Time Use and Occupational Performance Among Persons with Schizophrenia

Ulrika Bejerholm, Reg. OT, BSc Mona Eklund, PhD, Reg. OT

ABSTRACT. Schizophrenia is a complex disorder with a heavy impact on daily life. Since the human occupational pattern is a product of person-occupation-environment interaction, it is of importance to explore all these factors to understand the daily occupational pattern among persons with schizophrenia. This study aimed to describe the time use of 10 persons with schizophrenia, reflecting the participants daily occupations, social and geographical environments, and emotional reaction and reflection on their occupational performance. The results showed stagnation in the participants occupational pattern and time use. Most activities were not triggered by a facilitating environment but from within the person by basic, immediate life needs, or wanting to escape reality. Occupational therapists could assist this group in reshaping the environment and regaining roles that involve interacting with the outside world.
[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com> 2004 by The Haworth Press, Inc. All rights reserved.]

Ulrika Bejerholm is a doctoral student and Lecturer, and Mona Eklund is Associate Professor, Lund University, Department of Clinical Neuroscience, Division of Occupational Therapy. Address correspondence to: Ulrika Bejerholm, Lund University, Department of Clinical Neuroscience, Division of Occupational Therapy, P.O. Box 157, SE-221 00 Lund, Sweden (E-mail: uab@arb.lu.se). The authors would like to thank the participants and staff of Rundelen, Malm Psychiatry, for their collaboration and hospitality. Occupational Therapy in Mental Health, Vol. 20(1) 2004 http://www.haworthpress.com/web/OTMH 2004 by The Haworth Press, Inc. All rights reserved. Digital Object Identifier: 10.1300/J004v20n01_02

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KEYWORDS. Time use, occupational performance, occupational pattern, schizophrenia, psychiatry

INTRODUCTION The balance between the different types of occupations that compose peoples daily livesin terms of, e.g., work, self-maintenance, and play has been regarded as vital for adaptation ever since occupational therapy was founded (Meyer, 1922/1977). During the past few years the balance between different types of occupations has gained renewed and increasing interest, and it has been hypothesized that a balanced pattern of occupations may lead to better well-being (Erlandsson & Eklund, 2001; Persson, Erlandsson, Eklund, & Iwarsson, 2001). Furthermore, within occupational therapy it has been emphasized that participation in meaningful occupations stimulates health and well-being (Law et al., 1997; McLaughlin Gray, Kennedy, & Zemke, 1996; McLaughlin Gray, 2001; Wilcock, 1995; Wilcock et al., 1998; WHO, 2001). Presumably, if active involvement in occupations has been shown to positively affect health and well-being, an imbalance of activities and roles may cause problems with health and quality of life (Pentland, Harvey, & Walker, 1998). People who develop schizophrenia often fail to accomplish age-related developmental occupations in work, self-maintenance, and play (American Psychiatric Association, 1994). In general, there has been limited research into the patterns of occupational performance among persons with disabilities (Pentland et al., 1998). Besides, even though it is known that there is a relationship between mental illness and how time is experienced, there is no specific description of how the mentally ill spend their time (Suto & Frank, 1994; Emerson, Cook, Polatajko, & Segal, 1998), especially not among people with psychotic disorders (Rosenthal & Howe, 1984). Persons with schizophrenia often have problems with organising the daily occupations, which results in a chaotic way of dealing with time (Melges, 1982; Neville, 1980; Neville, Kreisberg & Kielhofner, 1985), and a disharmony between the future images, plans of action, and emotions (Melges, 1982). Time appears to stand still, often because of a decreased ability to integrate perceptual information (Creek, 1997; Hartocollis, 1975). A volitional problem is common in persons with schizophrenia, and a social regression occurs with few roles to fulfil (Creek, 1997), which in turn further decreases the possibility of organizing the occupational performance (Neville et

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al., 1985). Weeder (1986) showed that compared to a normal population, participants with schizophrenia spent more time in passive occupations, and their social activities were mostly planned and initiated externally. Schizophrenia is a complex disorder where health cannot be understood in relation to biological aspects only (Tsang & Pearson, 2000). Since the human occupational pattern is a product of the person-environment interaction (Dunn, Brown, & McGuigan, 1994; Kielhofner, 1995, 1997; McLaughlin Gray, 2001; WHO, 2000; von Bertalanffy, 1968; Zemke & Clarke, 1996) it is of importance to explore the contextual factors involved in order to understand the complexity of occupation for persons with schizophrenia. This implies a dynamic perspective on occupation, and according to Law et al. (1996) occupational performance is shaped by the occupational, the environmental, and the personal domain. Few studies, however, consider contextual factors from all domains (Crist, Davis, & Coffin, 2000; Robinson, 1997). For example, Weeder (1986) did not focus on the environmental domain. Similarly, few studies have looked into who mentally ill people typically spend their time with. Furthermore, to fully understand the occupational pattern, it is essential to have a time-use perspective when studying occupational performance (Creek, 1997; Meyer, 1922/1977). A time-use perspective deepens the understanding of how persons with schizophrenia go about their daily lives (Suto & Frank, 1994). To have a time-use perspective means reflecting as realistic a picture as possible of daily occupations (Robinson, 1977; Rosenthal & Howe, 1984; Slagle, 1922; Suto & Frank, 1994). Occupational factors, such as satisfaction with daily occupations in a broad sense, have been shown to be strongly related to quality of life and other aspects of well-being among people with schizophrenia (Eklund, Hansson, & Bejerholm, 2001). No empirical studies, however, seem to have addressed what people with severe mental illness really spontaneously do in their everyday lives, what occupies their time, what activities they experience as satisfying and anxiety-provoking, and in what social and geographical environments they perform their daily occupations. Knowing more about their spontaneous patterns of daily occupations, and how these occupations are experienced, would be important knowledge for the planning of care for the severely mentally ill and for assisting them in setting adequate life goals, congruent with their abilities, interests, and their environmental context. This was the impetus for this study, which aims to investigate in depth the occupational performance in a group of persons with schizophrenia in a time-use perspective.

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METHODS Selection Procedure A consecutive sampling method was used in this study. The first 10 participants who entered a larger study (Eklund et al., 2001), of which the present study is a part, were chosen. The selection criteria for the larger study, as well as for the present part, were between 20-55 years of age, and had a diagnosis of schizophrenia based on DSM-IV (American Psychiatric Association, 1994). The participants were registered patients at an outpatient unit in a geographically defined catchment area in a Swedish town and had visited the unit within the past 12 months. The initial contact with the participant was taken by the patients primary contact person who asked for his or her consent. The subsequent contact was maintained by the interviewer, the first author of this study, and time for an appointment was set. This study was based on informed consent, and the project was approved by the Research Ethics Committee, Faculty of Medicine at Lund University. Participants Out of the ten participants that were included in this study, eight were men and two were women. Their age ranged from 20 to 55 years. Five participants were diagnosed with paranoid schizophrenia. Other subgroups of schizophrenia represented among the patients were the disorganized type, the catatonic type, and schizoaffective disorder. Three of the participants had a relationship with a person of the opposite sex, but only one of them lived with that person. Nine participants lived alone in their own flats. Three of them had satellite accommodation, which meant living near a group home and having the opportunity to contact the staff there. All participants took medication for their mental disorders and none of them worked or had any children. Instrument and Interview There is agreement among scientists that a time-use diary is the most adequate and valid instrument when collecting reliable data about peoples time use and occupational performance (Creek, 1997; Cynkin & Robinson, 1990; Ellegrd & Nordell, 1997; Juster & Stafford, 1991; Karlsson, Sderback, Synnerholm, Ekholm, & Bergroth, 1996; Kielhofner, 1995; Robinson, 1997). The instrument in this study was a 24-hour diary.

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Twenty-four hours is an appropriate time limit and the 24-hour diary has good validity when it is used on a group belonging to the same population (Szalai, 1972). The instrument used in this study is based on a time-use diary developed for a study run by Statistics Sweden, investigating time use and living conditions among men and women in Sweden (Statistiska centralbyrn, 1992). The instructions were somewhat modified because of anticipated difficulties regarding the participants ability to comprehend complicated information. The participants were asked to provide a description of their actual time use in the past 24 hours. The appointments for the recording of the time-use diary were set on a weekday, except Mondays, implying that all reports concerned information about time use during weekdays. The time-use diary was administered as a self-report questionnaire. The sheets were divided into four columns, each with rows representing one-hour intervals. Each column had a question on top, the first asking what the participant performed, the second about geographic environment, the third about social environment, and finally personal comments or reflections about the performance. The time-use diary was completed with a supplementary interview, which was recorded in writing. The interview emanated from the 24-hour diary and served as a complement. It helped the participant recall what she or he did, for how long, and so on. This served to increased the validity (Robinson, 1997), since different types of data sources minimize distortion from a single data source or from a biased researcher (Knafl & Breitmeyer, 1989; Krefting, 1991). The data collection took place at the outpatient clinic, which was familiar to the participants, and took about 45 minutes. Data Analysis To categorize the reported material, a content analysis was used. Content analysis is an unobtrusive method and the observer has no effect upon the material collected (Fox, 1992; Sommer & Sommer, 1991). First, the information from the time-use diary and the supplementary interview were integrated and viewed as a single set of information. During the course of the content analysis a structure of domains, factors, and categories emerged, related to occupational performance. They were, in part, hierarchic, as presented in Table 1. The domains were derived from theory (Law et al., 1996) and corresponded closely to the factors, which were represented by the four columns of the 24-hour time-use diary. The only divergence was that the personal comments and reflections, which formed one column in the di-

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TABLE 1. Domains, Factors, and Categories Related to Occupational Performance, as Analyzed in This Study
Domain Factor occupational performed activity personal care at home alone environmental geographic social personal emotional reaction escapism/ emptiness household work eating/drinking transportation mass media playful activity quiet activity professionals smoking indoor walking thinking/brooding sleeping talking outdoors health-care center shop restaurant/caf day-care center public places indoor other people social interaction anxiety/worry pleasure paranoid/afraid negative positive reflection on the outcome Category neutral

ary, comprised two factors, emotional reactions and reflection on the outcome. Thus, both the domain and the factor levels were developed before the start of the analysis. The data were then studied to identify categories among the factors. Eventually, the list of categories covered the reported material for each factor. An independent person checked the data analysis, and agreement was reached concerning the categories. No predefined occupational category system was used, since it was considered important to give as true a reflection as possible of the participants daily occupationsto discover what the participants were actually doing. The time-use diary instrument is complex. Often more than one activity is performed at the same time, which means that the activities overlap (Creek, 1997; Kielhofner, 1995; Robinson, 1977, 1985; Szalai, 1972). In this study this meant that the sum of time spent in the occupational categories added up to more than 24 hours. Furthermore, the analysis focused on the activities as performed on their own as well as on how they occurred in combination with other activities, which, according to Juster and Stafford (1991), gives a balanced account of the great variety of activities that fill up everyday life. Thus,

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the time spent in every separate performed activity was analyzed. Similarly, in an initial phase of analysis, the occupational performance factors were analyzed separately. In this initial phase, the social and geographic environment, the emotional response and reflection on the outcome, were analyzed according to reported time spent within these factors. The time use was summed up in minutes and rounded into hours with one decimal. The activities, however, were frequently performed simultaneously. Therefore, the analysis also focused on how an activity was combined with other activities, and no judgement was made about whether any of them was more important than the others. In this second step it was discerned to what extent the activity was performed as a single activity or in combinations. A third step of the analysis also included the environment in which the activity was performed and the personal reflections it gave rise to, giving a multifaceted picture of the actual performance. In this study, such a combination, based either on activity categories only or on a combination of categories from two or more factors, was called a module. The frequency with which the modules appeared was recorded. RESULTS The Occupational Domain: Performed Activities Table 2 shows the distribution of the different activities for each respondent. Among all performed activities sleeping was the category on which the participants spent most time. The least time was spent on seeing a professional from the health care. Everyone spent time on consuming mass media, eating and drinking, performing quiet activities, and personal care, but to varying extents. With respect to consuming mass media, five participants alternated between watching television, listening to the radio, and reading the newspaper. Four participants watched television only, and one participant only listened to the radio. Having coffee was the main activity for three of the participants with respect to eating and drinking. For every participant, more than 1.2 hours was spent in a quiet activity, which means sitting or lying, looking at other people or objects. One participant spent 9.4 hours in this type of activity. Personal care mostly meant getting dressed or undressed and going to the toilet. Personal care and household work were activities that were performed only for short periods of time. For example, seven out of ten par-

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ticipants reported that they bought microwave dinners and fast food, instead of performing household work themselves. Eight participants smoked cigarettes for 2.7-13.2 hours. Two participants did not leave their homes during the investigated 24 hours. As to transportation, the participants mostly walked. Five participants spent more than 2 hours walking around indoors, and also thinking and brooding was an ingredient in the daily life of five participants. Playful activities engaged seven participants. Musical instruments were played by three of them and the other participants did various things such as writing philosophical notes, browsing in or reading books, and painting in an occupational therapy session. Talking with other people was an activity that occurred among seven participants. Most of them small-talked with staff or visitors at day-care centers. Two participants reported having a whole conversation, and in these cases the interlocutors were employees at a day-care center.
TABLE 2. Each Participants Time Spent on Different Activities (24 hr.)
Occupational Domain

Factor
Performed Activity Participants Category sleeping smoking mass media quiet activity eating/drinking talking transportation indoor walking personal care playful activity household work thinking/brooding professionals 1 2 3 4 5 6 7 8 9 10 mdn

10 3.8 2 1.9 3 5 1.4 0.5 0.8 0.2 1.8

4.8 7.3 6.8 1.8 7.7 3.5 1.2 2.8 1 1 0.2 1.9

10.5 2.5 2.2 1.8 2.8 2.2 0.9 2 2.2 0.2 1.2

8 5.9 6.4 3.9 4.2 4.7 0.8 3 1.7 0.2 3 2.3

11 2.7 0.9 5.2 2.3 5.6 1.7 0.2 0.9 0.2 -

6 13.2 3 9.4 4.8 3.2 2 0.5 1.8 0.2 1.8 -

7.8 9.8 1.2 1.6 8.2 1.8 6.7 2.7 9.3 -

14 4.2 1 5.8 2.8 1 0.8 1 0.2 -

9 6 6.7 3.5 1 4 2.2 1.8 9 -

6.8 8.2 7.8 1.7 1.6 4 1.8 1.8 2 -

8.5 5 4.7 2.8 2.6 3.2 1.3 1 1 0.8 0.2 0.1 0

Note. Figures in bold show the most common activity for each participant. The figures denote amount of time spent on activities, given that two or more activities can be performed simultaneously.

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Times spent in single and combined activities are shown in Table 3. For example, the categories, personal care, household work, transportation, seeing a professional, and sleeping were activities mostly performed as separate, single activities. Walking indoors and thinking/brooding were always combined with other categories and eating/drinking, mass media, playful activities, quiet activities, smoking, and talking were mostly performed in combinations. To further assess how the performed activities were typically combined, the most frequent modules for the whole group were discerned (Table 4). Quiet activity together with smoking was the most common module; it was included in the 49 most frequently occurring modules. In 14 instances this module was combined with mass media and in 13 cases with eating/drinking. The Environmental Domain: Geographic and Social Environment Table 5 shows that, as regards the geographic environment, all participants spent most of their time in their home environment, from 15 up to 24 hours. Eight participants went outdoors, mostly around the neighborhood, going to small shops to buy cigarettes and snacks.

TABLE 3. Time Spent in Combined and Single Activities, as a Sum for the Whole Group, N = 10 (24 hr.)
Category personal care household work eating/drinking transportation mass media playful activity quiet activity professionals smoking indoor walking thinking/brooding sleeping talking 87.8 6 17.8 Single activity 10.6 5.7 4 1.2 8.8 2.4 9.1 3.9 1.8 Combined activity 1 4 26.8 0.1 38.1 11 27.6 3.3 49.6 19.9 23.4

Note. Figures in bold indicate the most frequent mode (single or combined activity).

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OCCUPATIONAL THERAPY IN MENTAL HEALTH TABLE 4. The Most Frequent Modules of Activities, N = 10 (24 hr.)

Number of Modules

Modules of Activities

15 14 13 7 7 6 5 5 4 4 4 3 3

quiet activity, smoking quiet activity, smoking, mass media quiet activity, smoking, eating/drinking quiet activity, thinking/brooding mass media, eating/drinking mass media, indoor walking, smoking talking, smoking, eating/drinking talking, smoking talking, eating/drinking talking, transportation mass media, eating/drinking, smoking mass media, indoor walking mass media, indoor walking, thinking/brooding

Note. The number of modules, regardless of duration, is reported here. Activity modules less frequent than 3 are not registered in the table.

Five participants visited day-care centers and spent between 0.7 and 3.8 hours there. For these participants the day-care center was the most common geographic environment outside their homes. There is also a social environment to consider. As indicated in Table 5, all participants but one spent most of their time alone. Two of the participants did not see anyone at all. Seven participants performed activities on their own while other people were in the same environment. For the group as a whole, the least time was spent in activities that actually involved other persons. The Personal Domain: Emotional Reaction and Reflection on the Outcome of Performed Activities The participants were asked to give personal reflections and comments about the activities performed. The result related to the personal domain was divided into two types of factors: emotional reaction while performing the activity and reflection on how the actual activity was

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TABLE 5. Time Use in Relation to Factors in the Environmental Domain, N = 10 (24 hr.)
Environmental domain Range (h) Mdn(h)

Factor
Geographic environment Category at home outdoors day-care center health-care center shop restaurant/caf public places indoors 15-24 0-3.1 0-3.8 0-1.5 0-1 0-1 0-0.5 19.2 1.7 0.4 0 0.2 0 0

Factor
Social environment Category alone other people* others involved** *Other people in the environment while performing the activity **Others involved in the actual performance 9.5-24 0-11.3 0-8.1 17.4 3.2 2.8

performed, the outcome (Table 6). The feeling of escapism and emptiness, expressed as I escape from reality or I feel empty, was an emotional reaction that nine of the participants experienced. Five out of these participants reported that this was the most common emotional reaction, and one participant spent as much as 17.6 hours feeling empty, wanting to escape the situation (Table 6). The second most common category for the group as a whole was anxiety and worry. Statements like I get restless and worried and I feel anxious were common among eight participants. Seven participants experienced pleasure, expressed in statements like at ease, excited, feeling pleasure, and for two of them this state of mind was the most common emotion. Five participants reported paranoiac reactions and being afraid. Usual comments were afraid that people are talking about me, watching me though I was alone and I was scared.

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A neutral statement, like it was okay, a habit, as usual, about how the activity was performed was the most common reflection on the outcome among every participant but one. Eight participants reported negative reflections regarding the outcomes on at least one performed activity. I couldnt concentrate, it had no meaning and it was too difficult were comments that occurred. Five participants were positive about how they performed their activities some time during the day. Comments like it was meaningful, I was confident, and I could concentrate were reported. The amount of time the participants reported spending on activities that resulted in each type of reflection on the outcome is shown in Table 6. Occupational Performance as Indicated by Different Modules of Occupational Performance Factors Table 7 shows occupational performance modules, as composed by the performance factors in this study: performed activities, the geographic and social environment, emotional reaction, and reflections on the outcome. Out of a total of 50 occupational performance modules,
TABLE 6. Time Use in Relation to Factors in the Personal Domain, N = 10 (24 hr.)
Personal domain Range(h) Mdn(h)

Factor
Emotional reaction

Category escapism/emptiness anxiety/worry pleasure paranoid/afraid 0-17.6 0-10.8 0-7.7 0-1 4.5 1.5 1.2 0.2

Factor
Reflection on the outcome Category neutral negative positive 1.1-13.8 0-4.8 0-4 5 1.4 0

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Table 7 shows the 14 most common modules, performed by four or more participants. All participants but one reported the following module: a combination of performing personal care, being alone, at home, and feeling neutral as to how the activity was performed. The second most common module involved consuming mass media and smoking, combined with being alone, at home, with negative reflections on the performance, and they all felt worried and anxious. As many as seven participants were positive about the outcome and experienced pleasure while performing a playful activity alone at home at least once during the 24-hour period. Further modules of occupational performance factors clearly demonstrate that most of them included being at home and alone, while the personal experience varied. With the exception of transportation, lonely occupations were exclusively performed at home. Neutral reflections were predominant in these modules, but the combination of negative reflections and the feeling of worry and anxiety were also common. Most modules that involved transportation involved feelings of paranoia and fear. When others were included in the occupational performance at home or in service settings, talking was the most common activity. Another
TABLE 7. The Most Common Combinations of Occupational Performance Factors, N = 10 (24 hr.)
Number of participants 9 8 7 7 6 6 6 6 6 4 4 4 4 Performed activities personal care mass media + smoking playful activity eating/drinking quiet activity quiet activity sleeping transportation Geographic environment home home home home home home home outdoors Emotional reaction, refl. on the outcome neutral negative, worry/anxiety positive, pleasure neutral escapism/emptiness worry/anxiety neutral paranoid/afraid, worry

eating/drinking
mass media + smoking + indoor walking

day-care centre
home

neutral
worry/anxiety

quiet activity
talking talking + eating/drinking + smoking + mass media

day-care centre
home home

neutral
negative, worry/anxiety positive

Note: Combinations that are performed alone are in normal type. Combinations that are performed when other people are in the environment are in italics. Combinations that are performed while interacting socially are in bold letters.

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social aspect, that people were present in the environment but not involved in the activity, was combined with either eating/drinking or quiet activity. These activities took place at a day-care center and were typically perceived as neutral. The module that included quiet activity, consuming mass media, eating/drinking, and smoking was performed both at home and at a health-care center. The only difference between these environmental contexts was that the health-care center triggered a negative reflection and feelings of anxiety, while the home environment was perceived as positive. DISCUSSION As little is known about the daily occupations of persons with schizophrenia, this study aimed to reflect as original a picture as possible. The least time was spent in habitual and playful activities, and in accordance with Weeders study (1986), passive activities were predominant. The passive lifestyle is characteristic of persons with schizophrenia (Weeder, 1986; Suto & Frank, 1994), compared to the general population, where as little as 5% is spent on passive activities (Juster & Stafford, 1991). According to Bonder (1997), the way in which social interaction is experienced has to do with the perception of where the control of events rests. Persons with schizophrenia have been shown not to experience control when social activities were externally initiated (Weeder, 1986). Perhaps some of the social activities performed by the participants in the present study, such as performing quiet activities while other people were in the environment, made the participants feel in control since the activity was not externally initiated. Perhaps they preferred a less active social role, where they could study and observe their environment at their own pace, interacting socially according to their own capability and keeping in control. The present study, like Weeders (1986), clearly showed how much importance, perhaps too much importance, professionals and different social activity centers place on the need for a whole conversation to take place. The staffs empathetic qualitiesbeing interested and understanding, listening to and respecting the patients (Bjrkman, Hansson Svensson, & Berglund, 1995)are qualities in the social environment that might be essential for persons with schizophrenia, for communicating with others. This study clearly demonstrated that the participants occupational pattern was characterized by passivity and a low level of structure and organization. Smoking clearly worked as a behavioral filler for most of

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the participants, similar to what was found in a study by Ziedonis and George (1997). What does it mean to have no temporal framework, but to be predominantly passive and to have no time-bound activities? For persons with schizophrenia, having a job is often associated with a better quality of life (Eklund et al., 2001). Still, individuals with mental health problems have been shown to derive less enjoyment, competence, and importance from work than working individuals without mental health problems (Crist et al., 2000). In relation to this result, the finding of a strong relationship between daily occupations in a broad sense and quality of life (Eklund et al., 2001) seems even more important to acknowledge. It remains to be determined, however, what positive effects account for the more favorable quality of life that comes along with performing daily activities (Priebe, Warner, Hubschmid, & Eckle, 1998), knowledge related to occupational health that is of special interest to occupational therapists. According to Strong et al. (1999), the quality of a persons experience is determined by the outcome of the person-environment-occupation transaction. It is, therefore, important to understand how different occupational performance factors contribute to a more or less effective performance (Bonder, 1997). The environmental factors are a hindrance or a help to people wishing to get involved in activities (Corcoran & Gitlin, 1997; Neville et al., 1985). In the present study, the environment did not seem to provide many external cues that triggered any internal processes or led to interaction. It is as if the activities were performed in a vacuum, and in some ways they resembled the institutionalized living conditions and the passive occupational situation in a hospital ward. Hocking (1997) says that situations like these decrease the opportunities to develop. Arranging and reshaping the environment would most likely shape opportunities for promoting occupational performance among the participants. This would form an important strategy for occupational therapists in their work with this group of clients, diminishing the gap between the clients adaptive capacity and the environmental demands (Schkade & Schultz, 1997). As mentioned above, most activities reported in this study were not triggered by a facilitating environment but rather from within the person, by basic, immediate life needs, a wish for satisfaction, or wanting to escape reality. This is in line with what was found by Suto and Frank (1994), that a person with schizophrenia has this preference for immediate and proximal goal setting. Also, the neutral reflections about the performance of these activities tell us that they were neither very meaningful and inspiring nor negative to perform. It was as if nothing really got hold of the participants, inspiring

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them to interact and seek new challenges. This implies that few activities were performed because they were, as Lobo (1998) put it, pleasurable and pursued for their own rewards. Still, persons with schizophrenia do experience enjoyment (Emerson, Cook, Polatajko, & Segal, 1998). Winnicott (1981) stressed that playful and creative activities promote a healthy development and a sense of doing. Such self-rewarding activities could be introduced as therapy and serve as a basis for a positive spiral of activities and development. The participants in this study spent little time performing these personally satisfying activities. Clark (1997), however, argued that a small amount of time engaged in these activities may be far more determinant of health and well-being than more time spent on minimally to moderately satisfying activities. Therefore, it could be suggested that occupational therapy for persons with schizophrenia should reinforce and extend the duration of these activities. If anything, the participants in this study had low time pressure, which is often associated with the lowest levels of mental health (Lobo, 1998; Zuzanek, 1998). Homeless people in a similar situation said that there was no such thing as time, because the activities they performed meant living outside society (Robinson, 1997). According to Suto and Frank (1994), the occupational therapist should have an important role in determining who might benefit from a more passive lifestyle, a safe haven. Should it then be a main purpose to help persons back to a technocratic, economy-controlled society, that is hard to relate to even for persons without disabilities? It might be a better solution to aim for activities and environments that, according to Clark (1997), are related to an original, more natural way of being. Still, the activities should have features that are similar to the society in general, since it is important for this group of people not to form a subculture and remain in a chronically disabled situation. To meet the lack of engagement in activity that was indicated in this study, structured time-limited activity programs might serve as a trigger to overcome lack of personal initiative to engage in daily occupations. This study did not consider gender differences in relation to time use and occupational performance. There might be differences in how women and men with schizophrenia use their time, and a study of gender differences in this respect seems warranted. There is probably no methodology by which the actual dynamics between occupational, environmental, and personal factors could be fully caught and revealed. In the present study, however, the way in which occupational performance factors were combined was studied to increase an understanding of the dynamics. Also, the time-use diary em-

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ployed is considered to come close enough, giving a realistic picture of ongoing lives (Robinson, 1985; Szalai, 1972). Still, the time-use diary and the supplementary interview could only reflect certain facets of what went on in the participants daily occupational repertoire. Whether or not a person with schizophrenia is capable of reliably filling in the self-report instrument and participating in the supplementary interview is a relevant issue to discuss. Cognitive impairments (Spaulding et al., 1999), flattening of affect, and a feeling of alienation (Gerhardsson & Jonsson, 1996) may influence the ability to identify recent experiences of everyday life by means of a questionnaire. Clinical experiences, however, have indicated that a time-use diary and a supplementary interview constitute an appropriate and useful method when assessing occupational performance among persons with schizophrenia. The time-use diary seemed to provide a temporal order, the natural logic in which activities are performed helped the participants to remember. Since little time passed between the actual performance and the recording of the experience, the occupational performance was still fresh in mind. In addition, the bias effect in the exaggeration of socially acceptable activities is also likely to be minimized (Robinson, 1977). The fact that this study is based on reports from a singular weekday may be seen as a limitation. In this study, however, it is not the individual perspective on time use and occupational performance that is in the center of attention. Rather, the focus is on persons belonging to the one and same population, sharing common features and patterns. When a group perspective is applied on time use, a 24-hour diary is normally used (Szalai,1972). In conclusion, the participants performed most activities alone in their home environment. Few occupational situations worked as a routine, providing a structure in terms of familiarity of habits. Apart from these few habitual activities and the playful activities reported, the participants did not really seem to interact with the environment; they were rather observing or escaping from it. Furthermore, many activities were accompanied with a feeling of emptiness and neutral reflection over the occupational outcome. These results converge into a picture of stagnation and emptiness permeating the participants occupational pattern and time use. From an occupational therapy point of view it would probably be important to help reshape the environment and help regain roles that involve interacting with the outside world.

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