Occupational engagement: some assumptions to inform occupational therapy

Engajamento ocupacional: alguns pressupostos para informar a terapia ocupacional

Abstract

Occupational engagement has been conflated with other concepts, such as participation, active occupational performance, and therapeutic engagement. This critical review will discuss occupational engagement as a unique concept that describes a form of involvement in doing that does not require performance and foregrounds the subjective-affective and cognitive experiences of doing. We present some attributes of occupational engagement and the implications for the lack of clarity of this concept within the literature. The difference between occupational engagement and therapeutic engagement is discussed by comparing the foundational tenets of the Model of Human Occupation (MOHO) and the Canadian Model of Occupational Performance and Engagement (CMOP-E). Through one illustrative narrative, we discuss how occupational engagement can be understood as a phenomenon that is not performance-dependent and has different levels of engagement. To conclude, we point out some assumptions about occupational engagement that can inform occupational therapy research and practice.

Keywords:
Activities of Daily Living; Review; Therapeutics; Cognition; Affect

Resumo

Engajamento ocupacional é um conceito que tem sido confundido com outros conceitos, como participação, desempenho ocupacional ativo e engajamento terapêutico. Esta revisão crítica discutirá o engajamento ocupacional como um conceito único que descreve uma forma de envolvimento no fazer que não requer desempenho e coloca em primeiro plano as experiências subjetivas-afetivas e cognitivas do fazer. Apresentamos alguns atributos do engajamento ocupacional e as implicações da falta de clareza desse conceito na literatura. A diferença entre engajamento ocupacional e engajamento terapêutico é discutida comparando os princípios fundamentais do Modelo de Ocupação Humana (MOHO) e o Modelo Canadense de Desempenho Ocupacional e Engajamento (CMOP-E). Por meio de uma narrativa ilustrativa, discutimos como o engajamento ocupacional pode ser entendido como um fenômeno que não depende do desempenho e possui diferentes níveis de engajamento. Para concluir, apontamos algumas questões sobre o engajamento ocupacional que podem orientar a pesquisa e a prática da terapia ocupacional.

Keywords:
Atividades Cotidianas; Revisão; Terapêutica; Cognição; Afeto

Introduction

In 2020, a Spanish charity named “Asociacion Musica para Despertar” (Music Association for Awakening) published a video of former ballerina Ms. Martina Gonzalez, showing her listening to Tchaikovsky's Swan Lake¹. The footage received international attention because Ms. Gonzalez lived in a care home and was in the final stage of Alzheimer’s disease (British Broadcasting Corporation, 2020). Despite displaying little overt physical or observable behaviour, when Ms. Gonzalez listened to Swan Lake, it was clear that she was experiencing profound involvement in what the music represented to her: her life experience as a ballerina. At one point, she moved her arms emulating part of the choreography, evidence of how this music linked her to her previous occupation. This short everyday narrative raises questions about a phenomenon related to human occupation: “What happens when people experience a moment of cognitive and emotional involvement in an occupation that they are restricted from physically doing?”

The idea above is not new in the occupational therapy literature and has been captured under the concept of occupational engagement. Polatajko & Davis (2021, p. 78) point out that physicality is not required for occupational engagement; however, it may be a part of it. These authors view occupational engagement as a “neutral, non-evaluative concept” that amplifies possibilities for occupational behaviour when performance is impacted, as what happens with people who experience restrictions due to illness, disability (Polatajko & Davis, 2021), or occupational deprivation due to environmental circumstances or systemic discrimination (Stadnyk et al., 2010).

Polatajko (1992), in her Muriel Driver Lecture, illustrated the life of Nancy B, age 25, who was diagnosed with Guillain-Barre syndrome. After two and a half years in a hospital while paralysed from the neck down and breathing with a respirator, she decided to end her life. Polatajko (1992) argued that Nancy B died not from her medical condition, but from the occupational deprivation she experienced while living in the hospital, and that Nancy should have been supported in regaining occupation through occupational therapy (Polatajko, 1992). Although, Polatajko (1992) did not explicitly mention the term occupational engagement, her reasoning leads us to consider that occupation must have other forms of involvement that would have enabled Nancy B, who had no physicality, to engage in occupations that held purpose and meaning for her.

The two examples (Martina Gonzalez and Nancy B) illustrate that occupational engagement is an incredibly complex concept that needs further exploration by occupational therapy researchers and practitioners. Through in-depth examination, occupational therapists can expand their views of occupational performance to understand how people living under certain circumstances, such as disease, chronic illness, impairment, or occupational deprivation, can experience diverse modes of involvement in doing. These modes support fulfilment and flourishing and provide a sense of purpose to people when they engage in meaningful occupations—a profound essence of humankind (Rozario, 1994). Most people, under those circumstances, have a repertoire of meaningful occupations but may need support and opportunities for engagement in those occupations.

This critical review aims to reframe occupational engagement as a concept that describes a form of involvement in doing that does not require performance and foregrounds the subjective, affective, and cognitive dimensions of doing. We first underpin our discussion by highlighting the seminal work of Elizabeth Yerxa, who believed that human beings could achieve their potential through occupational engagement (Yerxa, 1992). Building upon that foundation, we present additional attributes of occupational engagement and the significant implications of the lack of clarity of this concept within the professional literature and, consequently, in occupational therapy practice. Next, we distinguish occupational engagement from therapeutic engagement by comparing the foundational tenets of the Model of Human Occupation (MOHO) with the Canadian Model of Occupational Performance and Engagement (CMOP-E). Through one illustrative narrative, we exemplify how occupational engagement can be better understood as a phenomenon that is not solely occupational performance-dependent but employs different levels of engagement. To conclude, we point out some assumptions relevant to explore the concept of occupational engagement and the contribution to occupational therapy profession.

Origins of the Concept of Occupational Engagement

Although some scholars attribute the concept of occupational engagement to the renowned occupational therapist and scientist Ann Wilcock (1940-2019) (see Craik, 2020; Black et al., 2019; Firby & Raine, 2022), this concept first appeared in the work of Elizabeth Yerxa, who in 1980 published a seminal article titled “Occupational therapy’s role in creating a future climate of caring,” where she proposed engagement in occupation as a fundamental premise of the emerging discipline of occupational science:

Engagement in occupation encompasses not only the observable performance of individuals, but also their subjective reactions to the activity and objects with which they are occupied (Yerxa, 1980, p. 534).

In Yerxa’s paper, she used the phrase “engagement in occupation” intentionally to extend her ideas beyond “observable performance” (although still including performance) and to present a new concept that is now conceptualized as “occupational engagement.” However, Yerxa’s phrase, "engagement in occupations"—as well as related phrases, such as engage or engaging in occupations—, is currently often written as part of simple prose, used interchangeably with terms such as participate or participation, and is not defined. Those authors who use Yerxa’s phrase, with the intention to capture the concept of occupational engagement and its complexities, also use “occupational engagement” interchangeably and define the concept. Thus, when selecting articles for this review, to be viewed as intentionally using the concept and not just the phrase or words as prose, an article had to contain the phrase “occupational engagement” at least once and/or express a definition or description including the concept’s attributes and features. For instance, Kielhofner (2008), in his Model of Human Occupation (MOHO), although using “engage in occupation,” he cited Yerxa’s (1980) work to infer that occupational engagement “involves not only performance but also subjective experience” (p. 102).

In subsequent work, Yerxa (1992) described occupation as “both a human process (the engagement) and an outcome, for example, health through increased skill, competency, or efficacy” (Yerxa, 1992, p. 79). Yerxa (1994, p. 587) also identified characteristics of occupation in terms of engagement in “self-initiated², self-directed, adaptive, purposeful³, culturally relevant, organized activity⁴”, driven by interest and curiosity (Yerxa, 1994). These concepts related to engagement—along with the emotional value of doing something meaningful—are consistent with the work of Hungarian psychologist Mihaly Csikszentmihalyi, who highlighted that the experience of doing is intrinsically rewarding, involves clear goals, features a balance between skills and challenges, and transcends time as one of the characteristics of the psychological state of flow (Csikszentmihalyi, 1990). Through decades of research, he identified that people experienced flow when engaged in activity with clear goals and a sense of control about what they were doing. Yerxa (1998, p. 367) further stated a similar idea that “to engage in occupation is to take control”, thus recognising the influence of Csikszentmihalyi in her work on the complexity of occupation and its relationship with health, satisfaction, and engagement in the routines, culture, and life of people (Yerxa, 2000).

Attributes of Occupational Engagement: Implications of the Lack of Clarity

Based on Yerxa’s concept of engagement as encompassing the subjective experience in occupation and its relationship with health, other scholars began to use it in occupational science and occupational therapy (Morris & Cox, 2017). Polatajko et al. (2007) emphasised that occupational engagement, despite its presence in the literature for some time, remained poorly described, often confounded with participation and involvement, an assertion that is supported more recently in conceptual reviews by Morris & Cox (2017) and Black et al. (2019) and demonstrated in research (e.g., Farrell et al., 2022; Firby & Raine, 2022; Hodson et al., 2021; Lim et al., 2022; Longpré et al., 2022; Sleight, 2017; Stav et al., 2012). Table 1 illustrates the lack of consensus on the concept of occupational engagement when used intentionally in research:

Table 1
Lack of consensus on the concept of occupational engagement when used intentionally in research.

Article title	Occupational engagement	Focus
Occupational engagement, fatigue, and upper and lower extremity abilities in persons with melorheostosis	“Fatigue and lesion location were two causal factors affecting occupational engagement in individuals with melorheostosis. These factors were shown to result in cessation or reduced participation in valued activities” (Farrell et al., 2022, p. 7).	Occupational participation in valued occupations
Systematic review of occupational engagement and health outcomes among community-dwelling older adults	“The focused question for this review, “What is the evidence that participation in occupation and activities supports the health of community-dwelling older adults?”(Stav et al., 2012, p. 302).	Occupational participation
Occupational engagement in low-income Latina breast cancer survivors	“In general, participants indicated that although they found occupational engagement to be health promoting, their functional participation in many daily activities was limited by cancer and its side effects” (Sleight, 2017, p. 5) “unique experiences of occupational engagement (Sleight, 2017, p. 7)	Subjective experience of occupational performance
Engaging with nature and the outdoors: A scoping review of therapeutic applications in contemporary occupational therapy	“Thus, the term ‘engagement’ is used within this review to reflect the experience of interacting with the natural outdoors, irrespective of physical participation” (Firby & Raine, 2022, p. 2).	Experience of interaction with the environment without physical requirement
Factors that influence occupational engagement of young adults who are cancer survivors: a pilot study	“This concept of occupational engagement evokes doing, thinking, and feeling as related to specific environmental conditions” (Taylor, 2017 cited in Longpré et al., 2022, p. 2).	Occupational performance
Occupational therapy practice with terminally ill Chinese older adults in Singapore	“Participants reported that they had to learn to be comfortable with other forms of engagement. For example, although not actively engaged in ‘doing’, just being present with clients could also be meaningful engagement with them” (Lim et al., 2022, p. 10).	Being present; meaningful engagement
Occupational engagement following mild stroke in the Australian context using the occupational gaps questionnaire	“Occupational engagement can be defined as a person’s participation, performance and doing of an occupation” (Townsend & Polatajko, 2013 cited in Hodson et al., 2021, p. 384).	Occupational participation, occupational performance, and doing.

The information provided on Table 1 shows the importance of naming and framing what we do (Polatajko, 1992) to deliver quality services and communicate the value of occupational therapy to the public. A commonly held and multifaceted definition of this concept is needed and promises to result in improvements in occupational therapy practice and maximise the potential scope of the profession (Xavier et al., 2012). The importance of debating and clarifying the concept of occupational engagement is essential for occupational therapy. Understanding this concept more fully will shape assessment and interventions enhancing practice (Black et al., 2019).

Another perspective—one not commonly held—recognises how occupational engagement foregrounds affective and cognitive aspects of the occupational experience, thus not requiring physical manifestations. Rather, it is through the elicitation of one’s affective and cognitive selves while ‘doing’ that one understands or experiences engagement (Kennedy & Davis, 2017). Therefore, “[...] if the construct of OE goes “beyond occupational performance,” it is necessary for client-centred practice to further understand clients [...]” (Kennedy & Davis, 2017, p. 99). Moreover, it is essential for truly client-centred practice which understand a person’s occupational life and their subjective experiences of it (Kennedy & Davis, 2017). Kennedy & Davis (2017) also highlighted the elements that are essential influences on engagement: association of meaning with occupation, interest invested by the person, physical and mental competencies for the occupation, motivation, self-determination, feeling of responsibility, challenge, fun, creativity, novelty, structured occupations (which provide structure and routine), sense of control or choice (perceiving control of what they are doing and not feeling that others are taking control of the occupation, leading to a decrease in the level of engagement), performing things with others, and a supportive environment (Kennedy & Davis, 2017).

Engagement is not only an individual phenomenon but inescapably social: we care about people, we do things together, we engage cognitively watching a play (occupation performed by others), a football match, a concert, a party and by engaging, we enact or express different moods that can illustrate our level of engagement in occupation. We suggest that occupational engagement is a richly complex concept that involves many different levels. Sutton et al. (2012) investigated the recovery of 13 participants with mental illness by exploring their narratives about recovery through interviews. This study found that stages of recovery involved multiple levels of engagement and sometimes even complete disengagement. The authors considered that disengagement could be a way to recover fuller engagement in other stages. In theory, it was also argued that stages of disengagement and engagement can be part of a universal human nature—not exclusive to people experiencing illness—as we make choices based on our needs for occupational engagement during certain times in our lives.

Based on an extensive conceptual review and analysis of occupational engagement, Morris & Cox (2017) proposed a new description of engagement by presenting a framework of practice and illustrating the value of the consequences of engagement. The authors concluded in their review that there exist several ideas about the precise nature of occupational engagement beyond agreement on its positive meaning for health and well-being (Morris & Cox, 2017). Morris (2020) recognises that occupational engagement is ‘involvement in’ occupation and fluctuating in nature; however, the author describes engagement as a consequence of participation (doing) and not as an essence that could be independent (since it is a level of involvement or a different dimension of occupation).

An interesting unpublished scoping review of the literature relevant to occupational engagement conducted by Xavier et al. (2012) identified that observing only performance is insufficient to affirm that a person is occupationally engaged. Through their review, the authors identified that engagement has the following attributes: (a) Type: engagement in a particular occupation (e.g., work, gaming, gambling; involves a state of mind and satisfaction, intensity and quality of the involvement); (b) Nature: intensity and duration, short and long-term, occurring over the time and that can change; (c) Intensity: a single occupation with a range of experiences (with high and low engagement, qualifying the level of engagement); and (d) Characteristics: objective and subjective dimensions, alone and with others (Xavier et al., 2012). Therefore, while the study concludes that a Delphi survey could further clarify the definition of this construct by occupational therapists, the literature reviewed is clear that occupational engagement is multifaceted.

Therapeutic Engagement Contrasted with Occupational Engagement

As we have shown, occupational therapists have discussed the phenomenon of being connected to a form of doing through absorption in affective and cognitive connections with the doing of an occupation (Kennedy & Davis, 2017). However, existing practice models are inconsistent and unclear in their use of the term “occupational engagement.” For instance, in the Model of Human Occupation (MOHO), engagement is presented within the concept of occupational participation and as a subjective part of performance, as noted below:

Occupational participation refers to engaging in work, play, or activities of daily living that are part of one’s socio-cultural context and desired and necessary to one’s well-being. Engagement involves not only performance but also subjective experience (Kielhofner, 2008, p. 101-102).

In the MOHO, occupational engagement is used to describe the client’s engagement in therapy through nine dimensions. These dimensions involve the active participation of the client to achieve change through the occupational therapy process as follows: (1) choose or make decisions; (2) commit; 3) explore; (4) identify; (5) negotiate; (6) plan; (7) practice; (8) re-examine; and (9) sustain (Kielhofner & Forsyth, 2008). These nine dimensions of occupational engagement comprise several cognitive and physical actions enacted to achieve a change through therapy along the occupational therapy process. In the most recent edition of the MOHO text, this characterization is maintained: “The process of change is always driven by the client’s occupational engagement. The true dynamic of change involves what the client does, thinks, and feels” (Pepin, 2017, p. 193). Influenced by the MOHO, Pepin (2017, p. 193) suggests the essential elements for engagement: “exploration, practice, re-examination, negotiation, sustainability and commitment”. These elements allude to active participation, and one could argue that someone who cannot participate actively within those dimensions cannot be engaged. Moreover, the salient question is whether occupational engagement is a phenomenon that happens exclusively during occupational therapy intervention or, much more than that, as part of the nature of humankind as occupational beings (Kennedy & Davis, 2017)?

The description of occupational engagement in the MOHO creates a clear association with therapeutic engagement. Occupational engagement is presented through different verbs that inform both what the client will do (occupation-focused) to engage in the therapy process to achieve goals and the level of cognitive and affective involvement in doing. For example, in their book “A guide to the formulation of plans and goals in occupational therapy,” based on the tenets of the MOHO, the authors suggest that the dimensions of occupational engagement be used to measure people’s progress while they negotiate measurable goals (Parkinson & Brooks, 2021), reinforcing the use of this concept to denote their engagement in therapy.

The concept of engagement from the American Occupational Therapy Association (2020) presents some of the main attributes of the first conceptualization by Yerxa (1980) when relating it to objective and subjective aspects:

Engagement in occupation—performance of occupations as the result of choice, motivation, and meaning within a supportive context (including environmental and personal factors). Engagement includes objective and subjective aspects of clients’ experiences and involves the transactional interaction of the mind, body, and spirit (American Occupational Therapy Association, 2020, p. 5-6).

The quotation above describes the complexity and power of occupational engagement; however, there is an inherent association with occupational performance. In the following section, we discuss how occupational engagement is an altogether different entity, not necessarily dependent on active occupational performance.

Occupational Engagement is not Occupational Performance-dependent

The Canadian Model of Occupational Performance and Engagement (CMOP-E) (Polatajko et al., 2007) was the first model to objectively separate the concepts of performance and engagement (Xavier et al., 2012). In the CMOP-E, the description of occupational engagement differs from that presented in the MOHO (therapeutic engagement or engagement in therapy), and the CMOP-E clearly demonstrates that occupational engagement is possible without performance. Polatajko et al. (2007) affirm that:

To have occupations is not the same as to perform occupations. At any given point in time, only one occupation can be performed. Yet, an individual or group has numerous occupations, and as occupational therapists, we are concerned with engagement in all of them. Further, humans frequently engage in occupations without performing them (Polatajko et al., 2007, p. 24).

In the new Canadian Model of Occupational Participation (CanMOP), it also recognised that occupational engagement “[...] goes beyond performance to consider qualities of ‘in the moment’ involvement [...]” (Egan & Restall, 2022, p. 76).

Following the discussion of engagement without active occupational performance, we now present the narrative of Joana⁵ and her experience going to the beach with friends, years after living with a physical condition:

Some experiences are unforgettable, and in my life, perhaps one of the most significant for so many reasons, was the one that happened in Aracaju, on the coast of the northeast of Brazil, in 2017, the last trip my mother and I took together (before she passed away).

Those were days of many joys and friends. Sunny days for me, of being able to (re)visit the sea since we haven't seen each other for 18 years, because being tetraplegic and using a powered wheelchair in inaccessible cities like ours shows me how much being a person with a disability makes me too a person socially invisible and deprived of so many things to do.

Lucky to be able to have my path crossed by inclusive people like the ones I met in Aracaju and who allowed me so many (re)discoveries. It was through them that I was able to use a wheelchair suitable for “walking” on the soft sand of the beach, entering the sea again, feeling that water in sensitive parts of my body, feeling that “taste of the sea”, feeling the sun burning my skin, the breeze hit the face and the salt sand sticks to my body. I could “surf” and smile, a bit afraid. I could look at the smile of someone who didn't even know how happy I was.

Sensations I didn't know or even remember what they were like, as some memories gradually fade away, and the possibility of placing experiences that made me so happy before my accident is almost always a (re)birth. I keep seeking those experiences throughout my daily life, whether in the most ordinary and unpretentious activities, like those that were almost impossible. These experiences keep me moving forward (Joana, Bahia, Brazil, 2022).

Joana’s narrative demonstrates how occupational engagement can be facilitated even when the physical aspects characterising occupational performance are not possible. However, we highlight that Joana was occupationally ‘present’; she was able to experience her occupation in a different form where the environment (physical and geographical spaces, people, and objects) facilitated her occupational engagement. Polatajko et al. (2007, p. 24) state that occupational therapists are concerned with additional aspects beyond performance, such as “other modes of occupational interactions”. Examples include the nature of the engagement (if passive or active performance), how frequent the engagement happens (intensity), how new the occupation is to a person (degree of establishment), the level of engagement (extent) and degree of expertise on performance (competence) (Polatajko et al., 2007, p. 24). Joana’s history of engagement is compatible with the ideas of Davis (2017, p. 155) that the concept of occupational engagement “broadens the scope of occupational therapy practice to help characterise people’s social participation in occupations regardless of their capacity to perform an occupation”. Although occupational performance may not be necessary for occupational engagement, occupational presence, or the ability to notice and pay attention to new elements and distinctions in compartmentalised aspects of occupation in our lives, is what underlies the present moment (Elliot, 2011; Reid, 2011). Joana was certainly living that sort of moment. The presumption that occupational engagement does not depend upon active performance but might instead be more related to levels of occupational presence needs to be further explored, for example, in terms of commitment, absorption, and the psychological state of flow.

In connection to Joana’s occupational engagement, we can also identify moods (e.g., frightened, anxious, happy). It could be argued that she, for a moment, was experiencing “flow” where she found the just right fit between her skills and the challenge of the occupation of swimming. This fit was achieved by adapting the occupation to the environment (technologies and people). For this reason, we argue that flow could be considered as a level of occupational engagement. In a study with Ikebana practitioners, Watters et al. (2013) identified that Ikebana was related to purposes, such as work, designing arrangements for events, self-expression, and doing something meaningful for others. This same study described engagement as an experience of transcendence, or flow experience, when practising Ikebana. Similarly, Reid (2011) suggests that theoretical and psychological perspectives of “flow” and “mindfulness” are both relevant constructs of occupational engagement. They are associated with occupational engagement in how they are experienced and practised. Thus, there is a clear relationship between mindfulness and flow, which serves to capture awareness of and presence in the occupation (Reid, 2011). Although “flow” and “mindfulness” have been considered as a mode of occupational engagement, we understand that they are a different phenomenon. Specifically with flow, there is a deep absorption in the occupation, a disconnecting from self and surroundings (Csikszentmihalyi, 1990). Conversely, mindfulness requires a presence for “[...] maintaining self-awareness throughout or even despite an activity [...]” (Sheldon et al., 2015, p. 1). Moreover, for Morris & Cox (2017, p. 162), “flow” has specific requirements for it to occur, and people can also experience other modes of engagement, such as relaxation:

It may be that, for occupational experiences meeting these specific requirements, occupational engagement and absorption are steps towards achieving a state of flow. However, as absorbing occupations are not required to meet the demands of flow, this allows occupational scientists to consider the full range of highly positively valued occupations, including those with relatively low physical or cognitive demands which may be comforting or used to aid relaxation.

Joana’s narrative provides one example of how occupational engagement involves connections with other people, their past, present (being present performing actively or passively) and future. Joana could be empowered to engage in occupations within an occupational therapy process if we shift the understanding of engagement beyond requiring performance.

The potential of this understanding for occupational therapy is captured in a study by Lim et al. (2022, p. 11). The qualitative study conducted in Singapore described the perceptions of occupational therapists who worked with Chinese older adults living with a terminal illness and their caregivers. They described the influence of culture on occupational therapy practice, where collectivist, family-centred societies strive to facilitate culturally relevant interdependence instead of independence. The researchers interviewed eleven occupational therapists who worked with clients living with a terminal illness and identified that they were able to engage through watching those who had the capacity to be actively involved with doing. The study suggested that although clients may appear physically passive, they can be “engaged cognitively, emotionally, and socially”. In the conclusion, authors affirmed that occupational therapists could engage clients through the dimension of “being” rather than “doing” occupation.

The relative importance of a person's capacity to generate satisfaction and fulfilment from their occupational experiences is often overshadowed by the central role that occupational performance plays in occupational therapy (Doble & Santha, 2008). In other words, we propose that the subjective experience is a different dimension of an occupation, not the doing (active performing something - occupational performance) that is commonly measured and part of an objective intervention in occupational therapy. In this sense, we argue that occupational engagement as a subjective experience with involvement with an occupation is overlooked as an outcome. Similarly, Doble & Santha (2008, p. 184) proposed the concept of occupational well-being and a framework for the occupational therapist to ascertain if and to what degree clients' subjective occupational experiences lead to satisfaction and fulfilment. The study emphasised “importance of individuals’ subjective occupational experiences”.

According to Rozario (1994), the focus on participation can be influenced by the predominance of an industrial, technical society primarily focused on productivity and performance, with values heavily influenced by the ability to ‘do’. Occupational therapy has evolved since its beginnings in the early 1900s focused on therapeutic use of occupation (Friedland, 2011). Although it has slowly returned to its occupational roots, it still bears powerful traces of the biomedical model based upon reductionism and traditional Western values of individualism and efficiency (Taff & Babulal, 2021). Although to different degrees across countries, this reductionist paradigm is amplified by neoliberal reimbursement and healthcare systems that prioritize objectivity, measurement, and commodification of the therapeutic encounter (Taff & Putnam, 2022). Within such a context, the affective and cognitive elements of occupational engagement are more easily relegated as secondarily important to performance and doing.

According to Yerxa (1994), occupational engagement cannot be separated from its personal meaning, which acknowledges that individuals can reflect on and interpret the personal meaning of engagement to increase their awareness as occupational beings. Thus, “[...] being human profoundly means to be open to the world, a world, that is, which is replete with other beings to encounter and with meanings to fulfil [...]” (Frankl, 1966, p. 97). Occupational engagement can be considered the phenomenon that fulfils those emergent meanings in ways that enhance occupational well-being.

The Importance of Questioning Assumptions Surrounding Occupational Engagement

Occupation is such a rich concept that it will never be exhausted of content but will continue to generate questions as long as issues are unsolved in the hearts and minds of occupational therapists and as long as we have the courage to risk, to question, and to love what we do, especially asking the questions (Yerxa, 2005, p. 111).

Following this encouragement from Yerxa (2005), we offer some final considerations surrounding the “mystery” or undiscovered essential knowledge about occupational engagement. Subsequently, this paper reminds us that the concept of engagement needs to be more deeply explored by questioning existing assumptions prevalent in the profession. These assumptions should not be viewed as detrimental, but rather as an opportunity for occupational scientists and occupational therapists to critically appraise and debate, therefore continuously evolving the depth of knowledge around this critically important concept.

First, occupational engagement is a fluctuating state (Morris & Cox, 2017) and can decrease according to a level of control in an occupation (Kennedy & Davis, 2017) or for other interrelated reasons, for example, as “competency of performance (novice or expert), and so on” (Polatajko et al., 2007, p. 24). Occupational engagement happens in a context of a continuum of meaning or purpose and may not necessarily always be pleasurable, fun, or support relaxation when it occurs. Engagement can be tricky (when someone is studying for an exam), complex (when a person is learning how to cook a new recipe), challenging (when a surgeon is doing a heart operation) or even painful (when an athlete is running a marathon under muscular pain and fatigue). All of these significant forces encourage humanity to engage because no matter the result (tasting a dreadful meal, passing or failing an exam, receiving a medal, or watching your competitor on the podium), engagement is a process or moment-to-moment experience that moves people forward to try again or to engage in new challenges.

Second, engagement is strongly related to meaning. However, meaning can be associated with purpose, choices, interests, and values reported consistently by someone in a broad sense; in contrast, engagement is more specific (moment-to-moment), variable, dynamic and never exactly the same. Over time, meaning can change. As described by Reed et al. (2013) and Lim et al. (2022), meaning changes according to historical societal values and culture. This understanding brings forth a host of questions: Can engagement in the long-term shape and modify meaning? Can we engage in occupations that are not meaningful to us and discover the meaning after the experience of occupational engagement?

Third, occupational engagement has an internal component but is socially connected to people’s experiences and context. Understanding occupational engagement requires knowing people’s occupational histories with particular focus on the experience of involvement with an occupation, both cognitively and affectively. We need to observe and actively listen to individuals and communities and those stakeholders related to them in the context of their environment where engagement happens. This action requires placing occupational engagement on the agenda of all occupational therapists as a fundamental concept for the profession to explore. If and when we discover the deep process mechanisms of how occupational engagement happens, we can offer our clients a thriving dimension of occupation that is mainly related to human beings. It is a crucial point of the reason to still live in this world with meaning, hope, goals, and self-direction. Can we invest more in studies about occupational engagement on what is happening moment-to-moment when people engage in occupations?

Fourth, we propose that occupational engagement is a powerful concept and tool for persons, groups, and communities to learn about themselves through the occupations that are meaningful or potentially will become meaningful to them. It can be dialogued and further explored with Freire’s (1998) concept of conscientization of a human process where the agent is the person “in the world” and “with the world”, together with others. This knowledge of oneself through occupations is taken for granted because people, in general, are not used to reflecting, feeling, and thinking about what they do, leading to a process of change or “adaptability”, as Yerxa (1998) called it. However, this occupational knowledge can be facilitated by the occupational therapy process, independently of disability or disease, for all who face occupational difficulties and meaninglessness. We ask here, how have we evaluated or assessed occupational engagement? Can we explore the occupational engagement experiences of our clients so they might find the optimal experiences balancing the challenges with their skills (Csikszentmihalyi, 1990), as the example of Joana’s experience demonstrates?

Fifth, the intentional act of naming and framing (Polatajko, 1992) engagement is needed to communicate its full promise. In a review of organizational and behavioural research, Podsakoff et al. (2016) stress their concern about concepts. They illuminate the need for a common language among professionals, which we can apply to the occupational therapy profession:

Another function of theoretical concepts is that they provide organizational and behavioral scientists with a common language to communicate their ideas to each other. Clear conceptual definitions not only identify the nature of the concept of interest, but they also help distinguish the focal concept from other, seemingly similar concepts in the field (Podsakoff et al., 2016, p. 165).

Consequently, the absence of a common language around occupational engagement can compromise what occupational therapy can offer to practice and research. One challenge caused by this lack of clarity would be if an organisation, professional body, institution, service, or professional uses occupational engagement but does not know how to define, describe, identify, measure, intervene, show its outcomes, and find consistent evidence about it to justify its practice.

We argue that well-defined concepts can also contribute to generate theories and further frameworks and conceptual models that will inform practices. As an example, the concept of occupational deprivation originally described by Wilcock (1998, p. 145) as “[...] the influence of an external circumstance that keeps a person from acquiring, using, or enjoying something [...]” was later explored by other scholars, such as Whiteford (2000), then included as a related concept of occupational justice/injustice (Wilcock & Townsend, 2000; Townsend & Wilcock, 2004), and further, as one of the outcomes of occupational justice in the framework of occupational justice (Stadnyk et al., 2010). Ultimately, a scoping review identified that occupational deprivation informed occupational therapists’ individual approaches in their practices (Malfitano et al., 2019).

The example above shows how a concept can be developed, explored and refined and integrated into a theory, supporting the development of a framework and, finally, informing practice. The evolution of a concept and its related issues constructs ultimately “an occupational perspective” of that concept (Townsend, 2022, p. 2), revealing critical gaps to be addressed by practitioners. These gaps can only be identified when the concept is clearly stated, researched, and developed. We believe that the concept of occupational engagement needs to follow this process, which has been used with the concepts of occupational deprivation and occupational justice.

Finally, but not least in importance, the framework of occupational justice provides some components of structural and contextual factors that can inform occupational justice outcomes of meaning, participation, choice, and balance (Townsend, 2012). We propose that engagement must be added to this list because life with only participation often can occur without engagement, for example, low work engagement, school failure, and so on. Therefore, can we consider engagement as an outcome? If the answer is yes, then we need to invest in studies that will offer evidence to clarify our understanding of engagement and its main attributes that can support future evidence-based assessments. While occupational engagement has been identified as a route of global health delivery (Carey et al., 2019), gaps remain, such as how to understand the ‘occupational engagement’ we say we deliver to achieve the outcomes of occupational participation?

To conclude, occupational engagement is clearly a fundamentally crucial process and outcome for the clients we serve; however, its many facets have not been fully explored. Our task in this paper was to offer the in-depth examination occupational engagement deserves, and, consequently, reveal new possibilities for its enactment in both scholarship and practice. Considering all the arguments presented, clearly occupational engagement is a core concept for occupational therapy and needs more of our attention.

• 1
  The video can be watched at: British Broadcasting Corporation (2020).
• 2
  Self-initiated: “[...] refers not only to psychological choice but to sensory-motor participation [...]” (Yerxa, 1967, p. 109). Based on Dr. Karl Smith’s theory, Yerxa (1967) described that “[...] self-initiated activity, specifically verbal and graphic skills, patterns of work and recreational pursuits – activity of concern to occupational therapists – is of primary importance in human motivation [...]” (Yerxa, 1967, p. 109).
• 3
  Purposeful activity: “[...] is an activity which has meaning to the client, not just to the occupational therapist. Our clients are individuals who have differing ideas of purpose [...]” (Yerxa, 1967, p. 109).
• 4
  Organized activity: “[...] approach to a task in an organized manner [...]” (Burke, 1998, p. 420).
• 5
  “Joana (Pseudonym) has provided consent to translate her narrative into Brazilian Portuguese, firstly published in social media. Names and places were changed to keep anonymity and confidentiality of Joana”.
• How to cite: Cruz, D. M. C., Taff, S., & Davis, J. (2023). Occupational engagement: some assumptions to inform occupational therapy. Cadernos Brasileiros de Terapia Ocupacional, 31, e3385. https://doi.org/10.1590/2526-8910.ctoAR259233852

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Edited by

Section editor

Profa. Dra. Ana Paula Serrata Malfitano

Publication Dates

• Publication in this collection
  23 Jan 2023
• Date of issue
  2023

History

• Received
  03 Aug 2022
• Reviewed
  05 Nov 2022
• Accepted
  15 Dec 2022