672274

research-article2016
CRE0010.1177/0269215516672274Clinical RehabilitationLee et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

Purposefulness as a critical factor 2017, Vol. 31(8) 1005­–1018

© The Author(s) 2016
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DOI: 10.1177/0269215516672274
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Joshua Y Lee1, Emily A Ready1, Eric N Davis1

and Philip C Doyle1,2

Abstract
Guided by theoretical frameworks of health and illness such as the International Classification of
Functioning, Disability, and Health (ICF), we seek to describe the importance of purposefulness in the
context of rehabilitation. We argue that ascribing meaning to life events, particularly changes in health, and
acting in a manner that is driven by purpose is a universal characteristic of human beings. The ability to
contextualize purposefulness within the broader biopsychosocial model of illness may provide a greater
understanding of the relationship of purpose in the process of rehabilitation.
We support the notion that purposefulness is an ever-present component throughout our lives and
it exists as a convergence of personal factors, past experiences, and our personal narrative. Having a
sense of purposefulness and being able to understand the meaning of different aspects of our lives is what
allows us to find purpose while experiencing a health condition. More importantly, and in the context
of rehabilitation efforts, we believe that if purposefulness can be identified or collectively defined by the
individual, then rehabilitation outcomes may be enhanced.
In a variety of contexts ranging from disease, aging, severe trauma, and even war, purposefulness and
its component elements consistently distinguish themselves as being essential for regaining a sense of
direction and facilitating one’s response to any health condition.

Keywords
Rehabilitation, disability, purpose, personal factors, biopsychosocial model

Received: 30 August 2015; accepted: 19 January 2015

“For the meaning of life differs from man to
man, from day to day and from hour to hour.
What matters therefore, is not the meaning of life
in general but rather the specific meaning of a
person’s life at a given moment.”
-Viktor Frankl
health status. However, just as in the regular psy-
chological transitions in life, Blair1 has suggested
that health changes impose transitions that can
1Rehabilitation
Sciences, University of Western Ontario,
London, Ontario, Canada
2Department of Otolaryngology, Head and Neck Surgery,

Introduction Western University, London, Ontario, Canada

Corresponding author:
Changes in life secondary to illness will have a Philip C Doyle, Rehabilitation Sciences, University of Western
profound, and in many instances, a lifelong impact Ontario, London, Ontario, Canada.
on individuals who experience reductions in their Email: pdoyle@uwo.ca
1006 Clinical Rehabilitation 31(8)
threaten our self-concept and self-esteem by dis-
rupting perceived roles and valued aspects of our
lives. She states, that a change in health “… is
inherently linked with self-esteem and a reap-
praisal of who, what and how the individual is
going to be in the changed situation,” (p.232),1
suggesting that illness poses a threat to sustaining
one’s identity and purpose. Thus, it is incumbent
that rehabilitation efforts actively consider the
unique factors of each individual as their starting
point, rather than simply following externally con-
ceived and standardized treatment protocols.
Similarly, theoretical frameworks pertaining to ill-
ness and/or disability should be built upon some-
thing that is both universal to humankind and
rooted in personal experience.2–5 We argue that
ascribing meaning to different things and acting in
a manner that is driven by purpose is universal. It
has been said that purposefulness is the root of both
vice and virtue; the perceived nature of our purpose
can lead us to choose either beneficent or destruc-
tive behaviours.6
Underlying the premise of the current paper, we
consider all humans as beings of purpose rather
than beings of mere existence. In rehabilitation, the
goal is to help people overcome threats to mean-
ingful activity and participation when something
interferes with ordinary functioning and the
engagement in purposeful activities.7 In particular,
rehabilitation efforts that facilitate and/or incorpo-
rate one’s sense of purpose or foster engagement in
purposeful activities is essential.7 The ability for
clinicians to actively and collaboratively work with
the person to redefine individual purposefulness
despite illness or disability is seen to be an essen-
tial component of rehabilitation endeavours. From
this central concept it may be possible to develop a
framework of understanding that describes the
more “intangible” aspects of human nature. The
ability to contextualize purposefulness within
the broader construct of what has been termed the
biopsychosocial model of illness may provide a
greater understanding of the relationship of pur-
pose in the process of rehabilitation.
The fundamental premise underlying the trea-
tise to follow is based on our view that purpose and
meaning are intrinsically linked and that both have
the potential to influence rehabilitation outcomes.
The goal of the present paper is to explore personal
factors through the critical lens that we are calling
purposefulness. We support the notion that having a
sense of purposefulness and being able to attribute
meaning to different aspects of our lives is what
allows us to create and find purpose while experi-
encing a health condition. More importantly, and in
the context of rehabilitation efforts, we believe that
if purposefulness can be identified or collectively
defined by the individual, then rehabilitation out-
comes may be enhanced. In addition, these out-
comes may even be contextualized via the driving
factor of optimism – a crucial element for purpose-
ful engagement in rehabilitation8 and resilience/
adaptability in adverse situations.9 We argue that
purposefulness, which subsumes optimism and
resilience, lies at the very core of our being; to over-
look its value in the presence of illness in general,
and most notably during recovery and rehabilita-
tion, will result in care that is narrow and incom-
plete. We offer a rationale for the belief that
purposefulness is a critical component in recovery
and rehabilitation. In doing so, we initially outline
how the transition from health to illness may be
viewed. However, we also seek to foster an
expanded view of how understanding one’s purpose
can be enhanced through appreciation of experience
and narrative and is advanced within the context of
the biopsychosocial model of illness.
The transition from health to
illness
The conceptual boundary between “health” and
“illness” is not easily partitioned into distinct enti-
ties; rather, it exists through an intricate relation-
ship between the two. Similarly, this transition
does not emerge as a simple linear progression or
continuum. Historically, the field of medicine has
often struggled with this relationship and the tran-
sitional properties that may define it. In many
instances the practice of medicine has been guided
by the inherent need to document both the charac-
teristics of normal health and functioning, as well
as that pertaining to the biological abnormalities
that develop as a consequence of illness. As a
result, challenges in more fully understanding ill-
ness and its impact have frequently emerged in the
Lee et al. 1007
breach formed between the patient-oriented and
disease-oriented perspectives in how one identifies
a change in health status.10 This observation is also
directly related to commensurate changes of how
the health care provider may consider and weigh a
client’s input and perceptions specific to a change
in health.
The documentation and treatment of disease has
historically and overwhelmingly been guided by
the consideration of objective evidence. Because
subjective information is not easily quantified it is
difficult to contextualize and interpret, it may con-
sequently add confounds and burden to the process
of assessment and treatment. As stated by Eric
Cassell11 (p. 20), technological medical advances
provide an increasing opportunity for “…banishing
the uncertainties of subjectivism” in the process of
providing medical care. However, another aspect of
subjectivism also may be equally disregarded. That
is, the failure by health care providers to identify,
accept, and possibly exploit the potential influence
of subjective factors and states relative to one’s
recovery and rehabilitation may restrict rather than
optimize outcomes. We believe that the integration
of purpose into rehabilitation is essential.
To not consider both objective (biological) and
subjective (psychological and social) indices in an
integrated, dynamic manner will almost certainly
limit the quality and completeness of care provided.
Despite this limitation in the conduct of many
aspects of medical and rehabilitation care, it is
equally clear certain specialties within medicine
have had longstanding interests that are obliged to
actively consider personal history, family and life
experience, as well as many other attributes that
may underlie a shift away from normal health.11,12
This valuation of a person’s life experience and
associated expectation as co-existing factors of
importance have also been acknowledge by those
from other disciplines such as sociology.13,14
Accordingly, and as a direct result of the limits of
solely viewing illness as a biological entity, alterna-
tive approaches to medicine to consider the behav-
ioural components of an illness have been suggested.
Efforts of this type were borne form the desire to
enhance care pursued as doing so permitted recog-
nition of the person experiencing illness.12 The
limitations of separating individual history from a
response to illness and, hence, the professional
abyss and hierarchy that is potentially created has
been eloquently described by Kleinman.12 The out-
come of this separation has a direct impact on the
person who is ill. Consequently, we believe that
personal factors may be of significant importance to
the process of navigating an illness and optimizing
one’s rehabilitation and return to functioning in as
full and complete manner as possible.
Most central to the aforementioned concerns are
the pioneering works of psychiatrist George
Engel,15 who provided the first conceptual sugges-
tion that consideration of multiple areas was
required to more completely identify a health con-
dition. Engel’s work was based on the underlying
philosophical premise that to not address the larger
impact of a health change on the person was insuf-
ficient to meet their care needs. The insufficiency
noted by Engel led to a new conceptualization of
medicine termed the “biopsychosocial” model. The
biopsychosocial model emphasizes the interaction
of multiple factors that coexist with a health condi-
tion; this should help in understanding the impact
of ill health upon the person. The intervening con-
ceptual zone between health and the experience of
illness and its associated disability, whether acute
or chronic, encompasses the individual’s specific
“response” to their situation. This individual
response is almost certainly influenced by the per-
son’s past experience. Intrinsic personal factors
will determine the meaning they attribute to previ-
ous experience and generate the meaning that is
attached to their current situation. Other important
contextual factors that centre on meaning include
personal roles, responsibilities, aspirations, and
expectations.4,16
The biopsychosocial model of
illness and the consideration of
personal factors
In an editorial written in Psychological Medicine
nearly 30 years ago, David Mechanic explicitly
stated that “Cultural definitions, social development,
and personal needs…”17 (p. 1) serve as critical fac-
tors in how individuals attribute meaning to illness.
1008 Clinical Rehabilitation 31(8)
The American Psychological Association suggested
that a variety of personal characteristics direct many
of the challenges we face. In the context of health
challenges, and more specifically on how we func-
tion when disabled or facing catastrophic outcomes
because of illness or disease, a crisis is contextual-
ized as an event that challenges the person’s health
and well-being and ultimately, one’s quality of life.
Personal factors that are of importance relative
to health are also encompassed in the International
Classification of Functioning, Disability and
Health.5 Personal factors are explicitly defined by
the WHO ICF as:
“…the particular background of an individual’s life
and living, and comprises features of the individual
that are not part of a health condition. These factors
include gender, age, race, other conditions, fitness,
lifestyle, habits, upbringing, coping styles, social
background, education, profession, past and current
experiences, overall behaviour pattern and character
style, individual psychological assets and other
characteristics, all or any of which may play a role in
disability at any level.” (p.17).5
Previous efforts to define personal factors have
been insightful and we argue that they converge
upon a central theme. However, as an essential
component we propose purposefulness as a com-
mon foundation for the myriad of potentially divi-
sive characteristics within the classification of
personal factors.
Grotkamp and colleagues18 recently sought to
comprehensively address personal factors within
the ICF and discussed how people view their func-
tioning which they termed “satisfaction with life”.
Thus, Grotkamp et al. attempted to investigate sev-
eral overlapping conceptual themes (e.g., personal
feelings, view of own achievements, judgement
and evaluation of self). They draw specific atten-
tion to the fact that personal factors are character-
ized by an “inherent self-assessment”18 (p. 18) and
an intrinsic perception of one’s self. Huber et al.4
have also acknowledged that the ICF overlooks an
individual’s perception of their own health condi-
tion. Further, Huber et al.4 suggest that a disregard
for the subjective experience of the individual con-
flicts with the biopsychosocial framework15 upon
which the WHO ICF was built. They argue that
personal perception must be incorporated into any
attempt to define more fully a person’s health-
related state and its resultant influence on per-
ceived quality of life. Collectively, both papers
illustrate that current descriptions of health status
are incomplete.
The core of any proper and complete model of
illness, such as the biopsychosocial framework,
must include the construct of quality of life, which
by the WHO’s own definition includes (p. 1):
“An individual’s perception [italics added by authors]
of their position in life in the context of the culture
and value systems in which they live and in relation
to their goals, expectations, standards and concerns.
It is a broad ranging concept affected in a complex
way by the person’s physical health, psychological
state, level of independence, social relationships,
personal beliefs and their relationship to salient
features of their environment.”19
Operationally defining the array of personal fac-
tors that influence the individual’s journey through a
health condition is replete with challenges. We
believe that failing to do so increases the risk that
rehabilitation efforts may be without direction or
effect because the unique needs of each individual
may be overlooked. It is both reasonable and essen-
tial that the meaning people place on their health
condition and the potential restrictions they face
must be considered in the context of rehabilitation.
Both Huber et al.4 and Grotkamp et al.18 have
identified critical dimensions of subjectivity and
perception as they relate to health. In fact, Huber
et al.4 explicitly note that a person’s aspiration to,
or acquisition of, a goal-directed behaviour, regard-
less of how simple or elaborate, is made more
meaningful when it is contextualized to one’s spe-
cific aspirations. This is not meant to suggest that
all goals will be achieved either in whole or part,
but it does consider the “aspirations” of those who
experience a health condition (p. 7).4
Factors that arise within the person are essential
considerations because their perceptions may differ
considerably from that of health care providers.20
Central to these dimensions, it is our belief that pur-
posefulness is a core element of the self and, thus,
Lee et al. 1009
cannot be separated from its larger role in how indi-
viduals respond to health challenges. The ICF’s
acknowledgement that personal factors “may play a
role in disability at any level” and that “their assess-
ment is left to the user, if needed”5 (p. 19) is grossly
understating the role they may have on functioning
and, to a greater extent, what it means to be human.
Consequently, the importance of purposefulness
would appear to emerge as a critical dimension of
functioning and the subsequent response to illness.
The influence of life experiences
Past experience guides our interpretation of each
life event. Arthur Kleinman has suggested that life
experience forms the illness narrative (i.e., one’s
personal story that contextualizes a health condi-
tion).12 Kleinman12 states that our apparently
“seamless” lives are a direct outgrowth of “…the
interconnectedness between affect, cognition, and
local social system…” (p. 39), and these factors
provide additional structure for the generation of
meaning in the context of a health condition. In
such instances, one’s response to a health challenge
is likely to be influenced by prior events in that
individual’s life. The product of this interconnect-
edness is, however, more than the sum of its parts;
the health condition itself may in fact create oppor-
tunities for the emergence of considerable and per-
haps previously unrecognized personal strengths.
Illness may be seen to disrupt the “flow of experi-
ence” (p. 146).21 In fact, Kleinman12 suggests that
illness itself provides a context from which its con-
sequentially derived meaning is “inescapable” – it
is “…an occasion for growth, a point of departure
for something deeper and finer…” (p. 144).
In the present context, life experiences, roles,
and expectations, may be of particular importance
when a health condition emerges.21 How any given
individual confronts and responds to such health
challenges may be directly influenced by personal
traits that have developed over time. While factors
such as gender, age, ethnic or cultural background,
and many others may be easily discerned, at least
from the standpoint of assessing demographics,
intrinsic personal factors are not easily defined.
Clinical literature suggests there is a clear link
between an individual’s psychological status and
their compliance with treatment.22–25 However, in
the situation of a health condition, optimized out-
comes may be facilitated by personal temperament
and desire, in addition to one’s capacity to find
meaning and purposefulness in the context of their
illness.
Narrative approaches, which incorporate per-
sonal stories of illness, reveal considerable depth of
how illness (i.e., a health condition) is inter-
preted.12,26,27 It has been suggested that interpreta-
tion of this type, that is, the contextualization of a
health condition, is comprehensively borne of life
experience. We believe that experience and purpose-
fulness may drive the response to a positive change
in health. As stated by Arthur Frank in his book The
Wounded Storyteller, “stories have to repair the
damage that illness has done to the ill person’s sense
of where she is in life, and where she may be going”
(p. 53).28 In that sense, the purpose for seeking the
new or continuing destination of one’s life in the
context of a health condition becomes a paramount
personal factor that cannot be overlooked, no matter
how difficult it is to define. Consequently, we
believe that purposefulness forms a primary attrib-
ute of many illness narratives.2,12,13,28,29
As suggested by Cassell,30 a health condition
poses a “threat of disintegration” to both the body
and mind; hence, recovery, adaptation, or rehabili-
tation must be found in the ability to “overcome”
such challenges. But of equal importance in a per-
son’s attempt to overcome challenges is the oppor-
tunity for direct patient input and informed
decision-making.20 The importance of purposeful-
ness in the context of changes in one’s health may
then be viewed as a primary contributor to a health
outcome. Thus, in the sections to follow we outline
the complexity of purposefulness as being central
and universal for all individuals.
The universality of purpose
Previous efforts to organize personal factors in the
ICF have yielded thought-provoking and creative
solutions. Ueda and Okawa31 suggested combining
the objective measures of the ICF with the element
of subjective experience. Recognizing that an
1010 Clinical Rehabilitation 31(8)
accurate definition of a health condition requires
both objective and subjective components, it was
suggested that each aspect of the ICF be paired
with a measure of personal satisfaction. In addi-
tion, measures of relationships, group dynamics,
and meaning of life were included to better define
the individual’s subjective experience.31 This was
an important contribution to the ICF as it provided
personal factors with a crucial starting point for
classifying less tangible aspects of health. Over the
years, ICF personal factors have taken on different
forms either in keeping with the flexibility of a
conceptual framework4, or by introducing a struc-
tured classification scheme.18 Despite these differ-
ent approaches, each has emerged from the
foundational concept of what is deemed “universal
to humankind”.
In 1989, a seminal paper by Irving Zola32 intro-
duced the concept of “universality” into rehabilita-
tion literature. Zola expounded the idea that a
health condition exists on a continuum that is sub-
ject to change. At any given moment, an individual
may be placed at any point on the continuum
between able or disabled in a mental, physical, or
social context. Furthermore, if society operated
under this important assumption, then the concept
of “accessibility for the disabled” would simply be
seen as universal accessibility and not as a separate
issue.32
For the first time, disability rights were por-
trayed as simply an extension of basic human rights
that could accommodate for something that we all
must face, either directly or indirectly. This essen-
tial concept became an integral part of the ICF in
its current form. It is also worth noting that one of
the essential principles put forth by Zola,32 and
refined by Ueda and Okawa31 was the idea that
none of the health conditions are inherently “good”
or “bad”. That is, the supposed “goodness”, or
favourability from a physical and social function-
ing standpoint, of any health state depends entirely
upon the subjective experiences of the individual
that is currently in that state.31,32 In this regard, the
consequences of illness or subsequent disability
may create opportunities that are not viewed as
limitations by the individual and potentially that of
others. In keeping with the spirit of universality,
many of the same concepts that we have identified
as purposefulness, are both common and funda-
mental to a person’s subjective experience.
Formation of a purposeful identity is an insepara-
ble part of guiding our transitions within an ever-
changing health condition.
Purposefulness and the
formation of self and
circumstance
As we learn who we are, we also yearn for an under-
standing of why we are. Purpose cannot be imposed
but rather, it is inherently discovered as our life
experiences coalesce. Therefore, the goal of reha-
bilitation must be to aid in its rediscovery. Survival
and purpose are two sides of the same coin and
Abraham Maslow was keenly aware of this princi-
ple as outlined in his well-known “hierarchy of
needs”.33 At the very foundation of the hierarchy
lay the physical and psychological requirements
needed to sustain biological functioning, safety and
stability. Although these requirements are identified
as fundamental to all humans, it is crucial to note
that the hierarchy does not end here. Once these
needs have been met and sustained, they become
forgotten as people are drawn towards the “higher
ideals” of love, esteem, and eventually, the realiza-
tion of one’s true potential, or self-actualization.
According to Maslow, to self-actualize is to find
meaning, to seek beauty, to gain knowledge, and to
be fulfilled. These abstract ideals can mean differ-
ent things to different people, but the longing to
reach such ideals is the basis of purposefulness and
the source of our “quiet desperation”.3
The presence of purposefulness, even from
youth, lends credence to the theories of Viktor
Frankl, the founder of a meaning-centered therapy
known as Logotherapy. Frankl states that humans
are inherently responsible creatures that are drawn
towards purposeful, rather than anarchic, behav-
iour.34 In addition, this purposeful behaviour
endeavours to go beyond oneself to form a com-
mitment to others in an effort to achieve self-
transcendence.35 To that effect, recognizing others
is closely tied to the recognition of oneself, or self-
actualization.36 As we continue to interact with our
Lee et al. 1011
surroundings, we are led down a path of self-
development that satisfies two essential require-
ments for growth: 1) we see ourselves as individu-
als compared to others, and 2) we come to recognize
our own uniqueness within a community. Yet at the
same time, we develop a sense of belonging, which
extends to caring for others in the community.37
How we choose to operate within these relational
settings dictates understanding of one’s self in the
greater social context. It has been widely agreed
that self-actualization reaches its peak with self-
transcendence, or the ability to view the world
beyond the boundaries of the self and others.38
As part of our development we adopt different
styles of identity formation that include actively
seeking input and information from multiple
sources, or restricting input to more immediate and
familial surroundings, or avoiding potentially criti-
cal input and relying on immediate consequences.39
Regardless of the style of identity development,
each one depends on an interaction with one’s social
environment. As development progresses we are
constantly negotiating our own social contexts and
responding to positive and negative reactions or
consequences.40 Yet even during the late childhood
and early adolescent stages of identity development,
a need for purposefulness is clearly identified.
Although identity formation takes place during
infancy and early childhood, many clear examples
stem from later childhood and adolescence. During
adolescence, purposefulness increasingly directs
behaviour and is considered a developmental asset
in establishing identity. When adolescents demon-
strate a commitment to purposeful actions, it results
in an increase in their positive well-being along
with hope and happiness.41 In practical terms, peo-
ple whose identities are based more on critical self-
reflection, openness, and empathy tend to move
towards self-transcendence, and, consequently,
they experience a greater sense of meaning and
subjective happiness. This trend, however, is not as
evident in those who tend towards more rigid or
avoidant behaviours.38 Finding this deeper mean-
ing is a crucial requirement for progressing reha-
bilitation; both as an individual experiencing a
fluctuating health condition42 or as a member of a
multidisciplinary health care team.43 Based on
these recent studies, becoming attuned to these
self-transcendent aspects in oneself and others is
positively associated with successful subjective
outcomes in rehabilitation.
In a study that explored the regrets of the typical
American, a nationally representative sample dem-
onstrated that the most common regrets were inac-
tion regrets related to love and family.44 In an
affluent society that places such an importance on
material success, purposeful behaviours such as
connectedness and responsibility still emerge as
central themes. It is also important to note that the
formation of identity and perceived purposefulness
are not restricted to a particular corridor of time.
The process of developing an increasing sense of
purpose continues beyond adolescence and well
into adulthood where identity and purposefulness
continue to mature symbiotically. For example, a
longitudinal study of adults at ages 27 and 36
revealed that identity continues to develop, particu-
larly in areas relating to involvement with others.45
In five major domains of identity (including life-
style, beliefs, career, relationships, and political
ideology), it was noted that maturation for both
men and women was enhanced in the more com-
mitment-focused areas of life such as one’s beliefs,
career and relationships.45 It can be argued that
these represent the more outwardly directed aspects
of the self, that is, an increasing devotion to greater
causes and other people.
Studies with the elderly also suggest that pur-
poseful living is also an active and conscientious
effort. Not all elderly people age successfully from
the standpoint of purposefulness in their lives, and
some are affected by many different physical and
psychological challenges. Those who are successful
indicate higher levels of personal meaning and pur-
pose in their lives. Additionally, those who derive
their meaning from sources beyond themselves
express an even deeper sense of meaning46 which
may then direct purposefulness as an inherent per-
sonal factor. As a result of this relationship, a loss of
purposefulness may be a cause of increasing depres-
sion and dependence seen in many people after
retirement. We believe that this relationship may be
mimicked during rehabilitation among people who
experience a threat to purposefulness – whether
1012 Clinical Rehabilitation 31(8)
psychologically, socially, or physically – where a
decreased sense of purpose may hinder optimal pro-
gression through rehabilitation programs.
Purpose vs. personality
Outside of the various personal factors that com-
bine to form a unique personality, purposefulness
may provide “directionality” for these characteris-
tics. Although certain characteristics may be
thought of as “purposeful”, purpose itself extends
further than personality; purpose is closely linked
to self-transcendence. Thus, purposefulness forms
momentum towards something that is inherently
greater than the individual alone, and so is not lim-
ited by any perceived deficiencies of individual
functioning.
Purposefulness is a product of the will – the will
to take one’s place in a far greater narrative.
Therefore, to address purposefulness is to address
the individual as a whole as it acknowledges both
their capacity to choose, and the recognition of
their own perceptions.47 We do not simply pass
through life, as was elegantly stated in a study by
Ittyerah and Kumar,48 based on their study which
explored the self-concept of individuals with con-
genital defects (either physical or sensory). Adults
in the study who had grown accustomed to living
with various disabling conditions expressed similar
narrative themes such as striving to overcome their
difficulties and accepting the challenge to integrate
into everyday society. Despite the many hardships
they faced as children, they described a desire to
maintain a sense of self-respect and contribute to
others.48 Thus, we argue that a healthy life is not
based on others’ perceptions of wholeness, but on
the willful progression of the self.
Manifestations of purposefulness
One public example of how personal traits may
influence one’s response to a health condition is
the story of Randy Pausch as part of his The
Last Lecture.29 Pausch discussed his life while
at the same time acknowledging the fact that he
had pancreatic cancer which would shortly there-
after claim his life.49 Pausch’s lecture is replete
with purposefulness relative to his life and its
challenges. In either watching or reading The Last
Lecture, one cannot help being struck by the pur-
posefulness behind this lecture. The Last Lecture
received considerable public attention both prior to
and after Pausch’s death and it represented an
uncontrived and masterful presentation of how a
person’s individual traits come to the forefront
when facing challenges.
In the context of Pausch’s health condition, it
was evident through multiple examples that pur-
posefulness “drove” his life and created meaning
for him. In Pausch’s terms, “brick walls” that are
often confronted in life may facilitate a response
that seeks to overcome the challenge. As part of the
many examples he provided from his own life
events, it was obvious that the same attributes and
personal factors exhibited in health were repre-
sented when his health condition changed.
Expanding the definition and
inherent value of personal
factors
There have been considerable efforts to provide a
comprehensive description of pertinent factors in
the context of a health condition, but our inability
to fully understand and define the influence of per-
sonal factors on one’s response to a health condi-
tion persists. Regardless, it is clear that personal
factors, those features that may define one’s
response to a health crisis, also are likely to influ-
ence (either negatively or positively) both short-
and long-term health outcomes. It is our view that
the internalized perception of purposefulness is a
critical factor that drives one’s response to the
“opportunities” created by a health condition. We
suggest that these two concepts, namely perception
of purposefulness and the generation of meaning,
are intrinsically linked. Necessarily, these types of
critical personal factors would almost certainly
influence recovery and rehabilitation across all
types of health conditions.
It is unlikely that any health condition will be
met initially with a positive or favourable response;
no one wishes to experience a reduction in health.
A restriction or frank loss of functioning at any
Lee et al. 1013
level poses real and significant challenges to all
individuals. The question that emerges centers on
those indefinable, intrinsic personal factors that
form one’s being. Personal factors of this type can-
not and do not lend themselves to taxonomies or
outcome algorithms; however, we believe that clin-
ical observations strongly suggest that personal
factors provide an enhanced understanding of how
an individual responds to a health condition and/or
the potential consequences of its treatment. This
belief not only centers on the concept of purpose-
fulness, but more importantly, it must be contextu-
alized to past life experiences and interpretations of
meaning that may emerge when faced with a health
condition.
Operationalizing purpose –
rehabilitation for a storied life
While human experiences represent our interac-
tions with society and environment, and personal
factors contribute to how we experience our life
events, we propose that the personal narrative also
be introduced as part of the overarching construct
that forms purposefulness.
The formation of narrative has long been con-
sidered a way of framing our chaotic experience of
time into something more tangible. By shaping
events in this manner, we create a model of both
expression and interpretation of our experience
through what could arguably be called purposeful
imagination.50 What makes narrative such an
essential component to our proposed model of pur-
pose is the universality of the phenomenon. That is,
it spans economic and cultural borders and repre-
sents one of the first forms of communication we
learn as children (p. 3).51 Being a universal feature,
it lends itself well to the interdisciplinary model of
care that is at the heart of rehabilitation (p. 1).51
Jerome Bruner, an influential figure in the field
of constructivist theory, outlined several factors
that are found in the formation of a narrative.52
Using particular events as key reference points,
narratives always involve the passing of time and
invariably refer to something that is ongoing.
They typically focus on an individual’s response to
a given situation within the context of various
intentions. Narratives can arise due to factors such
as beliefs, desires, principles, etc., and these can
often be categorized into “genres” or schemas.
Although not all facets of an individual’s life can
be described as a “story worth telling”, those that
are the most compelling usually involve an inciting
event that challenges established conventions in
our lives. Perhaps one of the more salient points is
that a narrative does not necessarily resolve a spe-
cific crisis or plight, but rather, contains it and
seeks to understand it; being able to interpret a spe-
cific sequence of events may permit one to more
easily bear its consequences.52,53 Finally, the events
of an individual’s life tend to naturally accrue into
different narratives and there is a sense of coher-
ence that ensures that the pieces make sense as a
larger whole. Based on this collective perspective,
all life events eventually accumulate into a narra-
tive of someone behaving more or less purpose-
fully in a given span of time.52
Based on our arguments above, we propose the
following model of purposefulness as it relates to
rehabilitation:
It is essential that we highlight some of the spe-
cific points outlined above. Narratives are ongoing
and continuous. They form the basis of a continu-
ing identity and facilitate purposeful behavior. It is
the common thread that connects the past and the
future and provides the context for purposefulness
in the present.54,55 Since the more profound stories
typically involve a challenge to convention, it is
reasonable to assume that a change in health condi-
tion would fall within this category. Thus, a health
crisis could easily set the stage for the creation of a
compelling narrative guided by purposefulness.
For example, in examples involving traumatic
brain injury, it was found that narrative therapy
allowed for the “re-authoring” of one’s story to
develop a preferred view of the self. This alternate
view provided an opportunity to redefine one’s
existence and create a story replete with new pos-
sibilities, new relationships, and new outcomes.55,56
Work conducted by Morris55 also demonstrated
that a different view of one’s self was nurtured with
new experiences that were not a part of what he
called the “dominant problem-saturated story” of
one’s life; that is, the story that focuses on being a
1014 Clinical Rehabilitation 31(8)
Figure 1.  Purposefulness in rehabilitation.
“disabled” individual. It was also noted that whether
the new story was characterized by feelings of
gratefulness for second chances, or anger and deter-
mination to not be defeated, the need to develop an
understandable narrative was universal.55 This
aligns with Bruner’s principles that individual
experiences will naturally assemble into a larger
narrative that is coherent in light of its individual
components – a narrative does not necessarily
function to resolve a crisis, but instead to under-
stand that one may endure the circumstances.52,53
Therefore, the utility of the narrative is not to pro-
vide a “consoling plot”,53 but to empower the indi-
vidual to be an active contributor to a new narrative
and continue on in a purposeful manner.57
The study of life-narratives themselves has shed
light on the importance of purposefulness in reha-
bilitation. Through the study of 60 individuals with
varying disabilities, life-story narratives were ana-
lyzed to understand the perceived importance of dis-
ability rights.58 Those who perceived their identity
in terms of disablement rather than capability often
failed to see disability rights as relevant to their
experiences and employment. However, those who
focused more on their capabilities viewed employ-
ment barriers as a denial of an opportunity to con-
tribute to society. By changing disability rights
policies, it may be possible to influence the develop-
ment of identities of those with disabilities by creat-
ing new perceptions of ability and opportunity.
To summarize, purposefulness is an ever-pre-
sent component throughout our lives and it exists
as a convergence of narrative, personal factors,
and experience. The existence of purpose is not
the primary issue, but rather our awareness of it.
This awareness is arguably made manifest by our
sense of purposefulness. Our core characteristics
outline who we are, our experiences illustrate the
paths we have taken and what we have endured,
and our narrative creates the coherence between
our past and our future. Since our personal narra-
tives are critical to rehabilitation efforts, individ-
ual purpose must be actively considered when
goals are established. Based on the literature
reviewed herein, if we truly are beings of purpose,
then to disregard the evolution of individual pur-
posefulness may only serve to limit rehabilitation
outcomes both short- and long-term.
Personal disposition and
purposefulness
Purposefulness is an essential component for peo-
ple from the time of their youth to the twilight
years and the presence of this attribute can mani-
fest itself in one’s disposition. If purposefulness is
the engine, then an optimistic disposition can be
thought of as the wheels that give direction and
momentum to a life of meaning. The ability to look
forward with acknowledgement of a realistic out-
come is what connects an individual’s purposeful-
ness with their sense of well-being. Optimism has
been shown to mediate the relationship between
these two aspects in both a cross-sectional and lon-
gitudinal contexts with no difference between the
genders.59
A study investigating meaningful life experi-
ences found that both the youngest men (adoles-
cence to young adult) and the oldest men (90+ years)
were identified as having the lowest perceived pur-
pose in life. These age categories also had the high-
est suicide rates,60 and this may be related to the
lower levels of purposefulness in these two age
groups. If meaning and purpose are correlated with
the presence of optimism,41 then purposefulness is
crucial for an optimistic disposition. A sense of pur-
posefulness facilitates the development of a stable
identity and a sense of well-being in adolescents.
During this crucial period of identity formation, a
Lee et al. 1015
lack of purpose can inhibit one’s optimistic disposi-
tion and potentially lead to depression and delin-
quency.61 Similarly, institutionalized elderly people
demonstrate a strong correlation between a sense of
purpose, an optimistic disposition, and the absence
of late-life depression.46 Based on these findings, it
is conceivable that adolescent depression may be
linked to a lack of purposefulness associated with
identity and elderly depression may be linked to a
loss of purposefulness resulting from decreasing
independence.
The passing of time, however, is not the only
event in life that can bring about feelings of existen-
tial uncertainty. Whether we are dealing with termi-
nal illness61 or paralyzing disability,62 therapy
centered around identifying meaning in one’s life
(e.g. Logotherapy) was shown to be effective in alle-
viating the loss of meaning and promoting a sense of
well-being in both populations. Not only does pur-
posefulness alleviate a sense of loss, it is also capa-
ble of providing meaning to the lived experience.
Consequently, when purposeful behaviour is dis-
rupted or lost, does the possibility exist that such
uncertainty or loss may manifest as depression?
While this potential relationship is complex, its
potential impact on the process of recovery and
rehabilitation becomes of significant importance.
Regardless of one’s illness, optimism acts as a
strong predictor of survival.63 Although the will to
live is both cognitive and instinctual, the conscious
component is influenced by both attribution and
motivation, both of which intersect with opti-
mism.63,64 This effect extends to both mental and
physical levels of functioning. Studies performed
among the “oldest-old” populations also have
found that an optimistic outlook of the future can
reliably predict survival.65 Any stressful or trau-
matic event will arguably have a “derailing” effect
as the natural state is being perturbed, but resil-
ience keeps them from breaking and eventually
restores their original functioning.66
In a profound 37-year study, Segovia and col-
leagues67 analyzed the effects of optimism on
American prisoners of war (POW) who were
detained in Vietnam from the 1960s to the early
1970s. In this study, resilience was defined as those
individuals having no diagnosed psychological
impairments within the 37-year follow-up period.
Using multivariate analyses, it was determined that
dispositional optimism was a strong determinant of
long-term psychological resilience. It is important
to note that these prisoners were not simply
detained, but they were also subjected to extreme
exhaustion, malnourishment, and prolonged peri-
ods of torture. Representing the longest held group
of American soldiers, the repatriated POWs dem-
onstrated the essential role of optimism in one’s
ability to endure some of the most adverse condi-
tions imaginable and successfully re-enter society
following these experiences.
Similarly, critical studies funded by the
Templeton Foundation analyzed different dimen-
sions of resilience among 133 Holocaust survivors
in nine different locations in the United States.
Before the war, many survivors described growing
up in a loving family and a community that heavily
invested in future generations.68 During the war, a
major theme that emerged was a strong engage-
ment in purposeful and altruistic behaviours such
as banding together, finding food and shelter, bar-
tering goods, exchanging favours, and organizing
an underground resistance.69
Along with these more immediate manifesta-
tions of purposefulness were the larger, overarch-
ing resolutions that the survivors held. These
included a strong desire to reconnect with loved
ones, and a duty to tell future generations about
the atrocities that they had endured.68,69 Perhaps as
an indication of the importance of optimism and
self-transcendence, the majority of these survivors
perceived themselves (and other survivors) as
being very hopeful people with strong connections
to their communities. The presence of these cru-
cial elements is evidenced by the fact that the vast
majority of these individuals went on to finish
their education, obtain professional careers, raise a
family and create a nurturing environment within
their communities. Despite the difficulties associ-
ated with reliving this truly horrific chapter in
their lives, many of these survivors continued to
pass on their knowledge and experiences to others
long after the war.68
1016 Clinical Rehabilitation 31(8)
Conclusions
A change in health may prevent participation in
the valued aspects of our lives and consequently
threaten our identity and purpose.1 How a person
navigates through the challenges posed by a
health condition may be influenced by personal
factors and past experiences. We argue that
ascribing meaning to different life events and act-
ing in a manner that is driven by purpose is uni-
versal to all human beings. A person’s unique
combination of personal factors and past experi-
ences ultimately coalesce to form the subjective
experience of illness. The collective examples
that emerge from the literature provide support
for the notion that individualized responses to
health conditions may be directly influenced and
mediated by purposefulness. Specifically, per-
sonal factors, life experience, and our unique nar-
ratives guide our response to a health crisis and
provide meaning, which in turn can generate
purposefulness.
It is for these reasons that we advocate for
attention to purposefulness during the rehabilita-
tion process. Purposefulness cannot be imposed,
however it can be discovered and harnessed in the
rehabilitation process. Personal narratives that
reconstruct purpose and opportunities that align
with one’s perceived identity have been demon-
strated to effectively improve psychosocial
healing.70 It is our belief that this psychosocial
rehabilitation may mediate responses to other
areas of rehabilitation by facilitating motivation,
optimism, clearer goals, and consequently resil-
ience. As such, attention to purposefulness may
facilitate a more holistic and successful rehabilita-
tion process. Some of this may be determined
through the clinician’s willingness to understand
“who” their client is – their desires, values, and
needs – features that are often driven by purpose.
To disengage from knowing a client’s history, that
which is beyond medical, may serve to develop
a rehabilitative path that meets the needs of the
individual and thus, restores purpose to their life.
Therefore, we believe that comprehensive care
cannot be fully achieved without recognition of
the individual’s sense of purpose; to live beyond
the challenging moments for the sake of a far
greater personal story.
Acknowledgments
The authors would like to extend our thanks to
Dr. Doreen Bartlett, Dr. Sandi Spaulding, and
Dr. Elizabeth Skarakis-Doyle for their helpful comments
and suggestions on earlier versions of this paper.
Additionally, we wish to thank Shamiram Zendo for
her discussions with one of the authors (JL) and for
providing some of the key references for operational
narrative. Finally, the authors wish to express our sin-
cere appreciation to the journal editor, Professor Derick
Wade, for his very comprehensive, instructive, and
generous input on this manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
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