Daily Time Use as a Measure of Community Adjustment for
Persons Served By Assertive Community Treatment Teams
KEY WORDS
• community integration
• daily time use
• severe mental illness
Terry Krupa, PhD, OT Reg (Ont), is Associate Professor
and Chair, Occupational Therapy Program, School of
Rehabilitation Therapy, Queen’s University, Kingston,
Ontario, Canada; krupat@post.queensu.ca
Heather McLean, MSc (Rehab), is Policy Analyst,
Department of Justice, Government of Canada, Ottawa,
Canada. At the time of this study Ms. McLean was Graduate
Student at the School of Rehabilitation Therapy, Queen’s
University, Kingston, Ontario, Canada.
Shirley Eastabrook, PhD, RN, is Assistant Professor, School
of Nursing, Queen’s University, Kingston, Ontario, Canada.
Alison Bonham, BSc(OT), OT Reg (Ont), is Occupational
Therapist, Lennox and Addington Community Mental
Health Program, Napanee, Ontario, Canada. At the time of
the study Ms. Bonham was Occupational Therapist,
Assertive Community Care Team, Frontenac Community
Mental Health Services, Kingston, Ontario, Canada.
LeeAnn Baksh, BSc(OT), was Occupational Therapist,
Assertive Community Care Team, Frontenac Community
Mental Health Services, Kingston, Ontario, Canada, at the
time of the study.
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Terry Krupa, Heather McLean,
Shirley Eastabrook, Alison Bonham,
LeeAnn Baksh
PURPOSE. The purpose of the study was to examine daily time use of clients of Assertive Community
Treatment (ACT) as a measure of their community adjustment and well-being. The actual daily time use of ACT
clients in the four categories of personal care, productivity, leisure, and sleep were compared to the data for
Canadian population norms.
METHOD. Daily time use data were collected from 27 adult clients from two Assertive Community Treatment
Teams in southeastern Ontario using recall time diaries of two weekdays. The data were coded using the
Statistics Canada (1999) coding scheme. Descriptive statistics were used to determine time in the major cate-
gories of time use and z scores were used to compare the study sample to the adult Canadian population. The
percentages of time spent in specific subcategories of activity were also compared.
RESULTS. The results indicated an imbalance in occupation with time use dominated by leisure and sleep
activities. Study participants spent significantly more time in passive leisure compared to active leisure and
socialization.
CONCLUSION. The activity patterns of ACT clients were not consistent with those associated with com-
munity adjustment, health, and well-being. Occupational therapists working in ACT are in a good position to
contribute to the literature regarding occupational performance and mental illness and to lead ACT teams in
discussions and practices that may promote health through activity.
Krupa, T., McLean, H., Eastabrook, S., Bonham, A., & Baksh, L. (2003). Daily time use as a measure of community adjust-
ment for persons served by Assertive Community Treatment teams. American Journal of Occupational Therapy, 57,
558-565.
ssertive Community Treatment (ACT) is a model of service delivery that pro-
A
vides continuous and intensive treatment, rehabilitation, and support to
increase the community tenure and adjustment of persons with severe mental ill-
ness who are heavy users of the service system (Stein & Santos, 1998). Since its
inception in the early 1970s, ACT has been widely disseminated and researched
internationally (Marshall & Lockwood, 2001).
The model of ACT has been shown to have overall positive effects on symp-
tomotology and reduction of hospitalization for persons with severe mental illness
(see below). Its impact on psychological well-being and quality of life is less clear.
The study reported here contributes to our understanding of the outcomes associ-
ated with ACT by examining the daily time use patterns of ACT clients as a mea-
sure of community adjustment and personal well-being. The discussion focuses on
the implications of the study for occupational therapists working with ACT teams.
The ACT Model of Service Delivery
ACT was designed to overcome the limitations associated with short-term and hos-
pital-based services (Stein & Test, 1979). An ACT team works with clients in the
community as required, 24 hours a day, 7 days per week. The team functions as a
client’s “primary therapist” and caseloads are shared among ACT staff. To ensure
September/October 2003, Volume 57, Number 5
 that services are assertive, individualized, and intensive,
staff–client ratios are low, typically not exceeding one to
ten. The ACT team works directly with clients in the com-
munity to promote the development of required daily liv-
ing skills and to enable accessibility and participation in reg-
ular community environments (McGrew & Bond, 1995;
McGrew, Bond, Dietzen, & Slayers, 1994).
ACT teams are multidisciplinary, with most team
members providing generalist community mental health
functions as well as specialist, discipline-specific functions.
Occupational therapy has been identified as one of the pro-
fessions that could fulfill a rehabilitation specialist role on
an ACT team (see, for example, the Ontario Ministry of
Health, 1998). There is, however, a lack of published liter-
ature that details the potential contributions of occupation-
al therapy within the context of ACT (Krupa, Radloff-
Gabriel, Whippey, & Kirsh, 2002).
ACT Outcome Studies
Research has repeatedly demonstrated the effectiveness of
ACT in decreasing psychiatric hospitalizations and psychi-
atric symptoms (Burns & Santos, 1995; Essock & Kontos,
1995; Lafave, deSouza, & Gerber, 1996; McGrew et al.,
1994; Scott & Dixon, 1995), increasing community tenure
and stability in independent living (Essock & Kontos,
1995; Lafave et al., 1996; Scott & Dixon, 1995) and treat-
ment compliance (Scott & Dixon, 1995). The model has
been found to be particularly effective for individuals diag-
nosed with severe mental illness who are high users of inpa-
tient mental health services (Marshall & Lockwood, 2001).
Efforts to understand the nature of the community
lives of ACT clients have been less definitive. These studies
have typically focused on quality of life and employment
outcomes. Early reports by the originators of the ACT
model (Stein & Test, 1979) stated that ACT clients experi-
enced a better quality of life then those who were hospital-
ized, but these differences were not found when ACT was
compared to other community-based case management
programs (McGrew, Bond, Dietzen, McKasson, & Miller,
1995). Quality of life research in community mental health
has been associated with several limitations including the
difficulties associated with improving the harsh community
lives of persons with severe mental illness (Davidson, Hoge,
Merrill, Rakfeldt, & Griffith, 1995), the methodological
shortcomings of quality of life research and disagreement
about the variables that influence quality of life (DeSouza,
2000).
The developers of the ACT service model believed that
community outcomes were enhanced if clients were pro-
vided support for participation in meaningful activities
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such as work (Stein & Santos, 1998). They focused on inte-
grating treatment and productivity-related outcomes and
defined a vocational component for ACT teams. Studies
examining employment outcomes suggested that clients of
ACT teams with a dedicated vocational specialist demon-
strated improved productivity outcomes when compared to
those teams without this vocational component (McGrew
et al., 1995; Russert & Frey, 1991). It is important to note
that a dedicated vocational specialist is not consistently
regarded as a critical feature of ACT in replications of the
model (McGrew et al., 1995)
Daily Time Use As a Measure of
Community Adjustment
Although work status is an important indicator of commu-
nity adjustment, it provides a restricted view of the daily
lives of persons with severe mental illness living in the com-
munity. The employment rates for this population are
exceptionally low with only 10 to 20 percent competitively
employed (Baron, 1995). Employment as an outcome is, at
this time, a meaningful descriptor of community adjust-
ment for only a subset of ACT clients. Considered on its
own, work status fails to capture the complex relationship
between activity participation, health, and well-being in the
community. In response to these limitations we suggest that
daily time use may be a useful outcome measure of com-
munity adjustment.
Daily time use patterns are related to community
adjustment levels both because of the tangible outcomes or
products of these activities and because of the sense of sat-
isfaction that can be generated by participation in activities
(Juster, Courant, & Dow, 1985). For persons with severe
mental illness, daily time use patterns have the potential to
enhance community adjustment by providing structure to
daily events (Bachrach, 1996; Kotake Smith, 2000; Lette,
1989), and the means to contribute to the broader com-
munity and to develop a personal sense of purpose and
meaning and worth (Hatfield & Lefley, 1993; Lunt, 2000).
Activity involvement is believed to play an important role
in adjustment to mental illness and disability (Williamson,
1998). Davidson and Strauss (1995) propose that this daily
life context can serve as a powerful framework for recovery
from mental illness. They suggest that it enables our under-
standing of how strengths and weaknesses, and health and
disorder, can coexist within individuals as they go about
their daily lives.
In his review of studies that examined activity prefer-
ences in the general population, Juster (1985) found that
individuals had high preferences for certain types of pro-
ductivity, mainly paid work and childcare, and for active
559
 leisure and socializing activities. Those activities that were
least preferred were passive and did not involve personal
interaction with others, such as passive leisure and house-
work. This finding is consistent with Csikszentmihalyi’s
(1993) assertion that the intrinsic rewards of participation
in daily activities are realized within the context of active
involvement in daily pastimes that are experienced as pro-
moting growth at the personal and the social level. Juster’s
work is also consistent with empowerment paradigms in
community mental health that suggest that active engage-
ment in social roles and activities promote health by pro-
moting interactions with supportive community structures
(Clark & Krupa, 2002).
Daily time use studies aim to determine the amount of
time that individuals allocate to various daily living activi-
ties (Harvey & Singleton, 1989; McKinnon, 1991;
Statistics Canada, 1995; Weeder, 1986). They reveal the
types of activities that a population of individuals engage in
throughout the day as well as amount of time that they
devote to these activities. Consistent with models of occu-
pational performance, daily time use activities are typically
organized by the major categories of personal care, leisure,
productivity, and sleep and rest. These studies may also
report on the locations and social contexts of activity par-
ticipation and on the individual’s experience of satisfaction
while engaging in the activity.
Time use studies have been conducted with the gener-
al population (Statistics Canada, 1995, 1999), and with
individuals with disabilities (see, for example, Pentland,
Harvey, & Walker, 1998), including individuals with psy-
chiatric disorders living in the community (Hayes &
Halford, 1996; Weeder, 1986). Thus, the results of time use
studies permit comparisons of time use patterns between
various populations.
Study Objective
The purpose of this study was to examine the daily time use
patterns of clients of ACT. Our research was directed by the
following questions: (1) What are the daily time use pat-
terns of clients of ACT? ( 2) How does the daily time use of
clients of ACT compare to those reported for the general
Canadian adult population? We believed that this informa-
tion would contribute to the understanding of the commu-
nity adjustment of clients of ACT.
Method
The study was descriptive and exploratory. The research was
designed to advance our knowledge about daily time use
patterns among the ACT client population and promote
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discussion about the implications for occupational therapy
practice.
Study Participants
Twenty-seven clients of two ACT teams were recruited. We
used convenience sampling when random sampling failed
to enlist an adequate number of participants. The study
received approval from a university ethics board and
informed consent was obtained from all participants.
Twelve participants were recruited from ACT team “A”
and fifteen from ACT team “B.” The majority of the par-
ticipants were male (n = 16) and single (n = 24). The mean
age for the participants was 41 with a range from 26 to 51
years. The sample was equally split between those who had
completed high school or higher and those who had not
completed high school. Two thirds of the sample described
their prior work histories as unskilled work, while one third
reported histories of skilled or professional work.
Diagnostically, the majority of the sample were diagnosed
with either schizophrenia (n = 11) or mood–personality dis-
orders (n = 11).
Consistent with ACT standards, the eligibility criteria
for both of these ACT teams focused on servicing individ-
uals with severe psychiatric disorders who had multiple
needs and were heavy users of the mental health system.
Both of the teams in this study were located in the same
small city of approximately 120,000 with an economy
based primarily in the public sector.
Procedures
To ensure agreement with the standard models of ACT, we
administered two standard fidelity measures of ACT to each
of the participating ACT teams. The Index of Fidelity for
Assertive Community Treatment (McGrew, et al., 1994)
and the Critical Ingredients of Assertive Community
Treatment (McGrew & Bond, 1995) are standardized sur-
veys of the extent to which ACT teams implement key fea-
tures of the service delivery model. Both of the teams rated
high in fidelity to the standard ACT model but inconsistent
with the standard critical features of ACT was the lack of a
dedicated vocational specialist on both of these teams. ACT
team “A” had access to occupational therapists and voca-
tional specialists through a referral process. ACT team “B”
had two full-time occupational therapists functioning in a
generic ACT mental health worker role.
We used the recall time diary method to collect data
about time use. This method involved the systematic recall
of a person’s use of time over a given 24-hour period
through the retrospective, sequential recording of each
activity, including start and end times (Harvey & Singleton,
1989). Although people do not typically spend identical
September/October 2003, Volume 57, Number 5
 portions of time engaging in the same activities from day to
day, time use studies need to attend to the confounding
influence of atypical days. In this study we followed Kalton’s
(1985) recommendation that smaller samples should use
more than one daily time use measurement to obtain a rea-
sonable degree of reliability. We collected time use data for
2 weekdays per person.
One of the investigators met individually with each
study participant on three occasions. At the first meeting
each participant was introduced to the time budget recall
diary as a method of systematically recording time use over
a 24-hour period. Participants selected a weekday to apply
the time budget diary and a time on the following day to
meet with investigator to recall activities. At the second
meeting, the time use data were collected through an inter-
view during which the participant was asked “What were
you doing at 12:01 a.m. (on the diary day)?” The respons-
es were written verbatim on the diary form and followed by
additional questions about the activity such as:
“Where were you?”
“Were you doing anything else at the same time?”
“Who were you with?”
The rest of the diary was completed by “What did you
do next?” questions to include the full 24-hour period. The
same follow-up prompts were used with each participant to
gather complete time use data and to ensure consistency of
beginning and ending times for activities reported across
participants. Minutes were used as the unit of analysis for
time spent in activities. At the end of this second meeting,
another 24-hour period for applying the time budget diary
was selected by the participants and a third and final meet-
ing for data collection was organized.
Studies have supported recall time use diaries as a reli-
able and valid approach compared to other methods of
recording daily time use that have been presumed to have
greater reliability and validity but higher implementation
costs (Harvey & Singleton, 1989; Pentland et al., 1998;
Robinson, 1988).
Analysis
We used the coding scheme of the Statistics Canada
(1995; 1999) time use study, part of the General Social
Surveys of the Canadian population. The Statistics
Canada study reported on daily time use patterns of a rep-
resentative sample of more than 10,000 Canadians more
than 15 years of age, using a telephone survey and a recall
diary method to examine how participants spent their
time over a 24-hour period. We made two small revisions
to the Statistics Canada codes: (1) We separated sleep and
personal care to provide a more discrete description of
daily activities, and (2) we added day programs as a sub-
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category of productivity to account for a productivity
option available to persons diagnosed with severe mental
illnesses.
The raw data were converted into codes for four major
categories of daily activity—sleep, personal care, leisure,
and productivity—and then coded further into subcate-
gories, consistent with those of the Statistics Canada time
use study. The subcategories of productivity included paid
work, housework, voluntary and social support activities,
educational activities, and day program activities. Personal
activities were limited to the individual’s care of the self.
Leisure activities included socializing (interacting with oth-
ers as the primary focus of the activity), passive leisure
(activities characterized by witnessing or receiving an event
for recreation or rest), and active leisure (actual participa-
tion in the process of recreational activities). Finally, sleep
included both night sleep and incidental naps. Although
only one investigator actually coded the data, we had three
other rehabilitation personnel code pilot data for three
ACT clients to increase our confidence that the coding was
not influenced by rater error. The level of agreement
between raters for pilot data was high at 99.83%.
Guttman split-half reliability coefficients were com-
puted to determine the reliability of combining the two
interview days for each participant. This is a measurement
of the similarity of time use between the 2 days. The coef-
ficients were 0.41 for productivity, 0.56 for leisure, 0.64
for personal care, and 0.38 for leisure. These coefficients
were in keeping with Kalton’s (1985) recommendation of
reliability levels of 0.40 as compatible with combining
data.
To answer our research questions we used descriptive
statistics (means and standard deviations) to determine time
spent in the major categories of personal care, productivity,
leisure, and sleep. We used z scores to determine the dis-
tance of the mean of the sample population from that of the
Canadian population ages 25–64 years. The data for this
age group were obtained directly from Statistics Canada
based on the data from the 1998 General Social Survey
(Statistics Canada, 1999).
The z score was computed by subtracting the sample
means from the Canadian means and then dividing by the
standard deviation of the Canadian mean. The z score is
considered to be particularly useful for comparing the find-
ings of several measures each with differing means and
standard deviations (Vogt, 1999). Since the amount of time
available in any given day is 24 hours, the major categories
of time use are not independent. Knowing the amount of
time that is spent in any three categories determines the
amount of time for the fourth category. Thus, one catego-
ry, sleep, was excluded from the analysis of z scores, as it
561
 describes time when individuals are at rest from the activi- Table 2. Percentage of time spent in subcategories of major daily
ties of daily life. activities for ACT clients and adult Canadian population.
Activity Mean hours spent in subcategories as a percentage
We then examined the distribution of specific subcate- subcategories of mean hours spent in major activity
gories of time use as a percentage of time spent within the ACT clients ages 26–51 Canadians ages 25–64
major categories of leisure, productivity, personal care, and (n = 27) (n > 10,000)
sleep and examined these findings, descriptively, in relation Productivity 3.43 (100%) 8.69 (100%)
Paid work 0.64 (18.66%) 4.57 (52.59%)
to the Canadian population. This allowed us to explore the Household work 2.42 (70.55%) 3.56 (40.97%)
way time was actually spent within each of the major cate- Volunteer/Education/ 0.34 (9.91%) 0.54 (6.21%)
gories. Day program
Leisure 8.68 (100%) 5.15 (100%)
Active leisure 0.80 (9.21%) 1.02 (19.81%)
Socialization 2.83 (32.60%) 1.74 (33.78%)
Results Passive leisure 5.04 (58.06%) 2.39 (46. 41%)

We found the daily time use patterns of the study partici-
pants to be heavily dominated by time spent in sleep and
leisure activities. Over a 24-hour day, the study participants
spent a mean of 3.43 hours involved in productivity (SD =
2.08), 2.43 hours in personal care (SD = 1.40), 8.68 hours
in leisure (SD = 2.45), and 9.46 hours in sleep (SD = 2.28).
The daily time use patterns for productivity were con-
siderably different from those of the general adult Canadian
population (see Table 1). The study means were 1.75 stan-
dard deviations below the Canadian mean for productivity,
and 1.18 standard deviations higher for leisure. The means
for personal care for the sample and Canadian populations
were very similar.
Table 2 provides a description of how time was actual-
ly spent in each of the major categories of time use. The
productivity time of ACT clients was spent predominantly
in household activities (70.55%), while Canadian adults
spent more than half their time in paid work activities
(52.59%). There was little difference between the two pop-
ulations for the time spent on nonpaid work such as volun-
teer or educational activities.
Both the ACT clients and the Canadian adults spent
approximately one third of their leisure time in socialization
activities. The ACT clients spent more time in passive
leisure activities (58% compared to 46%) and the Canadian
population sample spent more time in active leisure (20%
compared to 9%).
The total sleep of ACT clients was distributed between
night sleep (86.47%) and naps or incidental sleep
Table 1. Time spent in daily activities (hours): A comparison of
ACT clients (N = 27, ages 26–51) with Canadian adults (n > 10,000,
ages 25–64 years).
ACT Client Means and Canadian Means and
Activity Standard Deviations Standard Deviations
(in hours) (in hours)
Productivity 3.43 (2.08) 8.69 (0.05)
Leisure 8.68 (2.45) 5.15 (0.04)
Personal Care 2.43 (1.40) 2.26 (0.02)
Sleep 9.46 (2.28) 7.89 (0.02)
Note: ACT = Assertive Community Treatment
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Personal Care 2.43 (100%) 2.26 (100%)
Sleep 9.46 (100%) 7.89 (100%)
Night sleep 8.18 (86.47%) 7.89 (100%)
Naps 1.28 (13.53%) (data unavailable)
Note: ACT = Assertive Community Treatment
(13.53%). Data related to the sleep patterns for the
Canadian population were unavailable.
Discussion
The interpretation of these findings needs to be considered
within the limitations of this descriptive study. Because
information about the total client population was unavail-
able to us at the time of this study, we do not know if the
study participants are representative of the population of
clients served by the two teams. This is an important con-
sideration because time use could be influenced by a wide
variety of factors such as length of time in a program or
length of time since last hospitalization. In addition, while
both of the ACT teams displayed high fidelity to the criti-
cal features of ACT, they did not have an integrated voca-
tional component. Generalizing these findings to other
ACT teams needs to be done with caution, since teams that
have dedicated vocational resources are explicitly structured
to positively influence engagement in productivity (Russert
& Frey, 1991).
The results demonstrated an imbalance of occupation-
al activities among the ACT clients as compared to the
adult Canadian population survey data. They spent fewer
hours in productivity and only a small percentage of these
hours involved paid work. This finding is not particularly
surprising given the low employment rates for this popula-
tion (Baron, 1995). It is important to note that this low
z Scores employment was not counterbalanced by participation in
nonpaid work activities such as volunteer, school, or atten-
1.75
dance at day programs. Instead, 70% of the limited hours
-1.47
-0.14 in productivity were spent on housework activities.
Low productivity was offset by leisure; these activities
were predominantly passive and compounded by the large
September/October 2003, Volume 57, Number 5
 portion of the day spent taking incidental naps. While the
Canadian data for leisure indicate that participation in
active leisure constitutes the smallest percentage of time in
leisure activities, the data for this study suggests that this
small percentage is still considerably higher than that of the
ACT clients. The total time spent in socialization and the
percentage of time spent in socialization as a leisure activity
did not differ between the two populations. This lack of dif-
ference is particularly interesting given the common idea
that people with severe mental illness are less likely to par-
ticipate in socialization because of the impairments associ-
ated with the illnesses, the isolating effects of institutional-
ization, and community and internalized stigma.
Theorists and researchers studying the influences of
activity on health point out that any activity has the poten-
tial to contribute to well-being in a manner that cannot be
recognized by simply tallying the number of hours spent in
any given pursuit. More important is the extent to which
activity participation is experienced as meaningful, engag-
ing, and enhancing community life and personal develop-
ment (Csikszentmihalyi, 1993; Hasselkus, 2002). This said,
an imbalance between work, leisure, and rest is considered
a risk factor for compromised well-being, because of its
potential to limit the discovery and expression of interests
and capacities and the benefits experienced through com-
munity participation. In addition, passive leisure, and
housework activities have been associated with lower levels
of satisfaction and well-being because they are less likely to
engender those conditions for health through activity
(Csikszentmihalyi, 1993; Juster, 1985).
It is not clear whether the theoretical frameworks
developed for daily time use adequately reflect the experi-
ences of persons with severe mental illness. While people
with severe mental illnesses have occupational goals and
desires similar to the general population (Lord, Schnarr, &
Hutchinson, 1987), the relationship between the time they
spend in activities and well-being needs further exploration.
Certainly the field of psychiatric rehabilitation is char-
acterized by conceptual models with contradictory perspec-
tives on the role of activity in promoting health in the face
of severe mental illness and the extent to which participa-
tion in community activities is possible or desirable. Stress
paradigms in mental health suggest that individuals with
severe mental illness expend considerable psychoemotional
and physical effort in dealing with the demands of activities
of daily life. This is believed to lead to a low tolerance for
ongoing and active engagement and the potential for exac-
erbation of acute symptoms of mental illness (Anthony &
Liberman, 1986). From this perspective, activity participa-
tion has potentially toxic consequences and needs to be
carefully monitored. On the other hand, contemporary
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recovery frameworks argue that increased participation in
meaningful activities, grounded in a community context,
promotes health and well-being through the development
of a personal and social identity, engaging the individual in
illness self-management strategies and forging connections
to supportive structures and people (Jacobson & Greenly,
2001; Krupa, 2000). From this perspective, recovery from
mental illness depends on enabling activity participation in
the community. Finally, empowerment-oriented frame-
works propose that the alienation from activities of daily life
experienced by persons with severe mental illness is largely
a reflection of poverty and community stigma that deny
equitable access to activities (Clark & Krupa, 2002; Nelson,
Lord, & Ochocka, 2001). From this perspective, failure to
address activity involvement in the community overempha-
sizes the role of illness and its impact on capacity and
ignores the community contexts and social structures that
support participation.
Occupational Therapy, Daily Time Use, and ACT
The findings from this study suggest interesting possibilities
for the development of the occupational therapy contribu-
tion on ACT teams. The benefits of participation in the
activities and routines of daily life are central to the occu-
pational therapy paradigm of health and well-being (see, for
example, Wilcock, 1998; Hasselkus, 2002). While partici-
pation in daily activities inevitably leads to encountering
challenges, the persistent absence of engagement in activi-
ties has been associated with self-alienation, chronicity in
disease, and high levels of stress (Fieldhouse, 2000).
The findings from this study indicate a need for occu-
pational therapy research addressing the relationship
between activity participation, mental illness, community
adjustment, and models of service delivery. The ACT ser-
vice model was designed to continuously integrate clinical,
rehabilitation, and community integration perspectives to
provide individuals with the best supports possible in the
community (Stein & Santos, 1998). As such, ACT could
prove to be an important avenue for research that addresses
activity participation in the life context over time.
Occupational therapists might use the concept of daily
time use to encourage the ACT team to think beyond clin-
ical and functional independence outcomes, to consider
more directly the occupational well-being of clients in the
community. Daily time use, with its attention to all areas of
occupation, provides the opportunity for discussion about
the meaning of community adjustment, health, and well-
being, beyond single dimension outcomes such as employ-
ment without undermining the importance of employment
as an important and viable goal. With their knowledge and
experience in this area, occupational therapists could pro-
563
 vide education and consultation for issues related to time
use planning and intervention both at the individual and
service level.
Conclusion
This descriptive study of ACT clients’ daily time use as a
measure of community adjustment has yielded several
important findings. The daily time use of ACT clients was
considerably different from that of the Canadian adult
population, with an imbalance of work and leisure. The
ACT clients spent 14.5 hours a day in passive leisure and
sleep activities. Time in productivity was largely invested in
housework. Overall, the pattern of daily time use for ACT
clients was not consistent with patterns associated with
health and well-being.
The lack of a clear theoretical framework for under-
standing the relationship between activity participation and
severe mental illness suggests the need for more investiga-
tion in this area. Occupational therapists, who focus on
influencing health and personal growth through participa-
tion in the routines and activities of daily life, could take a
lead role in directing the ACT team’s attention toward
developing research and practice guidelines related to client
patterns of daily time use. ▲
Acknowledgments
The authors thank Dr. Terry Smith and Dr. Stuart Lawson
for their assistance with the statistical analysis and Ms.
Salinda Horgan for her contributions as project coordina-
tor. We also thank the ACT clients and staff for their time
and interest in seeing this study through to completion.
This project was supported by a grant from the Ontario
Ministry of Health and Long-Term Care, administered on
its behalf by the Ontario Mental Health Foundation. The
authors acknowledge the support of the Mental Health
Policy Research Group, which is a coalition of the
Foundation, the Centre for Addictions and Mental Health,
and the Canadian Mental Health Association, (Ontario
Division).
References
Anthony, W. A., & Liberman, R. P. (1986). The practice of psy-
chiatric rehabilitation: Historical, conceptual and research
base. Schizophrenia Bulletin, 12, 542–553.
Bachrach, L. (1996). Psychosocial rehabilitation and psychiatry:
What are the boundaries? Canadian Journal of Psychiatry, 41,
28–35.
Baron, R. (1995, Spring). Establishing employment services as a
priority for persons with long term mental illness. American
Rehabilitation, 32–35.
564
Downloaded from http://ajot.aota.org on 08/22/2020 Terms of use: http://AOTA.org/terms
Burns, B., & Santos, A. (1995). Assertive Community Treatment:
An update of randomized trials. Psychiatric Services, 46(7),
669–675.
Clark, C., & Krupa, T. (2002). Reflections on empowerment in
community mental health: Giving shape to an elusive idea.
Psychiatric Rehabilitation Journal, 25, 341–349.
Csikszentmihalyi, M. (1993). The evolving self: A psychology for the
third millennium. New York: Harper Perennial.
Davidson, L., Hoge, M. A., Merrill, M. E., Rakfeldt, J., &
Griffith, E. E. (1995). The experiences of long-stay inpa-
tients returning to the community. Psychiatry: Interpersonal
and Biological Processes, 58(2), 122–132.
Davidson, L., & Strauss, J. (1995). Beyond the psychosocial
model: Integrating disorder, health and recovery. Psychiatry,
58, 44–55.
DeSouza, H. (2000). Use of the Delphi technique and qualitative
method to compare the way in which mental health consumers
and providers understand quality of life. Unpublished master’s
thesis, School of Rehabilitation Therapy, Queen’s University,
Kingston, Ontario, Canada.
Essock, S., & Kontos, N. (1995). Implementing Assertive
Community Treatment teams. Psychiatric Services, 46(7),
667–668.
Fieldhouse, J. (2000). Occupational science and community
mental health: Using occupational risk factors as a frame-
work for exploring chronicity. British Journal of Occupational
Therapy, 63(5), 211–217.
Harvey, A., & Singleton, J. (1989). Canadian activity patterns
across the life span: A time budget perspective. Canadian
Journal on Aging, 8(3), 268–284.
Hasselkus, B. R. (2002). The meaning of everyday occupation.
Thorofare, NJ: Slack.
Hatfield, A., & Lefley, P. (1993). Surviving mental illness: Stress,
coping and adaptation. New York: Guilford Press.
Hayes, R., & Halford, W. (1996) Time use of unemployed and
employed single male schizophrenia subjects. Schizophrenia
Bulletin, 22(4), 659–669.
Jacobson, N., & Greenly, D. (2001). What is recovery? A con-
ceptual model and explication. Psychiatric Services, 52,
482–485.
Juster, F. (1985). Preferences for work and leisure. In F. T. Juster
and F. P. Stafford (Eds.), Time, goods, and well-being (pp.
333–351). Ann Arbor, MI: The University of Michigan.
Juster, F., Courant, P., & Dow, G. (1985). A conceptual frame-
work for the analysis of time allocation data. In F. T. Juster &
F. P. Stafford (Eds.), Time, goods and well-being (pp.
113–127). Ann Arbor, MI: The University of Michigan.
Kalton, G. (1985). Sample design issues in time diary studies. In
F. T. Juster & F. P. Stafford (Eds.), Time, goods and well-being
(pp. 93–112). Ann Arbor, MI: The University of Michigan.
Kotake Smith, M. (2000). Recovery from a severe psychiatric dis-
ability: Findings of a qualitative study. Psychiatric Rehabil-
itation Journal, 24, 149–157.
Krupa, T. (2000). Work recovery in schizophrenia. Unpublished
doctoral thesis. Queen’s University, Kingston, Ontario,
Canada.
Krupa, T., Radloff-Gabriel, D., Whippey, E., & Kirsh, B. (2002).
Occupational therapy and assertive community treatment.
Canadian Journal of Occupational Therapy, 69, 153–157.
September/October 2003, Volume 57, Number 5
 Lafave, H., deSouza, H., & Gerber, G. (1996). Assertive com-
munity treatment of severe mental illness: A Canadian expe-
rience. Psychiatric Services, 47(7), 757–759.
Lette, E. (1989). How I perceive and manage my illness.
Schizophrenia Bulletin, 15(2), 197–200.
Lord, J., Schnarr, A., & Hutchinson, P. (1987). The voice of the
people: Qualitative research and the needs of consumers.
Canadian Journal of Community Mental Health, 6(2), 25–36.
Lunt, A. (2000). Recovery: Moving from concept toward a theo-
ry. Psychiatric Rehabilitation Journal, 23, 401–404.
Marshall, M., & Lockwood, A. (2001). Assertive community
treatment for people with severe mental disorders (Cochrane
Review). In the Cochrane Library, 3, Oxford: Update Software.
McGrew, J., & Bond, G. (1995). Critical ingredients of assertive
community treatment: Judgements of the experts. Journal of
Mental Health Administration, 22(2), 113–125.
McGrew, J., Bond, G., Dietzen, L., McKasson, M., & Miller, L.
(1995). A multisite study of client outcomes in Assertive
Community Treatment. Psychiatric Services, 46(7), 696–701.
McGrew, J., Bond, G., Dietzen, L., & Slayers, M. (1994).
Measuring the fidelity of implementation of a mental health
program model. Journal of Consulting and Clinical Psychology,
62(2), 670–678.
McKinnon, A. (1991). Occupational performance of activities of
daily living among elderly Canadians in the community.
Canadian Journal of Occupational Therapy, 58, 60–66.
Nelson, G., Lord, J., & Ochocka, J. (2001). Shifting the paradigm
in community mental health: Towards empowerment and com-
munity. Toronto, Ontario, Canada: University of Toronto
Press.
Ontario Ministry of Health. (1998). Standards for Assertive
Community Treatment. Toronto: Ontario Ministry of Health
and Long Term Care.
Pentland, W., Harvey, A., & Walker, J. T. (1998). The relationship
between time use, health and well-being in men with spinal
cord injury. Journal of Occupational Science, 5(1), 14–25.
Robinson, J. (1988). Time-diary evidence about the social psy-
chology of everyday life. In J. E. McGrath (Ed.), The Social
Psychology of Time (pp. 134–150). Newbury Park, CA: Sage
Publications.
Russert, M., & Frey, J. (1991). The PACT vocational model: A
step into the future. Psychosocial Rehabilitation Journal,
14(4), 7–17.
Scott, J., & Dixon, L. (1995). Assertive community treatment
and case management for schizophrenia. Schizophrenia
Bulletin, 21(4), 657–667.
Statistics Canada. (1995). As time goes by…time use of Canadians.
Ottawa, Ontario, Canada: Government of Canada.
Statistics Canada. (1999). Overview of the time use of Canadians
in 1998. Ottawa, Ontario, Canada: Government of Canada.
Stein, L. I., & Santos, A. B. (1998). Assertive community treatment
of persons with severe mental illness. New York: Norton.
Stein, L., & Test, M. (1979). From the hospital to the communi-
ty: A shift in the primary locus of care. New Directions for
Mental Health Services, 1, 15–32.
Vogt, W. P. (1999). Dictionary of statistics and methodology: A non-
technical guide for the social sciences. Thousand Oaks, CA:
Sage.
Weeder, T. (1986). Comparison of temporal patterns and mean-
ingfulness of the daily activities of schizophrenic and normal
adults. Occupational Therapy in Mental Health, 6(4), 27–44.
Wilcock, A. A. (1998). An occupational perspective of health.
Thorofare, NJ: Slack.
Williamson, G. (1998). The central role of restricted normal
activities in adjustment to illness and disability: A model of
depressed affect. Rehabilitation Psychology, 43(4), 327–347.

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