Messages from
Research, Thrive in association with the Centre for Child and Family Research, Loughborough University, Reading.
Söderback I, Söderström M & Schälander E (2004) ‘Horticultural therapy: the “healing garden” and gardening in
rehabilitation measures at Danderyd hospital rehabilitation clinic, Sweden’, Developmental Neurorehabilitation,
7 (4), pp245–60.
Sugiyama T & Thompson CW (2007) ‘Older people’s health, outdoor activity and supportiveness of neighbourhood
environments’, Landscape and Urban Planning, 83 (2–3), pp168–75.
Thompson Coon J, Boddy K, Stein K, Whear R, Barton J & Depledge MH (2011) ‘Does participating in physical activity
in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors?
A systematic review’, Environmental Science and Technology, 45 (5), pp1761–72.
Unruh AM (2004) ‘The meaning of gardens and gardening in daily life: a comparison between gardeners with serious health
problems and healthy participants’, Acta Horticulture, 639, pp67–73.
York M & Wiseman T (2012) ‘Gardening as an occupation: a critical review’, British Journal of Occupational Therapy,
75 (2), pp75–84.
Faith activities 6
Key messages
• Faith has been defined as a set of firmly held principles or beliefs. These can be:
either religious
or spiritual in nature.
• Being faithful can mean:
having faith
remaining true
being constant
being loyal.
• Spiritual and religious beliefs have been linked to:
reduced onset of physical and mental illness
increased recovery.
• The reasons for this link are unclear but it may be because of:
greater meaningfulness and sense of purpose
a sense of wellbeing and comfort
improved social support
healthier lifestyle, including reduced smoking and drinking.
• Religion and spirituality may involve:
going to certain places
valuing certain objects
participating in certain activities
being with certain people.
The value of faith activities

Introduction
There is considerable interest in the impact of faith (spiritual or religious beliefs) on the lives of people
living with disabilities, whether they have AIDS or cancer or are care givers for children with disabilities
(Boswell et al, 2001), or whether they experience problems with their mental health, such as depression,
anxiety, post-traumatic stress disorder or schizophrenia (Mental Health Foundation, 2006).
This has given rise to an increasing awareness of the varying roles that all health professionals have to
play in addressing spiritual needs and providing holistic care, including doctors, psychologists, social
workers, nurses or occupational therapists (Farrer, 2001; Kang, 2003; Phillips, 2003).
Links between spirituality, religion and health

Over time, faith has sometimes been viewed as being irrelevant to health (George et al, 2000, p102)
but it is now accepted that significant links exist between spirituality, religion and health (Hill and
Pargament, 2003). Spirituality and religious beliefs have been found to correspond with ‘reduced onset
of physical and mental illnesses, reduced mortality, and likelihood of recovery from or adjustment to
physical and mental illness’ (George et al, 2000, p102) and specific behaviours, such as attendance at
religious services, seem to have a protective effect on survival (Strawbridge et al, 2001).
The reasons for these associations remain unclear (Hill and Pargament, 2003) but they have been linked
to improved social support and enhanced meaningfulness (George et al, 2000) as well as a stronger
sense of self-efficacy (George et al, 2002). People also use religion or spirituality ‘to cope and construct
meaning in times of adversity’ (Mattis, 2002), which can lead to comfort, an inner sense of peace and
greater wellbeing (Fry, 2000). Moreover, religious involvement and spiritual practices have been linked to
healthier lifestyles (George et al, 2000, 2002), including reduced smoking and alcohol consumption,
more physical activity and increased participation in health checks (Strawbridge et al, 2001).
Faith may be associated with improved health but it is equally important to those experiencing ill health.
People who have become disabled sometimes regard their disability as ‘a catalyst for spiritual
awakening’ (Schulz, 2005a, p1283). Evidence of the importance of spirituality and religion in their lives
includes one study where 41 out of 58 mental health service users (71 per cent) reported that their
spiritual life had made a significant contribution to their recovery (Bussema and Bussema, 2007).
This significance has the potential to be harnessed by goal-directed health care. For instance, without
intervention, it has been found that religiousness and spirituality are significantly associated with
increased wellbeing and reduced symptoms but not with achievement of life goals (Corrigan et al, 2003).
Session 6 Faith activities
However, when 20 people in a rehabilitation programme took part in a voluntary spirituality group, they
all achieved their goals over the next six months, compared with 16 (57 per cent) out of the remaining
28 people on the programme (Wong-McDonald, 2007).
Religion, spirituality and health care

It is now widely accepted that spiritual needs should be addressed in holistic health care. This considers
the connections between the mind, the body and the spirit and should include an assessment of
spirituality, sensitive communication showing respect for a person’s beliefs, and support to access
spiritual resources (Phillips, 2003). Therapists in general have responded to this call, recognising that a
person’s relationship with the divine influences their relational identity and how they relate to the world
and other people within it (Carlson and Erickson, 2000).
Occupational therapists in particular have recognised the power that spirituality has to give meaning to
occupation which then builds a person’s sense of their identity (Griffith et al, 2007). The concept of
spirituality has been included in several occupational models of practice (Wilson, 2010) and spiritual
values and goals are an inherent part of the volitional concept within the Model of Human Occupation
(Kielhofner, 2008). The models help to emphasise the role that spirituality can have in allowing
connectedness and expressiveness to dispel the sense of disconnection felt by so many people with
disabilities (Schulz, 2005b).
Despite many positive evaluations, it should be noted that the benefits of spirituality for people with
schizophrenia are less clear cut (Mental Health Foundation, 2006).
• Koenig (2009, p283) states that ‘While religious beliefs and practices can represent powerful
sources of comfort, hope, and meaning, they are often intricately entangled with neurotic and
psychotic disorders, sometimes making it difficult to determine whether they are a resource or a
liability’.
• Huguelet et al (2006) conclude that, although psychotic symptoms can reflect a person’s religious
beliefs, religion is more often not connected with a person’s delusions and remains an important
aspect of a person’s life.
• Wilding et al (2005) argue that spiritual occupations support participants with serious mental illness
and that their vital importance to individuals can provide a foundation for meaningful action, both
with other people and alone.
• Smith and Suto (2012) found that participants used their religious or spiritual practices to help
them cope with the symptoms of schizophrenia and their freedom to choose spiritual options
empowered them.
Religion, spirituality and occupational therapy practice

The previous two references are both from occupational therapy literature. They confirm that the value
of religion and spirituality in people’s lives continues to be recognised by occupational therapists, just as
it was in 1997, when Howard and Howard made a case for ‘acknowledging spirituality in clinical
reasoning as a centralising component of the patient’s motivation and assignment of meaning to life’
(p181). Yet this understanding has not always been translated into practice. A survey (also in 1997) of
500 occupational therapists, yielding a sample of 270 respondents, found that 63 per cent were either
undecided about or disagreed with the idea of spiritual needs lying within the professional scope of
practice (Engquist et al, 1997).
By 2001, Farrer found that the majority of occupational therapist respondents agreed that spirituality
was an appropriate subject for their practice but they were unsure of how to address it. Meanwhile,
Collins et al (2001) stated that occupational therapists were more likely to discuss spiritual issues with
their clients but cited lack of education or experience as barriers to addressing issues more fully. More
recently, it has been conceded that even the occupational therapists who deal with spiritual issues
explicitly do so only when the client–therapist relationship is perceived to allow this (Johnston and
Mayers, 2005). More practical training and information are required (Belcham, 2004).
How occupational therapists address spiritual needs has varied and they have expressed concerns about
role ambiguity (Belcham, 2004). Beagan and Kumas-Tan (2005) concluded that, although occupational
therapists held many views that were similar to pastoral care workers, there were important distinctions
between the two professions in how they responded to clients’ needs. Yet it seems that occupational
therapists have struggled to articulate this difference. Instead, some have written about using their own
spirituality in their therapeutic use of self (Collins, 2007); others have admitted to praying for their
clients (Taylor et al, 2000); still more have talked in general terms of adopting ‘a listening and holistic
approach’ (Hoyland and Mayers, 2005).
Even when the intention is more clearly occupation-focused, many practices appear to overlap with
those of a pastoral care worker. For instance, Egan and Swedersky (2003) found that occupational
therapists were concerned with helping individuals to experience increased functioning by using their
unique gifts and interests. But they also identified that the therapists sought to address religious
concerns and relieve distress.
Religion and spirituality – definitions and related occupations

Religion and spirituality are related but distinct concepts with spirituality being the broader of the two
(Boswell et al, 2001). Corrigan et al (2003, p487) give the following definition when distinguishing
between religion and spirituality.
Religiousness is defined as participation in an institutionalised

doctrine while spirituality is framed as an individual pursuit of
meaning outside the world of immediate experience.
While some people may perceive themselves as lacking in religion (Boswell et al, 2001), it is assumed
that there is an intrinsic desire to make sense of the world (Mental Health Foundation, 2006). So, if
occupational therapists are uncomfortable with the prospect of addressing spiritual needs (Egan and
Swedersky, 2003), their discomfort is perhaps most apparent when dealing with the religious dimension
of spirituality (Unruh et al, 2004). This is because secular dimensions are viewed objectively as
opportunities for connectedness, meaning and purpose, while religious aspects may still have the
potential to conflict with our own subjective beliefs (Unruh et al, 2004). For instance, some religions may
advocate charity and social justice but others may be perceived as advocating submission or violence
(Devine and Deneulin, 2011).
There again, occupational therapists who share the same beliefs as their clients may feel more
comfortable supporting occupations that are religious in nature, such as prayer or attending services,
rather than recognising that spirituality can be expressed in many ways, including everyday occupations
such as appreciating nature or art (Johnston and Mayers, 2005). However, they would at least be
retaining an occupational focus because, surely, the unique contribution that occupational therapists can
make when addressing spiritual issues is to recognise how a person’s needs affect their function
(Udell and Chandler, 2000).
Religion and spirituality are not disembodied qualities; they have a material shape and form (McGuire,
2003). The International Classification of Functioning, Disability and Health (ICF) links religion and
spirituality to activities that seek to establish connection with a divine power (WHO, 2001). However,
‘lived religion’ is not just a question of affiliation or organisational participation; it is a highly individual
expression of experiences and concrete practices (McGuire, 2008). Also, it is often invested in specific
environments, whether they are spiritual buildings, cultural sites or natural locations (Mental Health
Foundation, 2006). It may involve rituals that sanctify ordinary activities of daily living (Frank et al, 1997),
or commemorative holidays (Luboshitzky and Gaber, 2001), or family interactions (Marks, 2004), or other
everyday activities that are imbued with spiritual meaning (Smith and Suto, 2012) for people who
consider themselves to be religious or non-religious (Johnston and Mayers, 2005).
Therefore, ’spiritual occupation’ encompasses prayer, scripture-reading, singing and chanting, belonging
to a community, yoga, t’ai chi and meditation, along with expressive arts, nature appreciation, gardening
and social or ecological activism (Kang, 2003). It is this outward expression of faith that should form the
main focus of the Recovery through Activity session.
Sample activities
Introduction
In Recovery through Activity this topic encompasses religious and spiritual activities – activities that are
related but distinct. Careful consideration is needed about whether faith activities should be included in
a Recovery through Activity group programme. Facilitators need to ensure that participants are able to
respect each other, and must be aware of how each participant’s beliefs might interact with their mental
illness.
Wellbeing requires a range of activities and it should be recognised that spiritual health requires a
balance that enables individuals to pay attention to their inner needs, while still engaging in the world
around them (Hasselkus, 2011).

Similarities and differences
Spend time setting the ground rules together, reinforcing the importance of respecting each other’s
beliefs, and looking for the beliefs that are held in common.
What does faith mean? (worksheet page 103)

• Ask whether any key words are missing for people.
• Discuss similarities and differences between people’s beliefs.
• Identify the words that are chosen most frequently.
• Encourage people to share their key beliefs.
Ask:
• Can you define your faith in no more than 30 words?
Faith lines (worksheet page 106)

Discuss formative experiences of faith.
Ask:
• Do you share the same faith as your parents or guardians?
• How has illness impacted on your faith?
• When has faith been important?
• Have there been times when your faith has been reawakened?
Faith and recovery (worksheet page 107)

Discuss how faith affects people’s ordinary lifestyles.
Ask:
• Does your faith affect what you want out of life and your motivation to change things?
• What is the most important thing that faith has given you?
Places and spaces

Do people go to a special place in order to practise their faith?
Ask:
• Where do you feel most spiritual? For example:
a place of worship
a place of natural beauty
a cultural place such as an art gallery or music concerts
a quiet space
a pilgrimage
anywhere.
• What is it about this place that helps your faith?
• How often do you go to this place?
Special things
Before the group session, participants could be asked to bring with them something that embodies
their faith.
Ask:
• Do you use particular things when practising your faith? For example:
books
special clothes or adornments
household objects
special food
music.
• What thing do you treasure most of all?
Outward practice
Spend some time focusing on the activities that participants do as part of their faith. For example:
• attending religious services, rituals at home, family routines
• praying, reading, singing, chanting
• meditation, t’ai chi, yoga
• nature appreciation, walking, gardening
• writing, artwork, cooking
• social activism, volunteering, helping other people.
Ask:
• Has your practice changed over time?
• Which activities bring you into contact with others?
• Which faith communities have you had contact with?
• Which activity would you like to do more of?

Visiting a place of worship
Arrange a visit to a local place of worship.
Guest speaker
Invite a chaplain to speak to the group, or someone from another faith, or someone from a humanist
association.
Shared activity
Participate in secular activity that is meaningful to the participants, such as singing, dancing, visiting an
art gallery, mediation, or tai chi.
What does faith mean?

✐
WORKSHEET
Faith means different things to different people. On this worksheet there are several different
words that people use to describe their faith.
Copy them, cut them out and stick them onto cards. Spread them on a table and ask the
participants to choose the ones that fit with their view of what faith means.
Alternatively, take one card at a time and encourage discussion about what the words mean
in relation to faith, starting with the two words’ spirituality’ and ‘religion’.
spirituality
religion
meaningfulness
connectedness
ethical beliefs
✐
WORKSHEET
doctrine
hope
truthfulness
worship
divine experience
enchantment
WORKSHEET
renewal
wholeness
commitment
love
devotion
reverence
Faith lines
✐
WORKSHEET
Draw a line on the blank graph overleaf to represent how your faith has changed during your
life. For example, what sparked your faith, how it has grown, and whether you have ever lost
or doubted your faith. Mark the events that have been the turning points.
Here is an example to get you started.
Increased faith
got married
rou -
h
p
bas ed fait
ed g
join
lif became
ew
as
piec p
bu
the ing u
at
sy
sc igi ed
es
ill
ho on
rel udi
pick
st
ol
Time
bec
am
dis e
illu
growing up sio
ned
Decreased faith
Decreased faith
Increased faith
WORKSHEET
Faith lines
✐
Time
Faith and recovery

✐
WORKSHEET
Which of the following benefits do you get from your faith?
Yes No
1 A chance to help other people
2 A daily or weekly routine
3 A reminder of what is important in life
4 A sense of belonging
5 A sense of proportion – acceptance of how things are
6 A sense of purpose
7 A source of strength, determination and hope
8 Activities that you value
9 Beauty
10 Comfort when life is difficult
11 Guidance that supports a healthy lifestyle
12 Increased contact with other people
13 Increased social support
14 Inner peace
15 Joy
16 Meaning
17 Music
18 Opportunities to celebrate life
19 Something that defines your identity – who you are
20 Somewhere to go to
21 Support to understand right and wrong
22 Support to understand the needs of other people
References
Beagan B & Kumas-Tan Z (2005) ‘Witnessing spirituality in practice’, British Journal of Occupational Therapy, 68 (1),
pp17–24.
Belcham C (2004) ‘Spirituality in Occupational Therapy: theory in practice?’, British Journal of Occupational Therapy, 67 (1),
pp39–46.
Boswell BB, Knight S, Hamer M & McChesney J (2001) ‘Disability and spirituality: a reciprocal relationship with
implications for the rehabilitation process’, Journal of Rehabilitation, 67 (4), pp20–25.
Bussema EF & Bussema KE (2007) ‘Gilead revisited: faith and recovery’, Psychiatric Rehabilitation Journal, 30 (4), pp301–5.
Carlson TD & Erickson MJ (2000) ‘Re-authoring spiritual narratives: God in persons’ relational identity stories’, Journal of
Systemic Therapies, 19 (2), pp65–83.
Collins JS, Paul S & West-Frazier J (2001) ‘The utilization of spirituality in occupational therapy: beliefs, practices, and
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Self-care activities 7
Key messages
• Self-care involves many different activities:
managing our health conditions
looking after our bodies – our eyesight, hearing, teeth, skin, hair, nails, etc
getting enough sleep
taking care of how we look
even pampering ourselves sometimes.
• Self-care is important for all other meaningful activities:
rest, relaxation, exercise and diet are important for energy and long-term health
taking care of our health and appearance can improve social relationships and self-
confidence.
• Ensuring that basic needs are met is important for recovery:
self-care is more commonly associated with an improved sense of wellbeing than
work or leisure.
• Self-care can be improved by:
peer support
setting goals and individual support
establishing a daily self-care routine
building a satisfying lifestyle that makes self-care worth while.
The value of self-care activities

Introduction
The importance of self-care is inextricably linked with the importance of all other meaningful activities.
Engaging in meaningful leisure and work activities gives people a reason to get up in the morning and to
attend to their self-care needs. Getting the right amount of rest is important both for illness
management and for having sufficient energy to pursue the activities that are important to us
(Sutton, 2008).
Therefore, the role of ‘health-maintainer’ or ‘self-maintainer’ (Hillman and Chapparo, 1996; Paul-Ward
et al, 2005) is a valid role which needs to be actively pursued. It is much more than the passive role of a
patient. Indeed, the self-care activities associated with the self-maintainer role are important to
everyone: to occupational therapists who are maintaining their resilience and avoiding burn-out
(Bannigan, 2009); and to their clients who are learning to ‘handle whatever comes along’ and find
‘new ways of living’ (Thompson, 2009, p408).
Self-care is multidimensional (McCormack, 2003) and, in its broadest sense, it encompasses the concept
of self-help whereby people work independently or in collaboration with healthcare agencies to
promote, maintain or enhance health (Sidani, 2003). However:
As with most things in life, self care means different things to

different people. Generally self care involves taking personal
responsibility for ensuring the maintenance of health and well-being.
(Bannigan, 2009, p302)
At a more basic level, self-care is often conceived as relating to the performance of personal activities
of daily living, such as eating, grooming, bathing, dressing and toileting (Gagné and Hoppes, 2003).
Self-care in physical health and mental health settings

In physical rehabilitation, self-care activities are a primary focus for intervention (Guidetti and Tham,
2002). For example, Legg et al (2007) identified nine randomised controlled trials investigating the
impact of occupational therapy on the personal activities of daily living of people who had had survived
strokes. Indeed, the emphasis on self-care is such that occupational therapists in this setting sometimes
need to be reminded that it should not be the sole focus of intervention (Polatajko and Davies, 2008).
Session 7 Self-care activities
This is because meaningfulness is more important than independence and being independent in
self-care ‘may rob the client of the energy needed to participate in occupations he [or she] finds more
meaningful’ (Gage, 2003, p35).
In comparison, far fewer articles have been written about self-care interventions in mental health
settings and yet self-care remains an important aspect of mental wellbeing.
People with severe mental illness often spend a lot of time on self-care activities such as eating and
sleeping (Eklund et al, 2009) but this does not lead to better health if their diet is poor or they have too
little exercise. On the contrary, severe mental illness is known to increase the risk of death (Laursen
et al, 2007) and this risk appears to be growing (Hoang et al, 2011). Poor self-care is a contributory
factor and occurs more frequently when people are socially isolated (Evert et al, 2003), demonstrating
that personal and social performance are clearly linked. For this reason, self-care should be included in
assessments of social and occupational functioning (Morosini et al, 2000).
In fact, interventions targeting social relationships are likely to improve self-care, just as interventions
targeting self-care are likely to improve social relationships (Evert et al, 2003). The two go hand-in-hand
and: ‘For people who have enduring psychotic conditions, interventions need to improve social
functioning as well as reducing clinical problems’ (Cook and Howe, 2003, p236).
The importance of self-care is apparent to service users themselves and has been confirmed by several
studies, as follows.
• Young and Ensing (1999) explored the concept of recovery from the perspective of people with
psychiatric disabilities and recognised that recovery involves ‘returning to basic functioning’.
• Aubin et al (2002) sought to determine the significance of daily activities in people with severe
mental disorders using the Occupational Questionnaire (Smith et al, 1986). They recognised that
‘hygiene and self-care, meals and sleep’ figured most frequently and contributed to a person’s sense
of competence, importance and pleasure (although work activities were viewed as more important
and social activities were associated with more pleasure).
• Leufstadius et al (2008) investigated the meaningfulness of daily occupations among individuals

with persistent mental illness and found that ‘taking care of oneself’ was one of the most frequently
occurring themes, especially if people were not engaged in vocational activities.
• Argentzell et al (2012) examined the experience of meaning in everyday occupations among

unemployed people with severe mental illness and identified ‘taking care of body and mind’ as one
of the key themes.
Strategies for improving self-care

Self-care ‘is influenced by knowledge, skills, values, motivation, locus of control and efficacy’
(McCormack, 2003, p49). The objective of self-care training is to ‘find the right way to motivate clients’
(Guidetti and Tham, 2002, p257) by combining opportunities for peer support (Bates et al, 2008) with
education and feasible goal-setting (Graff et al, 2006). Documenting goals and discussing them regularly
can make a self-care programme more effective (Gagné and Hoppes, 2003) and the personal nature of
self-care means that an individual approach is even more important.
The Recovery through Activity programme therefore recommends combining health promotion group
sessions – promoting the value of everyday activities in people’s lives – with individualised skills
training. This approach has been found to be more effective than health promotion alone
(Bartels et al, 2004).
Taking care of body and mind requires people to form daily routines and establish a balance between
purposeful activity and rest or sleep (Argentzell et al, 2012) with sleeping being generally recognised as
an ‘activity’ when use of time is discussed (Green, 2008). It might not be defined as an ‘occupation’ by
occupational therapists (Green, 2008), who question whether it is a legitimate concern for the profession
(Green et al, 2008), but it affects all areas of life, including work and leisure activities (Strine and
Chapman, 2005). There is also evidence that knowledge of ‘sleep hygiene’ (practices that are associated
with good sleep) can improve sleep quality (Brown et al, 2002).
Therefore, sleep hygiene is suggested as a strategy for improving self-care in the Recovery through
Activity programme. Mindfulness training is also recommended because it can provide a useful strategy
for self-care (Shapiro et al, 2007) by enabling participants to pay attention to the present and appreciate
things as they are (Thompson, 2009).
Ultimately, Recovery through Activity endeavours to ensure that therapy focuses on ‘enabling
occupational experience and adjust[ing] training to the needs of the client, rather than focusing on
teaching clients how to use technical and compensatory strategies’ (Guidetti and Tham, 2002, p257).
It aims to provide an alternative to the ubiquitous anxiety management and stress management
programmes that were facilitated by occupational therapists in the 1990s (Courtney and Escobedo,
1990; Craik et al, 1998; Prior, 1998), where the interventions’ titles implied that the overall aim was to
reduce symptoms rather than increase occupational participation.
However, anxiety and stress management techniques can still be offered to individuals as an adjunct to
the programme when appropriate, provided that the focus remains firmly fixed on increasing
participation in activities that support lasting occupations.
Sample activities
Introduction
Self-care may be too sensitive an issue to discuss in a group session. Consideration should be given to
whether this topic is included in a programme, especially if participants do not recognise the need for
self-care. Having said this, self-care is such an important activity – one that everyone needs to
participate in – that the session can provide an important time for participants to reflect on the value of
ensuring that their basic needs are met.
The emphasis of the session is on raising awareness, rather than providing comprehensive training.
Facilitators should endeavour to choose the exercises that are most relevant to the participants and
follow up any unmet needs on an individual basis.
Note: the importance of exercise is discussed in the physical activities section.

Hands up
Reassure participants that there are no wrong answers to the following questions. Keep the tone of
conversation as light as possible. The aim is to demonstrate that we are all involved in self-care
routines and are aware of the need to look after ourselves, although we also have our own priorities and
ways of doing things.
Ask:
• Who has ever gone on a diet to lose weight?
• Who has ever tried to stop smoking?
• Who has a hairbrush or comb with them?
• Who puts their clothes in a heap at the end of the day and who hangs them up? Does it matter?
• Who prefers a shower and who prefers a bath? Why?
• Who prefers to bath or shower in the morning and who prefers the evening? Why?
• Who likes the smell of perfume or aftershave and who doesn’t? Which scents do you like?
Activities that make us feel good

Ask participants what their ideas are for the perfect pampering session. For example, a candlelit dinner,
a long hot soak in the bath, a massage, putting your feet up with a good book and a glass of wine,
painting your nails, or walking in the countryside.
Ask:
• Are some activities healthier than others?
Favourite foods (worksheet page 121)

Give the participants time to think of their favourite breakfast, light lunch, main meal, drink and snack.
Then ask them to write these down on the left-hand side of the worksheet. Ask people to share their
answers with the group while you record the answers on a flipchart.
Ask:
• Which foods and drinks are the healthiest?
• Why are they healthier than the others?
• Does a little bit of what you fancy do you good?
Once participants have had time to discuss the healthiest foods and drinks, ask them to choose their
favourite healthy breakfast, light lunch, main meal, drink and snack. Their answers should be written on
the right-hand side of the worksheet and then shared with the group.
Healthy eating
Organise the participants to work together in pairs and think of their top tips for a healthy diet. For
example, reduce the amount of fat, eat fruit instead of sugary treats, cut down on salt, eat several
portions of fruit and vegetables a day, eat smaller portions, count calories, chew food slowly, don’t
snack, cut out sugary drinks, keep a food diary.
Sleep hygiene
Find a website that provides sensible advice about getting a good night’s sleep. Project this onto a
screen so that the participants can view the advice.
Ask:
• Is any of the advice new to you?
• Are any of the suggestions easier to put into practice than others?
• How much sleep do you like to have?
• Do you think that some suggestions are more effective than others?
Self-presentation and self-confidence

Discuss how people can change their appearance in order to look more confident. For example, their
posture, how they walk, their body language, their hair, their clothes.
Ask:
• Does looking more confident help us to feel more confident?
• What could you do to help you feel more confident when going out for a social evening? Or to a
formal meeting?
• Do certain colours suit you more than others and, if so, how do you know?
• Is it necessary to dye your hair or to shave in order to look good? (Help the participants to recognise
that this is not the case.)
• What were your favourite outfits when you were a teenager? What are your favourite clothes now?
Why?
Walking tall
Encourage participants to practise walking into the room, standing or sitting in a confident manner.
Suggest giving each other marks out of 10, as to how confident they appear.
Daily routines
Ask the participants whether they know of anyone – a friend or a family member – who uses a lot of
beauty products.
Ask:
• How long does it take you to complete your skin-care or hair-care routine?
• Why do you do it?
• Is it worth it?
• If you could take only one skin-care or hair-care or make-up product on a trip to the Moon, what
would it be?
• Do men or women spend more time looking after their appearance?
• Do we need to love ourselves if we are to love others?
Best tips
Discuss skin care, hair care and foot care.
Ask:
• Do you know any good tips for skin, hair or foot care?
• What are the most important tips for healthy skin, hair and feet?
• Have you got any other tips for staying healthy? For example, tips for remembering medication.
Hand-washing
Share the instructions for hand-washing used by health service staff.
Ask:
• Do people wash their hands like this?

Television makeover
Watch a television makeover show together and discuss whether the people in it look better either
before or after.
Expert advice
Organise a specialist to give a talk on:
• sleep hygiene
• relaxation
• mindfulness
• colours to suit different complexions
• nutrition
• medication management.
Supermarket checkout
Compile a shopping list and then visit a supermarket to check out the number of calories in each item.
Pamper session
• Organise a session to experience:
manicures and hand massage
fresh fruit smoothies
home-made beauty treatments.
Favourite foods
✐
WORKSHEET
What are your favourite things to eat and drink?
Write your favourites in the left-hand column – include all the food that you would eat in the
different categories.
Don’t write anything in the right-hand column until you are told what to do.
Breakfast
Light lunch
Main meal
Snacks
Drinks
References
Argentzell E, Håkansson C & Eklund M (2012) ‘Experience of meaning in everyday occupations among unemployed
people with severe mental illness’, Scandinavian Journal of Occupational Therapy, 19 (1), pp49–58.
Aubin G, Hachey R & Mercier C (2002) ‘The significance of daily activities in persons with severe mental
disorders’, Canadian Journal of Occupational Therapy, 69 (4), pp218–28.
Bannigan K (2009) ‘Management of self’, Duncan EAS (ed), Skills for Practice in Occupational Therapy, Churchill
Livingstone, Edinburgh, pp296–311.
Bartels SJ, Forester B, Mueser KT, Miles KM, Dums AR, Pratt SI, Sengupta A, Littlefield C, O’Hurley S, White P
& Perkins L (2004) ‘Enhanced skills training and health care management for older persons with severe mental
illness’, Community Mental Health Journal, 40 (1), pp75–90.
Bates A, Kemp V & Isaac M (2008) ‘Peer support shows promise in helping persons living with mental illness address their
physical health needs’, Canadian Journal of Community Mental Health, 27 (2), pp21–36.
Brown FC, Buboltz Jr WC & Soper B (2002) ‘Relationship of sleep hygiene awareness, sleep hygiene practices, and sleep
quality in university students’, Behavioral Medicine, 28 (1), pp33–38.
Cook S & Howe A (2003) ‘Engaging people with enduring psychotic conditions in primary mental health care and
occupational therapy’, British Journal of Occupational Therapy, 66 (6), pp236–46.
Courtney C & Escobedo B (1990) ‘A stress management program: inpatient-to-outpatient continuity’, American Journal of
Craik C, Chacksfield JD & Richards G (1998) ‘A survey of occupational therapy practitioners in mental health’, British
Eklund M, Leufstadius C & Bejerholm U (2009) ‘Time use among people with psychiatric disabilities: implications for
practice’, Psychiatric Rehabilitation Journal, 32 (3), pp177–91.
Evert H, Harvey C, Trauer T & Herrman H (2003) ‘The relationship between social networks and occupational and self-
care functioning in people with psychosis’, Social Psychiatry and Psychiatric Epidemiology, 38 (4), pp180–8.
Gage M (2003) ‘Sense of doing: the impact of restoration in the home’, Occupational Therapy Now, 5 (5), pp35–37.
Gagné DE & Hoppes S (2003) ‘The effects of collaborative goal-focused occupational therapy on self-care skills: a pilot
study’, American Journal of Occupational Therapy, 57 (2), pp215–9.
Graff MJL, Vernooij-Dassen MJM, Zajec J, Olde-Rikkert MGM, Hoefnagels WHL & Dekker J (2006) ‘How can
occupational therapy improve the daily performance and communication of an older patient with dementia and his primary
caregiver? A case study’, Dementia: The International Journal of Social Research and Practice, 5 (4), pp503–32.
Green A (2008) ‘Sleep, occupation and the passage of time’, British Journal of Occupational Therapy, 71 (8), pp339–47.
Green A, Hicks J & Wilson S (2008) ‘The experience of poor sleep and its consequences: a qualitative study involving
people referred for cognitive-behavioural management of chronic insomnia’, British Journal of Occupational Therapy,
71 (5), pp196–204.
Guidetti S & Tham K (2002) ‘Therapeutic strategies used by occupational therapists in self-care training: a qualitative
study’, Occupational Therapy International, 9 (4), pp257–76.
Hillman AM & Chapparo CJ (1996) ‘An investigation of occupational role performance in men over sixty years of age
following a stroke’, Journal of Occupational Science: Australia, 2 (3), pp88–99.
Hoang U, Stewart R & Goldacre MJ (2011) ‘Mortality after hospital discharge for people with schizophrenia or bipolar
disorder: retrospective study of linked English hospital episode statistics, 1999–2006’, British Medical Journal, 343, d5422.
Laursen TM, Munk-Olsen T, Nordentoft M & Mortensen PB (2007) ‘Increased mortality among patients admitted with
major psychiatric disorders: a register-based study comparing mortality in unipolar depressive disorder, bipolar affective
disorder, schizoaffective disorder, and schizophrenia’, Journal of Clinical Psychiatry, 68 (6), pp899–907.
Legg L, Drummond A, Leonardi-Bee J, Gladman JR, Corr S, Donkervoort M, Edmans J, Gilbertson L, Jongbloed L,
Logan P, Sackley C, Walker M & Langhorne P (2007) ‘Occupational therapy for patients with problems in personal
activities of daily living after stroke: systematic review of randomised trials’, British Medical Journal, 335 (7626), p992.
Leufstadius C, Erlandsson L-K, Björkman T & Eklund M (2008) ‘Meaningfulness in daily occupations among individuals
with persistent mental illness’, Journal of Occupational Science, 15 (1), pp27–35.
McCormack D (2003) ‘An examination of the self-care concept uncovers a new direction for healthcare reform’, Nursing
Leadership, 16 (4), pp48–62.
Morosini PL, Magliano L, Brambilla L, Ugolini S & Pioli R (2000) ‘Development, reliability and acceptability of a new
version of the DSM-IV Social and Occupational Functioning Assessment Scale (SOFAS) to assess routine social
functioning’, Acta Psychiatrica Scandinavica, 101 (4), pp323–9.
Paul-Ward A, Braveman B, Kielhofner K & Levin M (2005) ‘Developing employment services for individuals with
HIV/AIDS: participatory action strategies at work’, Journal of Vocational Rehabilitation, 22 (2), pp85–93.
Polatajko HJ & Davies JA (2008) ‘Sense of doing: capturing occupational knowledge: enabling powerful outcomes for our
clients’, Occupational Therapy Now, 10 (5), pp10–12.
Prior S (1998) ‘Determining the effectiveness of a short-term anxiety management course’, British Journal of Occupational
Therapy, 61 (5), pp207–13.
Shapiro SL, Brown KW & Biegel GM (2007) ‘Teaching self-care to caregivers: effects of mindfulness-based stress
reduction on the mental health of therapists in training’, Training and Education in Professional Psychology, 1 (2), pp105–15.
Sidani S (2003) ‘Operationalizing self-care within the healthcare system’, Nursing Leadership, 16 (4), pp63–65.
Smith NR, Kielhofner G & Watts JH (1986) ‘The relationships between volition, activity pattern, and life satisfaction in the
elderly’, American Journal of Occupational Therapy, 40 (4), pp278–83.
Strine TW & Chapman DP (2005) ‘Associations of frequent sleep insufficiency with health-related quality of life and health
behaviors’, Sleep Medicine, 6 (1), pp23–27.
Sutton D (2008) ‘Recovery as the re-fabrication of everyday life: exploring the meaning of doing for people recovering from
mental illness’, PhD thesis, University of Technology, Auckland.
Thompson B (2009) ‘Mindfulness-based stress reduction for people with chronic conditions’, British Journal of Occupational
Therapy, 72 (9), pp405–10.
Young SL & Ensing DS (1999) ‘Exploring recovery from the perspective of people with psychiatric disabilities’, Psychiatric
Rehabilitation Journal, 22 (3), pp219–31.
Domestic activities 8
Key messages
• Domestic activities can be viewed as:
self-care or
productivity or
leisure.
• Domestic activities are important for:
home management
home safety
home maintenance
home-making.
• Everyday activities such as shopping, cooking and cleaning contribute to a sense of our identity.
• Our homes give us shelter and privacy, but they also:
reflect our culture and fashion across the ages
can be personalised according to our own styles
can be modified to meet our needs.
• We develop a sense of place and belonging as we build up a store of memories associated with
our homes and neighbourhoods.
• The role of ‘home-maintainer’ is highly valued by individuals and cleanliness and home-cooking
continue to be viewed positively by society.
The value of domestic activities

Introduction
Activities of daily living include personal activities (self-care) and domestic activities. They have long
been thought of as belonging to ‘an area of occupational therapy expertise’ (Thornton and Rennie, 1988,
p49). Occupational therapists recognise that a person’s ability to perform daily tasks provides crucial
information about their ability to live independently (Aubin et al, 2009a). Therapists also appreciate the
importance of the ‘instrumental’ activities of daily living (Fricke and Unsworth, 2001). These activities
are instrumental to, or actively contribute towards, daily life in the home and community and include
everything from using a telephone to managing transport (including driving), medication management
and snack preparation (Gibson et al, 2011).
Domestic activities fall within the category of instrumental activities and, for the purposes of this
programme, can be defined as activities for home management, home maintenance and home-making.
They involve a range of tasks requiring organisational skills, including food preparation, laundry,
cleaning, shopping, home safety and budgeting (Thornton and Rennie, 1988).
Domestic identity and home-making

Domestic activities may be essential for independent living but they are valuable for other reasons too.
Food preparation, for instance, has a key role in maintaining physical health, but food and eating also
have a social function with many associated symbolic meanings for individuals and society (Lupton,
1994). In addition, baking not only enables people to learn new skills (Bartlett and Markham, 2009) but
also it helps them to gain confidence and add structure to their daily routines (Haley and McKay, 2004).
Moreover, despite the therapeutic value of everyday activities being questioned, and even trivialised at
times, the most simple, everyday shopping trip can provide opportunities for people to imagine their
future roles (Jackson, 1998). Such tasks allow people to build a sense of their ‘occupational identity’ and
‘occupational competence’ (Kielhofner, 2008). They make it possible for individuals to give practical
support to other people and evidence suggests that those who provide instrumental and emotional
support to their friends, relatives and neighbours live longer than those who do not (Brown et al, 2003).
When people open their homes to others, they do more than provide temporary shelter in a neutral
space. A home is an ‘organised world of meaning’ that gives people a sense of place and acts as a
‘container of memories of experience’ (Hasselkus, 2011, pp45, 41). We organise our home environments
according to cultural norms regarding furniture and possessions, and expectations for privacy and
Session 8 Domestic activities
cleanliness; we decorate them in order to personalise them according to our own sense of style;
and we modify the environment to suit our own needs (Rubinstein, 1989).
Homes, therefore, reflect our own unique characteristics and protect us from the intrusions of the
outside world (McCracken, 1989). They provide us with the potential to create meaning by manipulating
our environment and, in turn, they give meaning to our lives (Rowles, 2008).
Cultural expectations
Daily activities may be viewed as being necessary for self-care but they may also be considered to be
productive occupations or even leisure pursuits (Marino-Schorn, 1986). This will often depend on ‘the
person’s perceptions of what is expected of them by others, what they expect of themselves and what
resources are available to them’ (Hillman and Chapparo, 1996, p88). Domestic activities, like all other
activities, are loaded with cultural expectations. It has been found that people associate positive
characteristics with clean households, believing the housekeepers (whether male or female) to be more
‘agreeable’, ‘conscientious’, ‘intelligent’ and ‘feminine’ (Harris and Sachau, 2005).
This last attribute is linked to findings that women continue to take responsibility for more housework
than men, despite the fact that the balance has shifted since the 20th century (Coltrane, 2000). Male
unemployment leads to housework being reallocated to them, but when women are unemployed, they
do twice as much housework as an unemployed man (Gough and Killewald, 2011).
Life skills and mental health

Regardless of how much housework people do, the role of home-maintainer seems to be highly valued
by those with mental health problems. For instance, Prusti and Bränholm (2000) found that a group of
psychiatric out-patients valued being a home-maintainer more than having paid employment.
Yet, while many people with severe mental illness can perform activities of daily living with relative
ease, the majority experience problems living independently (Fossey et al, 2006). Their perceived sense
of efficacy can impact on their occupational performance (Eklund, 2007) and they can experience
problems with planning tasks (Aubin et al, 2009b) and perceiving what needs to be done in the first
place (Aubin et al, 2009c). In particular, those receiving in-patient care have noticeable problems with
food management, which would place them at nutritional risk in the community if appropriate support is
not available.
Support is sometimes provided through Life Skills or Living Skills programmes, often focusing on the
personal activities of daily living (self-care) as well as domestic activities (Ammeraal and Coppers,
2012). The programmes that have been described in the professional literature vary considerably with
some advocating practical group sessions on the basis that participants find these are most helpful
(Brown et al, 2001) and that training with a psycho-educational component results in no greater skill
acquisition than training that is more practical in nature (Grimm et al, 2009).
Other programmes require person-centred practice and collaborative intervention planning (Fricke and
Unsworth, 2001), so that mental health needs and life skill needs can be addressed simultaneously
(Gorde et al, 2004). Duncombe (2004) concludes that cooking skills are learned just as well in a clinic as
at home, but Luboshitzky and Gaber (2000) call for the systematic use of homework to support the
transfer of learning, while Ammeraal and Coppers (2012) argue that skills training is best provided in the
person’s natural context.
The Cochrane Database includes two systematic reviews for Life Skills programmes, but neither drew
any firm conclusions because it was difficult to make comparisons between the various studies
(Robertson et al, 1998; Tungpunkom and Nicol, 2009). There is still an urgent need for larger studies
(Robertson et al, 1998) with well-researched scales to measure the outcomes (Tungpunkom and Nicol,
2009). In addition, more research is required into the factors that influence occupational engagement
(Chugg and Craik, 2002), including studies that investigate the obstacles to participating in domestic
activities such as shopping, choosing what to eat, and preparing a meal (Levaux and Danion, 2011).
Sample activities
Introduction
Domestic activities can sometimes be viewed as being chores – boring, routine tasks that need to be
finished as soon as possible so that we have time to do more enjoyable activities. Yet they can also
bring a deep sense of satisfaction, and failing to manage our domestic affairs can result in a nagging
source of stress.
Some of the strongest arguments for engaging in domestic activities are related to a deep-felt desire
that is shared by many people: to make a house into a home. Facilitators of this session need to be
aware of whether participants have their own homes, as well as being sensitive to the barriers they
face in creating the homes that they would like.

There’s no place like home
Before discussing the value of domestic activities, encourage the participants to consider what comes to
mind when they think about ‘a place called home’.
Ask:
• Is an Englishman’s home his castle?
• Is a woman’s place in the home?
• What makes a house into a home?
• Do you believe that ‘Wherever I lay my hat, that’s my home’?
• Is the kitchen the heart of the home?
• What does ‘Home is where the heart is’ mean?
Ideal home
In an ideal world, and if money were no object, would your ideal home be:
• modern or traditional?
• in the country or in the town?
• open-plan or not?
• ready to move into or needing some work doing to it?
• cluttered or clutter-free?
Personal touches
Very few people live in their ideal home but most of us try to make the place where we live into a home.
Ask:
• What is the best thing that you have done to personalise the place where you live? For example,
furnishings, colours, decoration.
Chore or charm?
Ask whether the participants like or dislike the following activities. If people like certain activities,
encourage them to share their reasons.
• shopping • polishing shoes
• washing-up • hanging out the washing
• ironing • putting clothes away
• cooking • gardening
• cleaning • doing home improvements
Domestic routines
In the past, domestic activities took up a lot of time and people used to do certain tasks on certain days.
For instance:
Wash on Monday,
Iron on Tuesday,
Mend on Wednesday,
Shop on Thursday,
Clean on Friday,
Bake on Saturday,
Rest on Sunday.
Does anybody follow a routine these days? For example:

• shopping for food on a specific day?
• shopping in town on a specific day?
• cooking particular meals on different days?
• cleaning or ironing at a certain point in the week?
• gardening at a certain point in the week?
Division of household labour

Men are now doing more housework although, in general, they still do less than women.
Ask:
• What is people’s experience in their own lives?
• How much housework did your father do?
• Why are men now doing more housework than in the past?
Modern living
Discuss whether modern technology has made housework any easier.
Ask:
• How has housework changed since our parents or grandparents were young?
• Do you like household gadgets and, if so, what is your favourite household gadget?
• Does anyone shop online? (Eg for food or clothing?)
• Do you think that a time will come when housework can be done by robots?
‘Cleanliness is next to godliness’ – does cleanliness matter any more?

There are fridge magnets with the message ‘Clean houses belong to boring people’. Ask for people’s
opinions about whether keeping a house clean is important, whether for health reasons, or for ‘keeping
up appearances’, or because we feel less stressed when our home is clean.
Then share the results of the research study by Harris and Sachau (2005) below. They wanted to see
whether housekeeping made an impact on our impressions of an environment. Ask whether the results
surprise the participants.
Harris and Sachau wrote a story to read to more than 300 male and
female students.
The details in the story were always the same, except that sometimes
the character was male and sometimes female. Also, the character’s
home was described as being either clean or dirty.
The students were asked to rate the personality of the character.

Regardless of the gender of the students or the character, the
characters that had clean households were rated as being more:
• agreeable • conscientious
• intelligent • feminine.
Housework and keeping fit

If the group hasn’t already discussed this topic, ask them to guess the calories used when doing
housework. See the ‘Lost calories’ worksheet on page 79 (answers on pages 76–77).
Top tips
What are the participants’ top tips for the following activities?
• Cleaning, eg washing dishes or dusting or removing stains
• Decluttering
• Saving money
Smelling of roses
When people are selling their home, certain smells are supposed to be attractive. Which smells do the
group members prefer?
• Freshly baked bread

• Coffee
• Pot-pourri
• Air freshener

Cooking together
Plan a meal together, and share out the tasks for:
• shopping
• cooking
• clearing away and washing-up.
Expert advice
Organise a specialist to give a talk on:
• welfare benefits
• banking your money
• budgeting.
Decluttering
Bring in unwanted items and take them to a charity shop or organise a car-boot sale.
Shopping on a budget
Plan a weekly menu and price up the ingredients.
References
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Caring activities 9
Key messages
• It is now recognised that interdependence is more important in recovery than independence:
We all need to be cared for and almost everyone is able to show care.
By caring for other people we are also caring for ourselves by meeting our emotional
needs to be connected with others.
Caring is an important part of good citizenship and is necessary for an inclusive society.
• There are many aspects to caring:
It can be a continuous process or a single action.
It is a way of thinking and it involves practical actions.
Small gestures show that we care and taking care of other people can involve huge
responsibilities.
Many activities have an element of caring if we are responding to the needs of other people.
Care can be given to older people, to children, to partners, to friends, and even to pets and
the environment.
Acknowledging the care that we receive is just as important as giving care – care-giving
and care-receiving can both be meaningful activities.
• Care is a necessary part of family life and needs to be balanced by time for ourselves:
No two families are the same – what matters is how family members relate to each other.
Families spend time together in different ways – family meals and parental involvement in
education are key ways in which care makes a difference.
The value of caring activities

Independence and interdependence
The goal of occupational therapy used to hinge on restoring the highest possible level of independence
(Reed and Sanderson, 1999) and occupational therapists were more likely to talk about independence
through activity (Allen, 1982) than recovery through activity. In the 21st century, however, occupational
therapists are increasingly convinced that ideas of independence change and develop over time (Taylor,
2001) and that ‘independence’ is a relative term that is culturally constructed (Whiteford and Wilcock,
2000). In fact, the notion of independence as a positive attribute is now recognised as a western
concept that contrasts with other views from around the world, where independence might even be
regarded as a social and personal failure (Whiteford and Wilcock, 2000).
Interdependence is valued more highly in other cultures: African cultures prize a person’s function in the
community (Watson, 2006); eastern cultures place a high value on belonging (Iwama et al, 2009).
Western ideas are shifting too, especially about recovery. Independence may still be regarded as a key
issue but, in a nationwide study in the USA, interdependence was regarded as helpful:
Several participants felt independence was less important than

embracing interdependence with peers, family and with others in the
mental health system.
(Onken et al, 2002, p49)
Similarly, it is argued that social care should place more importance on ‘relationality [how we relate to
each other] and interdependence’ (Sevenhuijsen, 2003, p179).
Caring activities
Interdependence suggests that, in caring for other people, we also care for ourselves because
‘Opportunities for personal and emotional interaction are key to quality of life’ (Folbre and Bittman,
2004, p2). But what does caring actually involve?
Caring cannot easily be listed as a series of separate activities, and many different activities can have
an element of caring (Folbre and Bittman, 2004). Furthermore, caring is both a social activity that
requires daily action and a continuous process (Sevenhuijsen, 2002). It has a dual meaning because it
refers to the practical actions that people take when they care about someone or something and a mind-
set or way of thinking (Tronto, 2001). In fact, Tronto further subdivides caring into four different aspects.
Session 9 Caring activities
1 Caring about a state of mind – one which Recovery through Activity aims to reinforce by
enabling participants to attend to the importance of caring.
2 Caring for requiring individuals to take responsibility for initiating discrete

practical activities.
3 Taking care of denoting ongoing practical activity that is carried out competently on a
routine basis.
4 Receiving care reflecting the interactive nature of care and the critical importance of carers
being responsive to the needs of care receivers.
Indeed, care is a reciprocal interaction if we assume that we all need care at some point in our lives and
that almost everyone is capable of giving care (Sevenhuijsen, 2002). Ultimately, both care-giving and
care-receiving should be viewed as meaningful activities (Sevenhuijsen, 2002) that enable us to
maintain and repair the world we live in (Tronto, 2001).
Families and caring

Caring should be an active part of good citizenship (Sevenhuijsen, 2003) and is necessary for an
inclusive society (Sevenhuijsen, 2002). However, caring is more usually associated with family life and
the importance of maintaining or repairing good family relationships cannot be underestimated. For this
reason, families are a key topic in this session. However, remember that families take many different
forms (Sevenhuijsen, 2002) and that care-giving can be for older people as well as children, for partners,
for siblings and for friends, or for anyone who is conceived as ‘like family’. This might even include
caring for animals where reciprocal relationships are developed that benefit the carer (Velde et al,
2005), whether by increasing community integration (Zimolag and Krupa, 2009) or by reducing anxiety
levels (Barker and Dawson, 1998).
Contrary to the widely held belief that the significance of the family is in decline, there is some evidence
that relationships beyond the nuclear family are increasingly important in western society, as
grandparents and other relatives take on more family functions (Bengtson, 2001). According to
Bengtson, where grandparents are involved, their roles have extended because they are living longer
and because communication and travel are easier. Indeed, one study found that grandmothers can
become so involved with their grandchildren that their involvement in other meaningful activities suffers
(Ludwig et al, 2011). However, the same study also found that if their childcare responsibilities can be
fitted into their normal routines, this can lead to a greater sense of fulfilment.
Family bonds inevitably involve responsibilities, duties and obligations (Sevenhuijsen, 2002) as well as
‘family time’ or ‘quality time’ together (Daly, 2001). In practice, it can be hard to retain our positive
ideals about what it is like to belong to a caring family (or society) and not feel trapped by expectations,
or guilty because there is never enough time (Daly, 2001). The trick is to learn to achieve a measure of
individual freedom while remaining connected to the people who are important to us (Sevenhuijsen,
2002). We need to complete required tasks, support the health and wellbeing of those we care for and
maintain our own sense of health and wellbeing (Hasselkus, 1989). Various tensions are almost
inevitable, especially when negotiating a division of labour (Henwood and Procter, 2003).
When people spend more time with their families, this is equated with a higher quality of life
(Greenhaus et al, 2003), so finding a balance between work and family can be a key concern for men
and women alike. Some concerns might be allayed, by knowing that increased maternal employment,
for instance, does not necessarily lead to less time being spent with children (Bianchi, 2000); because
people have fewer children than they did in the past, mothers spend less time on domestic chores
(Bianchi, 2000); and fathers are more involved than they used to be (Yeung et al, 2001).
Moreover, even when mothers spend less time with their babies (when babies spend time in childcare,
for instance), evidence suggests that the quality of mother–child interaction does not change (Booth
et al, 2002). Similarly, fathers who work long hours appear able to maintain family relationships;
relationships only deteriorate when there are high levels of work overload (Crouter et al, 2001).
Impact of family
No two families are the same and the exact structure of the nuclear family can vary (Georgas et al,
2010). What is important is how members of the nuclear and the extended family relate to each other, in
terms of both how close they are on an emotional level and on a geographical basis and how well they
communicate and interact with one another (Georgas et al, 2010). Positive relationships can reap
long-term benefits, for example:
• early family experiences affect the success of future relationships (Wamboldt and Reiss, 1989)
• children who spend more time in shared activities with their parents provide more social support to
their parents as they get older (Silverstein et al, 2002)
• children who view their parents’ divorce as amicable also report having better relationships with
parents, grandparents, step-parents and siblings (Ahrons, 2007).
Each family will spend time together differently (Daly, 2001) and will be united by different tasks and
activities. However, two activities deserve a particular mention for having a positive impact: family
meals and parental involvement in education.
• Family meals are positively associated with eating a healthier diet (Boutelle et al, 2003;
Neumark-Sztainer et al, 2003; Larson et al, 2007). This happens especially when meals are planned
in advance, the television is switched off, and concerns about eating behaviours are not argued
about at the table (Boutelle et al, 2003). Moreover, healthy eating patterns established during
childhood persist into young adulthood, and family-style mealtimes in nursing homes lead to
residents demonstrating greater wellbeing, improved fine motor function and increased body weight
(Nijs et al, 2006).
• Parental involvement in education is linked to children showing improved academic performance

and social competence (Kohl et al, 2000). Their involvement may take many forms, including
participation in school events, discussion of homework, sharing educational values, and intellectual
stimulation, but ‘at home good parenting’ has the greatest impact, especially in the early years
(Desforges and Abouchaar, 2003). In particular, parental limits on television viewing is associated
with children spending more time reading (and completing homework), whereas having a television
in a child’s bedroom has the opposite effect (Wiecha et al, 2001).
Implications for occupational therapy

There is very little recent evidence regarding the role of occupational therapy in promoting and
supporting caring activities. In 1988, Hasselkus wrote about the need for professionals to understand
the perspectives of families in order to develop effective partnerships with care givers. When analysing
the meaning that people ascribe to giving care, she discovered five key themes: sense of self; sense of
managing; sense of the future; sense of fear or risk; and sense of changes to roles and relationships.
These themes warrant further investigation. Then, in 1995, Gitlin and her co-workers recognised that
occupational therapists needed to:
derive an understanding of the personal meaning of caregiving, the

way in which care is provided, and the specific aspects of caregiving
that are problematic from the perspective of the family member.
Services are then developed that reflect individual need as expressed
by the caregiver and that fit with the fundamental values and belief
system of the family unit.
(Gitlin et al, 1995, p802)
In 1997, Baum and Law concluded that occupational therapists needed to work with families and, by
1998, Thompson had discovered that ‘relaxed and friendly’ occupational therapists were viewed by
mothers in early intervention services as having a better understanding of family life and an increased
capacity to meet flexible family needs. Yet, at this time, little qualitative research had been done on the
experience and feelings of carers with a mental illness (Bassett et al, 1999) and parenthood was the
role for which people with major mental health problems received least support (Bassett et al, 2001).
In 2002, occupational therapists were urged once again to develop a deeper understanding of how
family life impacts on occupational participation (Law) and, in 2010, Gibbs et al described how
occupational therapy practice could be directed to focus on family-centred care in a neonatal
programme.
It is hoped that the Recovery through Activity programme will provide occupational therapists working in
mental health services with new opportunities to focus on the caring roles of participants; explore
perspectives in a relaxed and friendly way; and reinforce the value of caregiving and receiving, before
addressing any unmet needs in 1:1 interventions.
Sample activities
Introduction
This session has been designed to meet the needs of participants who want to maintain their caring
responsibilities or achieve a better balance between caring for other people and self-care. It is
particularly geared towards meeting the needs of those who have families of their own or have family
connections which they value. Sensitivity must be shown when planning a session for participants who
are no longer in contact with their families or who receive little family support.
Social activities and community activities (Sessions 11 and 12) may be better suited for meeting the
needs of participants who are looking for alternative ways to express their caring nature. However, this
session may be useful to help participants reflect on their experiences of caring and the family
relationships that they would like to have in the future.
When deciding whether to include this session in the Recovery through Activity programme, facilitators
should gauge whether the participants would feel comfortable discussing the topic with other group
members. Participants should be assured that the intention of the session is not to discuss family details
in particular (including any family problems), but to share and celebrate opportunities to build family
relationships in general. Facilitators should reinforce this message, and the importance of
confidentiality, at the beginning for the session.

Role models
Ask the group to think of as many television families as they can, from the past to the present day.
Perhaps provide television schedules to help get people started.
Ask:
• Which family would most like to belong to? Why?
• Do any of them include ‘father figures’ who you admire? or ‘mother figures’? … sisters? …
brothers? … grandparents? … aunts or uncles?
Broaden the discussion to include real role models who are perceived by participants as being truly
caring.
Ask:
• Can you think of anyone famous whom you admire for being truly caring?
• Can you describe anyone in your life who has inspired you?
• Do you know any really lovely families? What makes them so nice?
What does ‘caring’ mean? (worksheet p148)

Caring can mean different things to different people. This exercise is designed to help the participants
discuss the aspects of caring that they value the most.
Ask:
• When people care for you, what do you appreciate the most?
• How do you tend to express your care for other people?
Describing care
Search the web for ‘caring poems’ and print out a range of short poems describing the nature of caring.
Ask:
• Which poems are the most inspiring?
• Which poems are the most realistic?
Showing care for other people

Ask:
• What’s the nicest thing you’ve ever heard of that someone did to show they care?
• What kind of things have people done that show they care for you?
• What are you most proud of having done, to show someone that you care?
• How can you show other people that you appreciate the care they show towards you?
• Is there a difference between general politeness and caring for someone?
• To whom could you show that you care during a normal day?
• Do we have to be with people to express our care for them?
• Do we have to know people well to express our care for them?
• What examples can you think of where care is expressed, but not for people? (For example, for
animals, or plants, or the environment.)
Discuss whether actions are more important than words and what makes a gesture meaningful.
Also, discuss the importance of giving care over a period of time as well as showing care through
individual actions.
The nature of caring

Before starting a discussion about the nature of caring, facilitators should read ‘The value of caring
activities’ at the beginning of this section.
Ask:
• Do we all need care?
• Can everyone show care for other people?
• What is the difference between independence and interdependence and which is better?
• How do we benefit from interdependence and how does society benefit?
• Is there a difference between ‘caring about someone’, ‘caring for someone’ and ‘taking care of
someone’? If so, what is the difference?
• Should family members care about one another? Or care for one another? Or take care
of one another?
• In modern society, do families play a smaller role than in the past?
• Can we care ‘too much’?
Share the Key messages for this topic (page 137) with the participants.
No two families are the same (worksheet page 149)

Suggest that the group members try to draw their own family tree. They need only share as much as
they want to with the group and need not disclose any names. The purpose is simply to show that all
families are different and the facilitators should reinforce that what matters is how people relate to
each other.
Explain how to draw a family tree – with squares for men and circles for women – and ask the
participants to draw as much of their own tree as they can manage, starting with their grandparents.
Ask:
• Do you know anything about your grandparents’ jobs?
• How did your parents meet each other?
• Have the family units changed over the generations? (In terms of the number of children or
marriages.)
• Are there any step-brothers or sisters in the group’s family trees, or any half-brothers and sisters?
• Does anybody live in an extended family, with more than two generations living together?
• Is anybody particularly close to someone in the extended family who isn’t within the ‘nuclear family
unit’ (ie parents and children)? For example, aunts, uncles, cousins, or grandparents.
• Have the family roles changed over the generations? (In terms of who does what to care for the
family.)
Quality family time

Emphasise the fact that families do different things together according to the family structure, the age
of family members, and individual interests. Ask the participants about when their ‘birth families’ (ie the
families they were born into) come together or used to come together. For example: for special events
(weddings, birthdays); at particular times of the year (summer holidays, Christmas); or for more ordinary
occasions (evening meals, school events). Reinforce the importance of family mealtimes and parental
involvement in a child’s education.
Ask:
• Why are family mealtimes important?
• What can parents do to support their children’s education?
If appropriate, ask participants if they would be prepared to share a happy memory of a time spent with
the family from their childhood.
Shared interests (worksheet page 150)

When building a caring relationship, it is important to consider whether we share any particular
interests. A person might follow the same football team as a friend, like to spend time cooking with
their partner, be interested in their children’s education and enjoy helping them to play instruments. The
person’s friend, partner and children might also have other interests that are not shared (eg fishing,
pottery or video games).
Transfer the diagram on page 150 onto a flipchart to show how a person’s interests might overlap with
those of friends and family. If the group members all have close friendships or families then they might
like to draw their own diagrams. Otherwise, ask the participants:
• Do you share any interests with the people you care for?
• Could you spend more time following these interests together?
• How might you take an interest in what people do, even when you don’t share the same interests?
• Do the people you care for have any interests that you could support them with?
Time away
Remind the participants of the importance of having some time away from the people we look after, so
that we can ‘recharge our batteries’.
• Ask the group to share their tips for getting time to themselves.

Shared meal
If the group hasn’t cooked a meal together as part of the domestic activities session (Session 8), this
could be a good opportunity to celebrate the importance of peer support. It will encourage everyone to
do as much as they can to help each other.
Expert advice
Organise a specialist to give a talk on one of the following topics:
• parenting
• support for carers
• self-help groups
• volunteering.
What does ‘caring’ mean?

✐
WORKSHEET
When you consider what it means to be caring, what do you think it is most
important to be?
The words below are all linked to the idea of ‘caring’. In the first blank column,
tick five aspects of caring that fit in with how you think about ‘caring’.
Then, in the second column, rate these aspects from 1 to 5, where 1 is the most important.
Tick the five words that best fit in with your

Rating (1–5)
definition of what it means to be caring
appreciating
being affectionate
being attentive
being concerned
being considerate
being gentle
being helpful
being kind
being loving
being sensitive
being thoughtful
cherishing
enjoying
favouring
liking
looking after
showing compassion
showing interest
supervising
tending
thinking about
worrying about
No two families are the same

✐
WORKSHEET
Draw as much as you can of your family tree overleaf, based on the example below.
Start with your grandparents.
Don’t worry about being neat – try to spend no more than 5 minutes on this.
a woman a man
Married Died
re-married
Grandparents
Aunts &
Uncles
Twins
Married
Parents
Divorced Me engaged
Brothers &
Sisters
Children
Grandchildren
Shared interests
✐
WORKSHEET
My friend My partner
Me
ing
co
ok
fish
ing
ll
po
tba
tte
foo
ry
education &
music
video games
My children
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Vocational roles 10
Key messages
• Vocational roles include:
paid work
volunteering
studying.
• All of them help to:
provide a structure
support commitment and responsibility
lead to increased self-worth.
• Paid work provides an income and a social status, which helps recovery, but there are
disadvantages too.
On the whole, people who are in work recognise the benefits even if they are not fully
satisfied.
Unemployed people may have concerns about how work could affect their mental health.
• Voluntary work provides opportunities for:
increased confidence
social inclusion.
• Study enables people to prepare for work.
• Occupational therapists can assist people to:
explore their vocational needs
build vocational skills
access vocational opportunities
retain vocational roles.
The value of vocational activities

Introduction
In this context, ‘vocation’ covers a spectrum of activities, including: study, voluntary work and paid
employment; activities that benefit those involved by providing regular structure and tasks that can be
achieved (Williams et al, 2010). Their health-enhancing effects have been attributed to their obligatory
nature, which supports commitment and responsibility, and leads to increased self-worth (Iannelli and
Wilding, 2007), thereby providing a vehicle for promoting and maintaining mental health. So much so
that ‘being employed’ has been recognised as one of the indicators for a favourable long-term outcome
in the treatment of schizophrenia (Carter et al, 2011). This may be because people who find work are
functioning at a higher level but it could also be because employed people with long-term mental illness
are more satisfied with their daily occupations (Eklund et al, 2004).
Paid employment
The importance and value of work is a recurring theme when exploring the occupational experiences of
people with schizophrenia (Urlic and Lentin, 2010). Paid employment is the most frequently identified
long-term goal for mental health service users in general (Secker et al, 2001). They recognise that work
not only provides financial benefits and has personal meaning but also it promotes recovery (Dunn et al,
2008). However, it is undeniable that work holds multiple meanings for people with mental health
problems, that there are advantages and disadvantages to working, and that many barriers to work
exist’ (Blank et al, 2011, p190).
The diagnosis of schizophrenia is itself a predictor of unemployment (Butler et al, 2010). More
specifically, vocational function is reduced if the person’s attention, memory, reasoning and problem-
solving, and social awareness are compromised (Tan, 2009). In addition, a person’s chances of gaining
employment decline as their illness continues, and the situation can be exacerbated still further by drug
misuse (Marwaha et al, 2007). On the other hand, having a previous work history is associated with an
increased likelihood of obtaining and keeping work.
Perceptions of the benefits and drawbacks of work are influenced by people’s circumstances and
experiences and these will impact on the actions they take in relation to employment (Honey, 2004).
Those in employment are likely to recognise various benefits, even when they experience job
dissatisfaction (Boyce et al, 2008); while people who are unemployed may have substantial concerns
about how their symptoms could affect their ability to work and, conversely, how work will affect their
mental health (Marwaha and Johnson, 2005). Therefore, it is important to provide a diverse range of
supports, both within and outside the workplace, to strengthen the active self-management that is
necessary for seeking and maintaining employment (Fossey and Harvey, 2010).
Session 10 Vocational activities
Voluntary work
Voluntary work placements may provide a source of support, although more research is required to
confirm the exact benefits (Farrell and Bryant, 2009) and to fully appreciate the importance of training
and managing volunteers (Casiday et al, 2008).
Like paid employment, volunteering provides opportunities for increased confidence and self-esteem
and may also lead to greater social inclusion by generating social interaction and replacing lost roles
(Black and Living, 2004). It appears to benefit people who have disabilities as well as those who do not
(Miller et al, 2002). It has also been shown to increase wellbeing, although people with robust
wellbeing are more likely to volunteer in the first place (Thoits and Hewitt, 2001).
Once more, it appears that the therapeutic benefit of volunteering depends on the meaning and purpose
that it holds for the individual (Black and Living, 2004).
Study
What about the value of study? An evaluation of a cross-country project in Europe found that users of
mental health services who participated in lifelong learning interventions reported positive life changes
10 months later with ‘a sizeable minority moving on to unpaid or paid employment’ (Ramon et al, 2011,
p211). It was also noted that, despite the benefits of supported educational placements (Best et al,
2008; Robson et al, 2010), obstacles to learning were not eradicated entirely (Ramon et al, 2011).
Individual Placement Support

Individual Placement Support (IPS) is effective in helping people to gain and sustain employment
(Crowther et al, 2001; Porteous and Waghorn, 2007; Rinaldi et al, 2011). Occupational therapists may
enhance their services by using this evidence-based approach (Turner, 2009). Historically, however,
vocational rehabilitation in the UK has been poorly developed (Rinaldi et al, 2008) and there are
indications that IPS is less effective because it is not fully integrated with mental health services
(Howard et al, 2010).
The integration of mental health and employment services has distinct advantages (King et al, 2006) and
yet segregated services have also proved successful (Waghorn et al, 2011). Moreover, integration may
not always be achievable, in which case developing strong links between the different sectors may be
just as effective (Sherring et al, 2010).
Vocational rehabilitation
An increasing awareness of the value of work has encouraged occupational therapists to return to their
roots as specialists in vocational rehabilitation (Thurgood and Frank, 2007).
According to Lloyd and Waghorn (2007, p50):
A useful approach for occupational therapists to use is a recovery

framework combining evidence-based employment and educational
assistance with mental health care, provided in parallel with brief
vocational counselling, illness management skills, training in
stigma-countering and disclosure strategies, context-specific social
skills and skills in social network development.
In this way, vocational rehabilitation programmes can still have merit in enabling clients to access
mainstream education, voluntary work and competitive employment (Inman et al, 2007;
Rouleau et al, 2009).
In addition to building links with employment services, occupational therapists can provide a crucial
service in assessing a person’s vocational needs (Davis and Rinaldi, 2004). In this task, they are able to
benefit from a choice of evidence-based interventions derived from the Model of Human Occupation
(Lee and Kielhofner, 2010), including the Worker Role Interview (Lohss et al, 2012) and the Work
Environment Impact Scale (Williams et al, 2010).
To summarise: occupational therapists need to combine opportunities for experiencing work (Gewurtz
and Kirsch, 2007) with social skills training and goal-setting (Arbesman and Logsdon, 2011). Service
users need to be helped to explore their personal meanings of work (Kennedy-Jones et al, 2005) and
occupational therapists should continue to pursue a ‘broader approach to recovery-oriented practice,
alongside a process of enabling people with mental health problems to engage in personally meaningful
occupations’ (Blank and Hayward, 2009, p324).
Sample activities
Introduction
When planning this session, facilitators need to take both the past and the current experiences of
participants into account. Accordingly, they might focus the session more on paid employment or
voluntary work or study.

Definitions of productivity
Spend some time introducing the concept of vocation and the broader concept of productivity.
Ask:
• What does productivity include? For example, paid work, voluntary work, caring roles,
home-maintainer roles, health-maintainer roles, campaigning, study.
• When you think about ‘work’, what’s the first thing that comes to mind?
What about ‘volunteering’?
Or ‘study’?
Career decisions
Go round the group and ask the participants:
• When you were little, what did you want to be when you grew up?
• Have you ever had any careers advice? If so, what were you advised to do?
• What’s the worst job you’ve ever done?
What did it involve?
What was a typical day or shift like?
How did you come to work there?
Were there any benefits to working there?
• What’s the best job you’ve ever done? Why?
Study
Start the discussion with the saying that ‘school days are the best days of your life’ and ask is there any
truth in this? Encourage participants to share the things that they liked best about their school days.
Ask:
• Who were your favourite teachers?
• What games did you play in the playground?
• What were your best subjects at school?
If you could study something now, what would it be? (Consider adult education classes, school
subjects and university courses.)
Voluntary work
• Ask the participants what they would like to do if they could offer a few hours a week in a voluntary
capacity. For example, working:
with a conservation organisation
in a stately home
in a charity shop
in a school
in a theatre or an arts centre
with animals
with disabled people
with older people
with homeless people.
• In pairs, try to think of a time you’ve helped somebody or done a favour for someone, eg babysitting,
watering a neighbour’s plants while they were away.
What were your reasons for doing this?
How did it make you feel?
Would you do it again?
Ideal job (worksheet page 163)

Use the worksheet to identify the aspects that participants would like in their ideal job. Ask the
participants to circle the desirable aspects and, if possible, to rate the top six aspects.
In pairs, ask the participants to suggest ideal jobs for each other before sharing their ideas with the
whole group.
Ask:
• Has anyone ever worked in their ideal job?
• Would it still be ideal today?
The benefits of working (worksheet page 164)

Question: What are the benefits of working?
Answer: All of the statements are true.
For more information about the benefits of vocational roles, see the following publications.
• The systematic review commissioned by Volunteering England (Casiday et al, 2008) which, among
other things, cites evidence for better family relationships, healthier lifestyles, increased ability to
deal with the activities of daily life, longer life, and more social contact.
• The literature review by Dodu (2005) which, among other things, cites evidence for a sense of
achievement, an improved immune system, better sleep, higher status, and speedier recovery from
surgery.
• The report commissioned by the cross-government Health, Work and Well-being Progamme and
published by the Royal College of Psychiatrists (Lelliot et al, 2008) which, among other things,
cites evidence for a sense of achievement, better family relationships, increased involvement in
leisure activities, increased structure to time, increased activity (and therefore exercise), and more
social contact.
• The report commissioned by the Department for Work and Pensions (Waddell and Burton, 2006)
which, among other things, cites evidence for a sense of achievement, a better immune system,
longer life, and more money.
The worker role

Ask the participants to reflect on any feedback they might have received about their work skills.
Ask:
• What are your best qualities as a worker? For example, being a team player, loyal, conscientious,
caring, reliable, thorough, trustworthy, good with people.
• What would help you to find or keep a job?

• Visit a job centre or a volunteer bureau.
• Check what courses are available in adult education.
Careers advice
• Try out a free online careers matching service.
Expert opinion
• Organise a session about benefits advice.
Active experience
Try out some voluntary work:
• organise individual placements
• visit somewhere which has volunteer workers.
What would be your ideal job – paid or voluntary?

✐
WORKSHEET
First, circle the activities below that you would like your job to include.
using
writing talking using numbers computers
thinking leading cooperating teaching
helping other working with being creative being practical

people animals
working from
being active being outdoors being indoors home
working working in
in a big a small being working
organisation organisation independent sociable hours
freedom to
variety security responsibility smoke
Now rate the most important activities from 1 to 6.
Finally, in pairs, suggest possible jobs for your partner – be as imaginative as you like!
What are the benefits of working?

✐
WORKSHEET
Which of the following benefits are linked to working (whether paid or unpaid)?
True False
1 A sense of achievement
2 Better family relationships
3 Better immune system
4 Better sleep
5 Healthier lifestyle in terms of eating / drinking / smoking
6 Higher status
7 Increased involvement in leisure activities
8 Increased skills for dealing with the activities of daily life
9 Increased structure to time
10 Longer life
11 More exercise
12 More money
13 More social contact
14 Speedier recovery from surgery
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and Disability, 9 (1), pp17–33.
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Rinaldi M, Perkins R, Glynn E, Montibeller T, Clenaghan M & Rutherford J (2008) ‘Individual placement and support:
from research to practice’, Advances in Psychiatric Treatment, 14 (1), pp50–60.
Robson E, Waghorn G, Sherring J & Morris A (2010) ‘Preliminary outcomes from an individualised supported education
programme delivered by a community mental health service’, British Journal of Occupational Therapy, 73 (10), pp481–6.
Rouleau S, Saint-Jean M, Stip E & Fortier P (2009) ‘The impact of a pre-vocational program on cognition, symptoms, and
work re-integration in schizophrenia’, Occupational Therapy in Mental Health, 25 (1), pp26–43.
Secker J, Grove B & Seebohm P (2001) ‘Challenging barriers to employment, training and education for mental health
service users: the service user’s perspective’, Journal of Mental Health, 10 (4), pp395–404.
Sherring J, Robson E, Morris A, Frost B & Tirupati S (2010) ‘A working reality: evaluating enhanced intersectoral links in
supported employment for people with psychiatric disabilities’, Australian Occupational Therapy Journal, 57 (4), pp261–7.
Tan B-L (2009) ‘Profile of cognitive problems in schizophrenia and implications for vocational functioning’, Australian
Occupational Therapy Journal, 56 (4), pp220–8.
Thoits PA & Hewitt LN (2001) ‘Volunteer work and well-being’, Journal of Health and Social Behavior, 42 (2), pp115–31.
Thurgood J & Frank AO (2007) ‘Work is beneficial for health and wellbeing: can occupational therapists now return to their
roots?’, British Journal of Occupational Therapy, 70 (2), p49.
Turner N (2009) ‘Successful return to employment amongst people with mental health difficulties: a role for Occupational
Therapy?’, Irish Journal of Occupational Therapy 37 (1), pp16–23.
Urlic K & Lentin P (2010) ‘Exploration of the occupations of people with schizophrenia’, Australian Occupational Therapy
Journal, 57 (5), pp310–7.
Waddell G & Burton AK (2006) Is Work Good for Your Health and Well-being?, The Stationery Office, London.
Waghorn G, Stephenson A & Browne D (2011) ‘The importance of service integration in developing effective employment
services for people with severe mental health conditions, ’British Journal of Occupational Therapy, 74 (7), pp339–47.
Williams A, Fossey E & Harvey C (2010) ‘Sustaining employment in a social firm: use of the Work Environment Impact
Scale v2.0 to explore views of employees with psychiatric disabilities’, British Journal of Occupational Therapy,
73 (11), pp531–9.
Social activities 11
Key messages
• Human beings are naturally social:
our lives depend on other people
our basic needs include social support and a sense of belonging.
• Social interaction is an important aspect of leisure:
it is often more important than the leisure activity itself
the older we get, the more important social interaction becomes for our wellbeing
almost all social contact is valued.
• Social activities require us to practise communication and interaction skills in order to:
let people know what we plan to do and what our needs are
work with other people towards a common goal.
• Good social skills lead to stronger social networks:
the quality of social relationships is more important than the quantity of social interaction.
The value of social activities

Introduction
The importance of social interaction has long been recognised:
In our everyday lives, we encounter people all the time and in all
kinds of situations. We are continuously perceiving and interacting
with others.
(Hamilton et al, 2005, p405)
Moreover, there is a lot of empirical evidence that interpersonal relationships are linked to self-reported
happiness (Bruni, 2010). Social participation is also strongly associated with whether people view
themselves as having good health and it becomes even more important as people get older (Lee et al,
2008). For example, older women who engage in two social activities are more than twice as likely to
rate their health as good, compared with those who don’t take part in any activities (Lee et al, 2008).
Social interaction and social networks

Fuhrer et al (1999) discovered that women had more close relationships than men but that men had
wider social networks. Both of these facts have implications for mental health, and the importance of
socially inclusive networks should not be underestimated. The two are interrelated: good social
interaction skills lead to stronger social networks and better psychosocial adjustment, just as good
social networks will result in more opportunities for social interaction and improved quality of life
(Riggio et al, 1993; Eklund and Hansson, 2007).
Therefore, Recovery through Activity covers both topics: socially inclusive networks are discussed more
fully in the section on community activities, while social interaction is discussed in this section on social
activities. Together, they provide important support systems for people by promoting mental health, as
well as acting as a ‘buffer’ to help people cope with psychological stress (Greenblatt et al, 1982;
Dalgard et al, 1995; Albrecht and Goldsmith, 2003).
Relationships and mental health

Crucially, when considering the impact of social relationships on mental health, it is quality that matters,
not quantity, especially when considering the impact of family relationships (Pinquart and Sörensen,
2000). Indeed, Ryff and Singer (2000, p30) assert that ‘Quality ties to others are universally endorsed as
central to optimal living’.
Session 11 Social activities
Conversely, it should be acknowledged that critical or demanding relationships have the potential to
damage health (Seeman, 2000) because of overinvolvement (Coyne and DeLongis, 1986) or role strain
(Kawachi and Berkman, 2001). Yet almost all social contact is valued and perceived as being better than
none (Green et al, 2002) and there is evidence that people experiencing mental health problems value
support from people in similar situations (McCluskey et al, 2007).
Social support is even more important when people are vulnerable. It is recognised that the onset of
mental illness is associated with a reduced capacity to engage in social activities (Woodside et al, 2007;
Krupa et al, 2010) and that social stigma can have a deleterious effect on interpersonal relationships
(Lloyd et al, 2005). These problems are compounded when individuals cannot realistically appraise their
own abilities (Lindstedt et al, 2004).
Occupational therapy
Although the social environment influences health promotion (Seeman, 2000), more research is required
to establish the best interventions for enhancing social relationships (Kawachi and Berkman, 2001).
Occupational therapists undoubtedly have a role to play in enabling activity and social engagement
(Krupa et al, 2010). They have the potential to use psychosocial programmes such as Recovery through
Activity to help people explore the value of engaging in activities with family and friends, in order to
develop, maintain and re-establish social contacts (MacDonald et al, 2005). The group-based work in the
programme could be coupled with social skills training for the individuals, as necessary, because there
is extensive evidence for the effectiveness of this intervention when people experience severe mental
illness (Greenblatt et al, 1982; Dilk and Bond, 1996; Kopelowicz et al, 2006).
Finally, the programme participants need to have opportunities to generalise their skills in relevant
situations (Kopelowicz et al, 2006). The choice of activities is endless and will naturally depend on the
interests of those involved. However, there is evidence that many activities can increase opportunities
for social interaction, whether these involve contact with animals (Bernstein et al, 2000), music
(Nayak et al, 2000) or participation in a football team (Mynard et al, 2009).
Sample activities
Introduction
The following activities should be chosen with care to match the needs of the participants. In some
groups, the participants may already know each other, while others may need time to get to know each
other before sharing any information about their social lives. Some participants may have supportive
families and relationships but still be interested in increasing opportunities for social interaction. Other
participants may be more isolated, in which case more care is needed to ensure that the session retains
a positive focus. The participants’ circumstances will influence the choice of activities in the session.
If the group members are very comfortable with one another, the discussion topics can be much more
wide-ranging than the ideas suggested here. They could include anything from ‘best and worst chat-up
lines’ to ‘where I met my partner’ or even ‘how I coped with divorce’ – a skilled facilitator will steer the
conversation to retain a positive emphasis and include all of the participants.
Depending on whether the Recovery through Activity programme includes the session on community
activities or not, facilitators might want to start by discussing the difference between social interaction
and social inclusion, and perhaps include some of the suggested activities from the social inclusion
section.

Autograph sheet (worksheet page 175)
This ice-breaker exercise works well if the group members do not know each other well but have the
confidence to introduce themselves to each other.
Mottos (worksheet page 176)

This exercise is a useful starting place to discuss the value of social interaction and lead into discussing
the key messages for this session. The mottos can be spread around the room for people to choose the
one that they most agree with, or they could be discussed one at a time. They could also be rewritten on
a single sheet of paper for the participants to read through. The ensuing discussion could involve the
participants listing their top three mottos or discussing whether they disagree with any of the mottos.
Why are groups important? (worksheet page 179)

Before discussing the value of groups (based on Yalom’s curative factors, 1995), the participants might
be asked to think about the groups they have belonged to during their lifetime, eg school groups, family
groups, faith groups or work groups.
Friends
• Question: How many close friends do you think the average person has?
Answer: two (based on the American study by Brashears, 2011).
• Tell us about a childhood friend.
• What makes a good friend? For example, someone:
to visit places with
who is cheerful
who listens to you
who makes you laugh
who needs you
who you can ask for advice
you can rely on
you can share your interests with
you respect.
• Can your family also be your friends?
• What’s the best way to show appreciation of your friends?
Where to meet people

• Where are the best places to meet people?
Discuss the merits of a pub or a bar versus an interest group (such as a choir or a photography
club) versus a civic group (such as the Women’s Institute in the UK).
Discuss the merits of groups where people talk to each other (such as a book club) versus a group
where people are taught by someone (such as a yoga class or a language class).
Has anyone ever got to know somebody at their local shop?
How well do you know your neighbours?
• Where are the cheapest places to meet people?
Which places do not involve drinking alcohol?
Hot tips for confidence on a social occasion

What gives participants confidence when they go out? For example, being dressed for the occasion,
standing tall, knowing the other people, going with someone, doing something you enjoy.
Sociable activities
Are certain activities more sociable than others? For example, ten-pin bowling, karaoke, eating out,
going to the cinema. Or do you have to know people well already for these activities to be sociable?

Investigating local options (if this hasn’t already been done)
• Visit the local library to find out about local groups.
• Check out the ‘What’s on’ section of a local newspaper or magazine.
• Provide information about self-help groups.
Visiting a local meeting place or club

• For example, the cinema, a bowling alley, a karaoke night.
Social games
• For example, parachute games, Chinese whispers, wink murder.
Discussions
• For example, about favourite books, favourite music, favourite comedian, news stories.
Quiz or a friendly competition

• For example, general knowledge quiz, current events quiz, board games, Wii party games.
Social event
• For example, a barbeque or a murder mystery party.
Autograph sheet
✐
WORKSHEET
Go round the room and chat to the other people in the group. Ask them one of the questions
below.
If they answer ‘Yes’, ask them to sign your sheet and move on to ask another question of
someone else.
Try to collect as many signatures as possible in ten minutes.
Question Signed
Have you ever been to Spain?
Do you like cats?
Can you roll your tongue?
Is your birthday in March?
Are your eyes brown?
Have you ever had a parking ticket?
Do you watch any soap dramas on television?
Can you tell me a joke?
Do you like gardening?
Is your favourite colour blue?
Have you always lived in this county?
Are you any good at home improvements?
Do you like really hot weather?
Can you play a musical instrument?
Do you prefer tea more than coffee?
Mottos
✐
WORKSHEET
The following proverbs and sayings all express positive sentiments about social interaction.
Copy them, cut them out and spread them around.
Ask the participants to choose the one which they most agree with and to share their reasons
for their choice.
Smile and the

world smiles
with you
A friend in need is a
friend indeed
A problem shared is
a problem halved
Better to have loved and lost

than never to have loved at all
WORKSHEET
Do unto others as you
would have them do to you
It is better to give
than to receive
It takes all sorts to

make a world
It takes two to tango

It’s nice to be important but it’s
important to be nice
✐
WORKSHEET
Laughter is the best

medicine
Many hands make

light work
No man is an island
The more the merrier
Two heads are

better than one
Why are groups important?

✐
WORKSHEET
Write the following statements on a flipchart or whiteboard and ask
participants to share a time when being in a group of people has resulted in:
1 being inspired by others
2 learning from others
3 feeling good about helping others
4 making a good friend
5 giving a talk or making a speech
6 recognising that you are not the only person to feel or think something
7 finding a role model
8 learning something about yourself
9 feeling accepted and supported
10 feeling able to express yourself.
References
Albrecht TL & Goldsmith DJ (2003) ‘Social support, social networks and health’, Thompson TL, Dorsey AM,
Miller KI & Parrott R (eds), Handbook of Health Communication, Lawrence Erlbaum Associates, Mahwah, NJ, pp263–84.
Bernstein PL, Friedmann E & Malaspina A (2000) ‘Animal-assisted therapy enhances resident social interaction and
initiation in long-term care facilities’, Anthrozoos: A Multidisciplinary Journal of the Interactions of People & Animals,
13 (4), pp213–24.
Brashears ME (2011) ‘Small networks and high isolation? A re-examination of American discussion networks’, Social
Networks, 33 (4), pp331–41.
Bruni L (2010) ‘The happiness of sociality. Economics and eudaimonia: a necessary encounter’, Rationality and Society,
22 (4), pp383–406.
Coyne JC & DeLongis A (1986) ‘Going beyond social support: the role of social relationships in adaptation’, Journal of
Consulting and Clinical Psychology, 54 (4), pp454–60.
Dalgard OS, Bjørk S & Tambs K (1995) ‘Social support, negative life events and mental health’, British Journal of
Dilk MN & Bond GR (1996) ‘Meta-analytic evaluation of skills training research for individuals with severe mental
illness’, Journal of Consulting and Clinical Psychology, 64 (6), pp1337–46.
Eklund M & Hansson L (2007) ‘Social networks among people with persistent mental illness: associations with
sociodemographic, clinical and health-related factors’, International Journal of Social Psychiatry, 53 (4), pp293–305.
Fuhrer R, Stansfeld SA, Chemali J & Shipley MJ (1999) ‘Gender, social relations and mental health: prospective findings
from an occupational cohort (Whitehall II study)’, Social Science & Medicine, 48 (1), pp77–87.
Green G, Hayes C, Dickinson D, Whittaker A & Gilheany B (2002) ‘The role and impact of social relationships upon
well-being reported by mental health service users: a qualitative study’, Journal of Mental Health, 11 (5), pp565–79.
Greenblatt M, Becerra RM & Serafetinides EA (1982) ‘Social networks and mental health: an overview’, American
Journal of Psychiatry, 139 (8), pp977–84.
Hamilton, DL, Sherman SJ & Lickel B (2005) ‘Perceiving social groups: the importance of the entitativity
continuum’, Hamilton DL (ed), Social Cognition: Key Readings in Social Psychology, Psychology Press, Secaucus, NJ,
pp405–19.
Kawachi I & Berkman LF (2001) ‘Social ties and mental health’, Journal of Urban Health, 78 (3), pp458–67.
Kopelowicz A, Liberman RP & Zarate R (2006) ‘Recent advances in social skills training for schizophrenia’, Schizophrenia
Bulletin, 32 (1), ppS12–S23.
Krupa T, Woodside H & Pocock K (2010) ‘Activity and social participation in the period following a first episode of
psychosis and implications for occupational therapy’, British Journal of Occupational Therapy, 73 (1), pp13–20.
Lee HY, Jang S-N, Lee S, Cho S-I & Park E-O (2008) ‘The relationship between social participation and self-rated health
by sex and age: a cross-sectional survey’, International Journal of Nursing Studies, 45 (7), pp1042–54.
Lindstedt H, Söderlund A, Stålenheim G & Sjödén P (2004) ‘Mentally disordered offenders’ abilities in occupational
performance and social participation’, Scandinavian Journal of Occupational Therapy, 11 (3), pp118–27.
Lloyd C, Sullivan D & Williams PL (2005) ‘Perceptions of social stigma and its effect on interpersonal relationships of
young males who experience a psychotic disorder’, Australian Occupational Therapy Journal, 52 (3), pp243–50.
MacDonald E, Sauer K, Howie L & Albiston D (2005) ‘What happens to social relationships in early psychosis?
A phenomenological study of young people’s experiences’, Journal of Mental Health, 14 (2), pp129–43.
McCluskey A, Urlic K & Carr H (2007) ‘Young people recovering from early psychosis valued support from other young
people who had also experienced psychosis’, Australian Occupational Therapy Journal, 54 (1), pp76–78.
Mynard L, Howie L & Collister L (2009) ‘Belonging to a community-based football team: an ethnographic study’,
Nayak S, Wheeler BL, Shiflett SC & Agostinelli S (2000) ‘Effect of music therapy on mood and social interaction among
individuals with acute traumatic brain injury and stroke’, Rehabilitation Psychology, 45 (3), pp274–83.
Pinquart M & Sörensen S (2000) ‘Influences of socioeconomic status, social network, and competence on subjective
well-being in later life: a meta-analysis’, Psychology and Aging, 15 (2), pp187–224.
Riggio RE, Watring KP & Throckmorton B (1993) ‘Social skills, social support, and psychosocial adjustment’, Personality
and Individual Differences, 15 (3), pp275–80.
Ryff CD & Singer B (2000) ‘Interpersonal flourishing: a positive health agenda for the new millennium’, Personality and
Social Psychology Review, 4 (1), pp30–44.
Seeman TE (2000) ‘Health promoting effects of friends and family on health outcomes in older adults’, American Journal of
Health Promotion, 14 (6), pp362–70.
Woodside H, Krupa T & Pocock K (2007) ‘Early psychosis, activity performance and social participation: a conceptual
model to guide rehabilitation and recovery’, Psychiatric Rehabilitation Journal, 31 (2), pp125–30.
Yalom ID (1995) The Theory and Practice of Group Psychotherapy, 4th edn, Basic Books, New York.
Community activities 12
Key messages
• Community involvement includes:
social connections
shared concerns
community values.
• A sense of community leads to:
increased wellbeing
a sense of belonging and acceptance
increased support for each other
increased awareness of the local environment.
• A sense of community is linked to:
participation in community activities
the length of time we have lived in the same area
neighbourliness
satisfaction with local facilities and neighbourhood safety.
• Social groups include:
contact with family and workmates
membership of clubs and organisations
informal acquaintances at local meeting places.
The value of community activities

Introduction
This session is intended to cover a range of everyday cultural and organisational activities that are not
discussed elsewhere in the Recovery through Activity programme, and to reinforce the inclusive nature
and the possibilities for community integration that arise from participation in all activities.
For people with mental health problems to recover and rebuild their
lives they need access to those social, economic, recreational and
cultural opportunities, and physical health services, that most
citizens take for granted.
(National Social Inclusion Programme [NSIP] 2009, ‘Ten Key Messages’)
Social inclusion
The overarching feature of community activities is their social element (Morgan et al, 2007). Note that
the activities discussed in other sessions of Recovery through Activity can undoubtedly bring
participants into contact with the wider community and thereby support social inclusion. This can occur
when the activity is leisure-based (Heasman and Atwal, 2004), vocational (Davis and Rinaldi, 2004) or
religious in nature (Strawbridge et al, 2001). For instance, art projects have proved useful as ‘a first step
to community engagement’ (Thomas et al, 2011, p429); sports programmes can be community-based
(Mynard et al, 2009); and gardening has the potential to facilitate social inclusion (Fieldhouse, 2003;
Diamant and Waterhouse, 2010).
In addition, employment is perceived as a powerful vehicle for social inclusion (Evans and Repper, 2000).
Competitive work is seen as being more satisfying than any other community activity (Eklund et al,
2004), although volunteering and education still have positive effects in terms of building social
networks (Black and Living, 2004; Ramon et al, 2011).
Also, weekly religious attendance has been associated with good mental health and increased social
relationships (Strawbridge et al, 2001). Even self-care activities have a part to play in helping people
enter into socially inclusive activities (Boutillier and Croucher, 2010).
Community activities are important because they help to combat marginalisation and occupational
imbalance, by supporting every person’s right ‘to participate in a range of occupations for health and
social inclusion’ (Townsend and Wilcock, 2004, p75). They can enable people to fulfil valued roles as
Session 12 Community activities
contributing members of society (Davidson et al, 2001) and to be empowered by participating with
dignity (Whiteford and Pereira, 2012). In doing so, they help individuals to develop a sense of
‘connectedness and citizenship’ as they build reciprocal interpersonal relationships and take on the
responsibilities that democracy demands (Ware et al, 2007).
Essentially, community activities involve a sense of membership in society (Andonian and MacRae,
2011) and taking on roles that demand interaction with the outside world (Bejerholm and Eklund, 2004).
They can include ordinary, everyday activities such as shopping (Davidson et al, 2001) and might still
include participation in segregated service provision such as service user and advocacy groups. So, in
addition to understanding community activities, when considering community involvement we also need
to examine the people and places in people’s lives (Bates, 2010) and take into account the psychological
sense of community (Townley and Kloos, 2009). This includes variables such as neighbourhood
relationships, neighbourhood safety and neighbourhood satisfaction (Townley and Kloos, 2011).
They all have a part to play in making someone feel socially included.
Despite the seemingly obvious benefits of social inclusion for community living, note that some
individuals may not regard the advantages as being self-evident (Secker, 2009). For example, Lindstedt
et al (2004) found that mentally disordered offenders were satisfied with their level of participation,
despite acknowledging difficulties participating in community life. In fact, many people choose to mix in
restricted social circles – a reminder that social exclusion is not the preserve of people with mental
illness and inclusion is not mandatory (Spandler, 2007). Spandler also states it should always be a
matter of personal choice rather than a top-down mechanism for social engineering. In particular, paid
employment should not be viewed as the sole route to inclusion as this ‘ignores the necessity, value and
gendered nature of unpaid work’ (Spandler, 2007, p7). Instead, it must be recognised that social
integration can bring its own share of loneliness and may even heighten feelings of exclusion
(Granerud and Severinsson, 2006).
Thus, social inclusion should not require full participation and the notion of a ‘middle ground’ is possible
– ‘a personally defined position where an individual feels socially included regardless of his or her
physical involvement in the community’ (Boutillier and Croucher, 2010, p136).
Political and social focus

Health workers have a role to play in encouraging meaningful community activities (McKay, 2010).
However, before they promote the social inclusion agenda, they need to develop a political and social
awareness (Harrison and Sellers, 2008), so that they can work with service users in determining
whether and how to challenge discrimination (Sayce, 2001). In the long term, legal reforms and public
education are both required (Sayce and Measey, 1999), to promote a better understanding of mental
health issues and the need to deliver greater access to services (Huxley and Thornicroft, 2003).
Moreover, barriers to social inclusion, such as low income, unemployment and poor housing, should be
addressed (Morgan et al, 2007) and policy initiatives put in place to tackle prejudice and stigmatisation
(Secker, 2009).
Dorer et al (2009) found that the majority of mental health service users engaged in one or two of eight
identified community activities during a week. The most common activities were ‘use of local facilities’
and ‘contact with family and friends’ with far fewer respondents accessing arts, sporting, vocational or
faith activities, although faith activities were more fully inclusive than any other activity. This low level
of community involvement can be said to be both a cause and a consequence of mental ill health
(Sayce, 2001). The relationship is complex but indisputable. It explains, for instance, why women with
larger support networks have better mental health and overall quality of life than those with smaller
networks (Gielen et al, 2001).
Ultimately, we should remember that many mental health service users experience profound social
exclusion (Spandler, 2007) and may even be among the most excluded people in society (Huxley and
Thornicroft, 2003). In particular, people with schizophrenia who live alone are less likely to engage in
community activities than those who live with others (Harvey et al, 2006); while young people perceive
that they are subject to widespread stigmatisation (Jivanjee et al, 2008) and older people identify
problems in financing social participation and accessing safe transportation (Andonian and MacRae,
2011). Alarmingly, poor social integration confers an increased risk of suicide. Reduced social interaction
and low community involvement are both indicators of suicide risk, regardless of a person’s symptoms or
their employment status (Duberstein et al, 2004).
Occupational focus
In addition to having a political focus, there is a need for an occupational focus and ‘there is a strong
case for occupational therapists to take more of a lead with socially inclusive practice’ (Harrison and
Sellers, 2008, p216). Occupational therapy has a key role to play in connecting people with available
resources and developing healthy routines (Andonian and MacRae, 2011). In doing so, it can help people
to ‘reclaim lost dreams and lives’ (Gould et al, 2005, p467); social inclusion is not just a matter of
improved access, it is fundamentally about participation (NSIP, 2009).
Increasing participation in community activities challenges health workers to expand their knowledge of
local social networks (Granerud and Severinsson, 2007) and to capitalise on local initiatives such as
supported employment projects and working with voluntary organisations (Sayce and Measey, 1999).
It may involve setting up partnerships (Wildridge et al, 2004) and working across traditional boundaries
(NSIP, 2009); perhaps organising direct payments to allow service users to pay for services (Davidson
et al, 2001); or engaging with families and whole communities (Tew et al, 2012); as well as promoting
service user involvement in planning and researching mental health services (Tait and Lester, 2005;
Syrett, 2011).
There also remains a place for social inclusion programmes, like the one in a forensic service described
by Fitzgerald (2011). This involved graded community engagement using a range of activities coupled
with 1:1 goal-planning. It led to a significant improvement in occupational participation, as measured by
the Model of Human Occupation Screening Tool (Parkinson et al, 2006).
At an organisational level, it is imperative that people with mental health problems are actively involved
in setting policy agendas if social inclusion initiatives are to make a difference to people’s lives (NSIP,
2009). Meanwhile, when working with individuals, therapy workers need to demonstrate that they value
each person and to provide the right degree of encouragement (Cook and Chambers, 2009). Bates and
Seddon (2008) therefore recommend that any social inclusion plan starts with getting to know the
person and getting to know the community.
Sample activities
Introduction
This session can be used to provide an overview of all the other subjects discussed in the Recovery
through Activity programme. If some of the other topics haven’t been included in the programme then it
might be possible to incorporate some of the sample activities at this point, especially when thinking
about how an interest in a particular subject can lead to community involvement. This is also a good
point to remind the participants of the difference between an activity and an occupation (see ‘Promoting
the value of activity’ on page 13).

Neighbourhood satisfaction
This activity may work best if participants are given time to discuss their answers in pairs before
feeding back to the group.
Ask:
• What is the best thing about where you live? (your neighbourhood or your town) For example:
the facilities, such as shops, libraries, sports centres, schools
green spaces
safety and cleanliness
the people.
• If you ‘ruled the world’ (or at least the local council), what would you change to make your
neighbourhood a better place to live?
Neighbourliness
Ask:
• Have you ever been to a street party?
• Do you know your neighbours?
• Which facilities do you use most often in your neighbourhood?
• Who do you see on a local basis? For example, friends, family, neighbours, shopkeepers.
• Do you say ‘Hello’ to people you pass in the street?
• Would the world be a better place if we all walked short distances rather than driving?
• How can we support our neighbourhoods?
What are the opportunities and the challenges?
Community activities
This activity may work best if ideas are listed on a flipchart so that the participants can see all of them.
When do the following interests become community activities?
• Gardening, eg joining an allotment association, ‘guerrilla’ gardening.
• Musical activities, eg attending local concerts, joining a choir.
• Physical activities, eg joining a football team, going to a local fitness centre.
• Outdoor activities, eg joining a nature conservation group or a walking group.
• Faith activities, eg belonging to a faith group.
• Social activities, eg joining a civic society or a local history group.
Social inclusion (worksheet page 191)

Encourage the participants to explore what ‘social inclusion’ means.
Ask:
• Is social inclusion a feeling or something more practical?
• Is it possible (or desirable) to have 100 per cent social inclusion?
Venues (worksheet page 192) (Bates and Seddon, 2008)

This exercise requires analytical skills. Facilitators may need to support participants to recognise the
advantages and disadvantages of accessing different venues. For example:
• Advantages of red services: provides respite and security; enables access to specialist services;
allows cost-effective services that are free to individuals.
• Disadvantages of red services: distance from home; limited variety of activities; stigma; maintains
sick role.
• Advantages of amber services: nearer home; non-stigmatising environment; support from familiar
people; more opportunities.
• Disadvantages of amber services: requires organisation; limits activities to the interests of the
majority; maintains a degree of separation from the general public.
• Advantages of green services: retains lifelong roles; provides opportunities for new and lasting
friendships; increases personal responsibility and self-esteem; educates the community about
mental health issues.
• Disadvantages of green services: support may stand out; public may not understand needs; may be
challenging and increase sense of loneliness; may be expensive.
Opportunities (worksheet page 193)

Encourage discussion about local opportunities for social inclusion.
Ask:
• Do you know what the opportunities involve?
• Have you got any experience of doing any of the activities on the list?
• What other opportunities can you think of?
• Which opportunities are most important?
• Which opportunities have the biggest impact on how you feel?

• Find out about local community groups.
• Organise a talk from a civic society.
• Visit a community centre.
• Find out what’s on at the local library.
• Depending on the participants’ interests, visit a local allotment, a museum, or an art gallery.
• Go to a car-boot sale.
What does social inclusion mean to you?

✐
WORKSHEET
Tick each of the statements below either ‘Yes’ or ‘No’, according to what you think.
Yes No
1 A lack of stigma and prejudice
2 Being able to access local facilities
3 Being treated equally
4 Belonging to local groups
5 Feeling safe where I live
6 Having a close friend or partner
7 Having a large social network
8 Having a say in things
9 Having contact with family
10 Having enough money to visit places
11 Having lots of friends
12 Knowing my neighbours
13 Working in a team
Venues – advantages and disadvantages

✐
WORKSHEET
Bates and Seddon (2008) describe venues used by mental health services using a traffic light
system, to rate their potential for inclusive relationships:
Red = mental health services in mental health buildings
Amber = mental health services in local community settings
Green = individualised support alongside the general public.
Discuss and list the advantages and disadvantages of each setting.
Advantages Disadvantages
Red
Amber
Green
Opportunities to get involved

✐
WORKSHEET
First, tick the actions listed below that you have done.
Next, put a cross next to the actions listed below that you cannot imagine yourself ever doing.
Finally, discuss the reasons why you have done certain activities but would not consider doing
others. What might you do in future?
imagine doing
I have done
I cannot
Advertising something on Freecycle
Attending a community forum
Attending a local adult education class
Becoming a school governor
Befriending an older person
Belonging to a church or faith group
Commenting on planning proposals
Going on a march
Helping your neighbours
Holding a car-boot sale
Informing the council about local problems
Joining a book club
Joining a civic organisation (eg Round Table, Women’s Institute)
Joining a committee (eg for a local charity)
Joining a local campaign
Joining a service user group
Joining an environmental group
Joining Neighbourhood Watch
Saying ‘Hello’ to people you pass in the street
Taking things to be recycled
Using the local bus service
Voting in an election
Working in a charity shop or as a volunteer somewhere
Writing to your member of parliament (MP) or government representative
References
Andonian L & MacRae A (2011) ‘Well older adults within an urban context: strategies to create and maintain social
participation’, British Journal of Occupational Therapy, 74 (1), pp2–11.
Bates P (2010) Inclusion Web Resource Pack, National Development Team for Inclusion, Bath.
Bates P & Seddon J (2008) ‘Socially inclusive practice’, Stickley T & Basset T (eds), Learning about Mental Health Practice,
John Wiley & Sons, Chichester, pp253–69.
Bejerholm U & Eklund M (2004) ‘Time use and occupational performance among persons with schizophrenia’,
Occupational Therapy in Mental Health, 20 (1), pp27–47.
Black W & Living R (2004) ‘Volunteerism as an occupation and its relationship to health and wellbeing’, British Journal of
Boutillier CL & Croucher A (2010) ‘Social inclusion and mental health’, British Journal of Occupational Therapy,
73 (3), pp136–9.
Cook S & Chambers E (2009) ‘What helps and hinders people with psychotic conditions doing what they want in their daily
lives’, British Journal of Occupational Therapy, 72 (6), pp238–48.
Davidson L, Stayner DA, Nickou C, Styron TH, Rowe M & Chinman ML (2001) ‘“Simply to be let in”: inclusion as the
basis for recovery’, Psychiatric Rehabilitation Journal, 24 (4), pp375–88.
Davis M & Rinaldi M (2004) ‘Using an evidence-based approach to enable people with mental health problems to gain and
retain employment, education and voluntary work’, British Journal of Occupational Therapy, 67 (7), pp319–22.
Diamant E & Waterhouse A (2010) ‘Gardening and belonging: reflections on how social and therapeutic horticulture may
facilitate health, wellbeing and inclusion’, British Journal of Occupational Therapy, 73 (2), pp84–88.
Dorer G, Harries P & Marston L (2009) ‘Measuring social inclusion: a staff survey of mental health service users’
participation in community occupations’, British Journal of Occupational Therapy, 72 (12), pp520–30.
Duberstein PR, Conwell Y, Conner KR, Eberly S, Evinger JS & Caine ED (2004) ‘Poor social integration and suicide:
fact or artifact? A case-control study’, Psychological Medicine, 34 (7), pp1331–7.
Eklund M, Hansson L & Ahlqvist C (2004) ‘The importance of work as compared to other forms of daily occupations for
wellbeing and functioning among persons with long-term mental illness’, Community Mental Health Journal, 40 (5),
pp465–77.
Evans J & Repper J (2000) ‘Employment, social inclusion and mental health’, Journal of Psychiatric and Mental Health
Nursing, 7 (1), pp15–24.
Fieldhouse J (2003) ‘The impact of an allotment group on mental health clients’ health, wellbeing and social
networking’, British Journal of Occupational Therapy, 66 (7), pp286–96.
Fitzgerald M (2011) ‘An evaluation of the impact of a social inclusion programme on occupational functioning for forensic
service users’, British Journal of Occupational Therapy, 74 (10), pp465–72.
Gielen AC, McDonnell KA, Wu AW, O’Campo P & Faden R (2001) ‘Quality of life among women living with HIV:
the importance of violence, social support, and self care behaviors’, Social Science & Medicine, 52 (2), pp315–22.
Gould A, DeSouza S & Rebeiro-Gruhl KL (2005) ‘And then I lost that life: a shared narrative of four young men with
schizophrenia’, British Journal of Occupational Therapy, 68 (10), pp467–73.
Granerud A & Severinsson E (2006) ‘The struggle for social integration in the community: the experiences of people with
mental health problems’, Journal of Psychiatric and Mental Health Nursing, 13 (3), pp288–93.
Granerud A & Severinsson E (2007) ‘Knowledge about social networks and integration: a co-operative research
project’, Journal of Advanced Nursing, 58 (4), pp348–57.
Harrison D & Sellers A (2008) ‘Occupation for mental health and social inclusion’, British Journal of Occupational Therapy,
71 (5), pp216–9.
Harvey C, Fossey E, Jackson H & Shimitras L (2006) ‘Time use of people with schizophrenia living in North London:
predictors of participation in occupations and their implications for improving social inclusion’, Journal of Mental Health,
15 (1), pp43–55.
Heasman D & Atwal A (2004) ‘The Active Advice pilot project: leisure enhancement and social inclusion for people with
severe mental health problems’, British Journal of Occupational Therapy, 67 (11), pp511–4.
Huxley P & Thornicroft G (2003) ‘Social inclusion, social quality and mental illness’, British Journal of Psychiatry,
182 (4), pp289–90.
Jivanjee P, Kruzich J & Gordon LJ (2008) ‘Community integration of transition-age individuals: views of young with
mental health disorders’, Journal of Behavioral Health Services and Research, 35 (4), pp402–18.
Lindstedt H, Söderlund A, Stålenheim G & Sjödén P (2004) ‘Mentally disordered offenders’ abilities in occupational
performance and social participation’, Scandinavian Journal of Occupational Therapy, 11 (3), pp118–27.
McKay EA (2010) ‘“Rip that book up, I’ve changed”: unveiling the experiences of women living with and surviving enduring
mental illness’, British Journal of Occupational Therapy, 73 (3), pp96–105.
Morgan C, Burns T, Fitzpatrick R, Pinfold V & Priebe S (2007) ‘Social exclusion and mental health: conceptual and
methodological review’, British Journal of Psychiatry, 191 (12), pp477–83.
Mynard L, Howie L & Collister L (2009)‘Belonging to a community-based football team: an ethnographic study’,
National Social Inclusion Programme (NSIP) (2009) Vision and Progress: Social Inclusion and Mental Health,
NSIP, London.
Parkinson S, Forsyth K & Kielhofner G (2006) User’s Manual for the Model of Human Occupation Screening
Tool (MOHOST) (version 2.0), University of Illinois, Chicago, IL.
Ramon S, Griffiths CA, Nieminen I, Pedersen M & Dawson I (2011) ‘Towards social inclusion through lifelong learning
in mental health: analysis of change in the lives of the Emilia project service users’ International Journal of Social Psychiatry,
57 (3), pp211–23.
Sayce L (2001) ‘Social inclusion and mental health’, The Psychiatrist, 25 (4), pp121–3.
Sayce L & Measey L (1999); ‘Strategies to reduce social exclusion for people with mental health problems’, Psychiatric
Bulletin, 23, pp65–67.
Secker J (2009) ‘Mental health, social exclusion and social inclusion’, Mental Health Review Journal, 14 (4), pp4–11.
Spandler H (2007) ‘From social exclusion to inclusion? A critique of the inclusion imperative in mental health’, Medical
Sociology Online, 2 (2), pp3–16.
Strawbridge WR, Shema SJ, Cohen RD & Kaplan GA (2001) ‘Religious attendance increases survival by improving and
maintaining good health behaviors, mental health, and social relationships’, Annals of Behavioral Medicine, 23 (1), pp68–74.
Syrett M (2011) ‘Service user involvement in mental health research: a user’s perspective’, Advances in Psychiatric
Treatment, 17 (3), pp201–5.
Tait L & Lester H (2005) ‘Encouraging user involvement in mental health services’, Advances in Psychiatric Treatment,
11 (3), pp168–75.
Tew J, Ramon S, Slade M, Bird V, Melton J & Boutillier CL (2012) ‘Social factors and recovery from mental health
difficulties: a review of the evidence’, British Journal of Social Work, 42 (3), pp443–60.
Thomas Y, Gray M, McGinty S & Ebringer S (2011) ‘Homeless adults’ engagement in art: first steps towards identity,
recovery and social inclusion’, Australian Occupational Therapy Journal, 58 (6), pp429–36.
Townley G & Kloos B (2009) ‘Development of a measure of sense of community for individuals with serious mental illness
residing in community settings’, Journal of Community Psychology, 37 (3), pp362–80.
Townley G & Kloos B (2011) ‘Examining the psychological sense of community for individuals with serious mental illness
residing in supported housing environments’, Community Mental Health Journal, 47 (4), pp436–46.
Townsend E & Wilcock AA (2004) ‘Occupational justice and client-centred practice: a dialogue in progress’, Canadian
Ware NC, Hopper K, Tugenberg T, Dickey B & Fisher D (2007) ‘Connectedness and citizenship: redefining social
integration’, Psychiatric Services, 58 (4), pp469–74.
Whiteford GE & Pereira RB (2012) ‘Occupation, inclusion and participation’, Whiteford GE & Hocking C (eds), Occupational
Science: Society, Inclusion, Participation, Wiley-Blackwell, Oxford, pp187–208.
Wildridge V, Childs S, Cawthra L & Madge B (2004) ‘How to create successful partnerships: a review of the literature’,
Health Information & Libraries Journal, 21 (1), pp3–19.
Group profile
Group flyer
Activity checklist
Evaluation form for participants
Reflective log for facilitators
Participant outcomes
Appendix
Group profile
Occupational therapy interventions are provided on an individual basis as well as in groups.
Individuals may gain from group therapy when the following issues have been identified as
being beneficial: peer support and recognition, learning from others, social interaction, and
opportunities to take on roles (including helping others).
Group Recovery through Activity
Aims To investigate a range of lifestyle choices (including leisure and social choices, self-care and
spiritual activities, domestic and vocational activities) that enhance health and wellbeing.
To examine the impact of changing lifestyles on roles and routines.
To support experience of a range of activities that increase opportunities for social inclusion.
Interventions are designed to support three levels of change: exploration, competence and
achievement.
Occupational therapy focuses on three domains: self-care, productivity and leisure.
There are four areas of challenge to occupational participation: volition, habituation,

performance and environment.
Level of intervention Competence
Domain Self-care, productivity and leisure
Challenges to be addressed
• Volition Motivation to change
• Habituation Changes to habits and routines
• Performance Effect of changes on health
• Environment Practical support for making changes
Target group
Individuals who are interested in practising healthy lifestyles but may have:
• poor confidence in their ability to make changes
• difficulties making changes due to ingrained habits or multiple role demands
• restricted experience of a range of occupational roles
• limited knowledge about the impact of occupation on health and wellbeing
• reduced social support for making changes.
Assessment
A combination of the following assessments may be used as baseline assessment measures:
• Activity Checklist
• Occupational Self Assessment (OSA)
• The Inclusion Web
• Role Checklist
• Occupational Questionnaire
Possible goals for participants

• To reflect on current lifestyle choices.
• To practise a range of pursuits for a more balanced lifestyle.
• To plan how to introduce lifestyle changes with minimum disruption.
• To develop strategies and supports for sustaining change.
Groups may be ‘open’, (ie different participants may attend each session) or ‘closed’
(ie participants commit to attending a series of sessions).
Attendance may operate on a drop-in basis where participants are free to come and go as
they please or participants may be encouraged to stay for the full session.
Referral may be informal (including self-referrals by service users and recommendations by

the multidisciplinary team) or formal (referrals which require screening by occupational
therapists).
Appendix
Procedure
Duration To be arranged according to the setting
Location Group room + a range of community environments
Facilitators 2, including 1 occupational therapist
Maximum number 8
Group format Closed or open according to the setting
Attendance Participants will be encouraged to stay for the full session
Referral Formal or informal according to the setting
Structure
A variety of topics will be explored according to the needs of the group and may include the following.
• leisure activities • self-care activities
• creative activities • domestic activities
• technological activities • caring activities
• physical activities • vocational activities
• outdoor activities • social activities
• faith activities • community activities
The value of each topic will be explored in a discussion-based group.
Practical activities (taster sessions) will be used to complement the discussion and give participants the
opportunity to experience a range of activities.
The named occupational therapist will meet with each participant to review the content of the session,
reflect on the participant’s experience, establish goals and provide individual coaching.
Sample programme
Week
1 leisure option
2 choice of options
3 1:1
4 choice of options
5 taster session building on weeks 2 and 4
6 1:1
7 choice of options
8 choice of options
9 1:1
10 choice of options
11 taster session building on weeks 7, 8 and 10
12 1:1
Plus three further 1:1s around weeks 16, 20 and 24
Choices to include:
A At least one session from social, creative, technological and physical options (leisure options)
B At least one session from physical, outdoor, faith and self-care options (self-care/restorative
options)
C At least one session from domestic, caring, vocational and community options (productivity options)
Note: if the physical option is the only session chosen from group A, there should be at least one
choice from the remaining options in group B. Similarly, if the physical option is the only session
chosen from group B, there should be at least one choice from the remaining options in group A.
Appendix
Evaluation
In addition to baseline measures being repeated to measure outcomes, the following assessments may
be used to evaluate the needs and progress of individuals.
• Volitional Questionnaire (VQ)

• Assessment of Communication and Interaction Skills (ACIS)
• Assessment of Motor and Process Skills (AMPS)
• Worker Role Interview (WRI)
• Work Environment Impact Scale (WEIS).
(Source: Forsyth K, 2006, Group Protocols, Edinburgh, UK Centre for Outcomes Research and Education (UKCORE).)
Group flyer
RECOVERY THROUGH ACTIVITY

- a programme to
explore the value of
activity for wellbeing
The programme will explore a range of the
following topics, according to your needs
• leisure activities • self-care activities

• creative activities • domestic activities
• technological activities • caring activities
• physical activities • vocational activities
• outdoor activities • social activities
• faith activities • community activities
Activity has the power to change our lives
Take time to remember the importance of activity in

your life
For more information please contact:
…………………………………………………………
Appendix
Name ……………………………… ID No.: ……………….. Date of birth: ___/___/___
Occupational therapist………………… Signed…………………..…… Date ___/___/___
ACTIVITY CHECKLIST
Tick the activities below if you have spent time on them in the PAST, spend time on them
NOW, or would like to spend more time on them in the FUTURE.
Past Now Future Comments

Collecting
Listening to music
Home-based
Playing cards
Puzzles/crosswords
Reading – books/newspapers/magazines
Browsing the web
Watching television/DVDs
Writing letters/emails/texts
Other:
Board games/table games
Bowling/darts/pool/snooker
Social
Eating out
Going out to bars/clubs/pubs/bingo
Seeing friends and family
Other:
Art – painting/drawing/colouring/collage
Cooking – baking/cake-icing/sugarcraft
Craft – jewellery-making/mosaics/glass-painting
Creative writing – poems/calligraphy
Creative
Drama – play-reading/poetry-reading
Flowercraft – arranging/drying/pressing
Papercraft – card-making/printing/decoupage
Sewing/knitting/needlework
Music – singing/playing an instrument
Woodwork/metalwork/construction
Other:
Desk-top publishing
Technological
Digital photography/animation
Emailing
Keeping a blog
Social networking – online discussion
Video-gaming
Word-processing
Other:
Athletics – track/field
Bowls – boules
Cycling – stunt bikes/scrambling
Dancing – ballet/ballroom/disco/Latin/tap
Golf/cricket
Jogging – long-distance running
Physical
Keep fit – aerobics/gymnastics/zumba

Martial arts –boxing
Racquet sports – tennis/squash/badminton
Skateboarding/parcours
Team sports – football/volleyball/rugby/netball
Swimming/kayaking/water-skiing
Weights – gym
Winter sports – skiing/skating/ice hockey
Other:
Past Now Future Comments

Allotments/gardening
Camping
Climbing/potholing
Outdoor
Conservation work/farming
Fishing
Visiting the countryside/beach
Horse-riding
Nature-watching – birds/wildlife
Walking/hiking/rambling
Other:
Belonging to a faith community
Going to places of worship
Prayer/meditation
Faith
Reading/studying religious texts

Rituals/pilgrimage
Sacred songs/chanting
Other:
Clothes/fashion
Diet/nutrition
Self-care
Hair care/nail care/skin care

Self-help
Rest/relaxation
Yoga/t’ai chi
Other:
Car maintenance
Cleaning/washing/ironing
Domestic
Cooking
DIY/decorating/restoration/mending
Gardening – indoor plants
Shopping
Other:
Looking after – babies
– children
– family members
Caring
– friends
– neighbours
– older people
– pets
Charity work/fundraising
Other:
Study – distance learning
– short courses
Vocational
– talks/lectures
– university/college
Volunteering
Work – part-time
– full-time
Other:
Art galleries/museums
Belonging to an interest group
Campaigning - political/social activism
Community
Car boot sales/jumble sales

Concerts/theatre
Day trips/travelling
Driving/motorbiking
Going to the park
Spectating (watching sports)
Other:
Appendix
Evaluation form for participants

Name: ………………………………………………….
Recovery through Activity date: ___ / ___ / ___
Session topic: ………………………………………...
Name of service: ……………………………………...
Strongly disagree
Strongly agree
Disagree
Agree
The topic was interesting
The topic helped me reflect on the importance of lifestyle choices
The session was structured well
There was enough time for discussion
The session was the right length
I plan to make changes to my lifestyle
I would like help to make changes to my lifestyle
The part of the session that I found most valuable was:
Reflective log for facilitators

Session topic: ………………………….. Date: ___ / ___ / ___
Name of service: ………………………………………………………..
Number of participants: …………………………………………………
List the sample activities that you used for the main session:
What changes, if any, did you make to how the activities are described in the handbook?
What went well?
What would you change in future?
Attach any references for extra resources plus instructions for any adapted/new activities
Appendix
Did you organise a follow-up session? Yes No
If yes, describe the content of the follow-up session:
What went well?
What would you change in future?
Participant outcomes
Participant’s initials: __ __ __
Start date of programme: __ / __ / __ End date: __ / __ / __
Name of service: …………………………………………………
For each participant, record answers to the following questions.
1 Which sessions did the participant attend?
Main session Follow-up session

List session topics below Yes No Yes No
2 Did the participant engage in 1:1 sessions?

Yes No
If yes, list the dates below:
Appendix
3 List any goals that were set with the participant and indicate whether these goals were met.
Partially met
Exceeded
Not met
Met
List session topics below List goal(s) for each topic

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Recovery Through Activity Cover:Layout 1 7/17/14 11:44 PM Page 1

tivity RECOVERY through activity RECOVERY

First published 2014 by Speechmark Publishing Ltd.

Published 2017 by Routledge

Copyright © Sue Parkinson 2014

British Library Cataloguing in Publication Data

ISBN 9781909301207 (pbk)

Recovery through Activity

Dr Mary Morley Mary Birken

Recovery through Activity

Recovery through Activity

Introducing Recovery through Activity

Applying the Model of Human Occupation

Promoting the value of activity

Delivering a Recovery through Activity group programme

Providing one-to-one assessment and treatment-planning

Recovery through Activity

Recovery through Activity – purpose and content

Introducing Recovery through Activity

This handbook includes:

• a question-and-answer section for facilitators of a Recovery through Activity group programme

suggestions for formal assessments

informal assessment questions to help examine the needs of individual participants

guidelines for setting measurable goals with individual participants

Recovery through Activity

Each section includes:

• key messages to share with participants

Introducing Recovery through Activity

Recovery through Activity

Applying the Model of

Figure 1 The Model of Human Occupation (Source: Parkinson et al, 2006)

• Individual characteristics comprise volition, habituation and performance capacity.

Recovery through Activity

Habituation – the process of acquiring and repeating recurring patterns of occupational

Performance capacity – the complex interaction of musculoskeletal, neurological, perceptual

Applying the Model of Human Occupation

• Occupational competence is the degree to which we sustain a pattern of occupational

MOHO and Recovery through Activity

Recovery through Activity

Differentiating between the Recovery through Activity group programme and

Characteristic Group programme 1:1 work

Using key strategies: structuring identifying

Promoting the value

• Occupation is a broader and more individualised concept. By engaging in a cluster of related

Recovery through Activity

Activity and mental health

Promoting the value of activity

Activity and the occupational therapy process

magnificent hypothes[i]s … That man, through the use of his hands as

Recovery through Activity

The value of activity – key messages

• Wellbeing comes from having a balance in three types of activity:

Promoting the value of activity

Recovery through Activity

Royeen CB (2002) ‘Occupation reconsidered’, Occupational Therapy International, 9 (2), pp111–20.

Delivering the Recovery through

How often should the sessions be held?

Should group membership be closed or open?

Who should attend?

How many people should attend?

Recovery through Activity

Should all the session topics be included in a single programme?

Can activities from different topics be merged together?