CANADIAN JOURNAL OF OCCUPATIONAL THERAPY VOLUME 63 NO 1

BONNIE KIRSH

KEY WORDS

Occupational therapy in psychiatry

A narrative approach to
addressing spirituality in occupational therapy: Exploring persona! meaning and purpose

Spirituality
Values clarification

ABSTRACT

Spirituality has been recognized and documented as an essential component to be included by the occupational therapy profession in client-centred service delivery. However, methods of addressing and enhancing spirituality in occupational therapy practice remain relatively unexplored within the profession. This paper discusses the benefits of a narrative approach in addressing spirituality in everyday practice. It explores narrative as a mode of expression, its relationship to occupational therapy and its usefulness in addressing the spiritual component of the individual. A case study is provided to illustrate how a narrative approach enables an understanding of meaning and purpose in one's life.

Bonnie Kirsh, M.Ed., B.Sc.(0.T.) is a

Tutor in the Department of Occupational Therapy, University of Toronto, 256 McCaul St., Toronto, ON. M5T 1W5.

Il est reconnu et document que la spiritualit constitue un lment essentiel de l'ergothrapie dans la prestation des soins centrs sur le client. Il semble toutefois que les mthodes pour tenir compte de la spiritualit et la mettre en valeur dans la pratique de l'ergothrapie, demeurent relativement inexplores au sein de la profession. Cet article fait tat des aspects positifs d'une approche narrative pour tenir compte de la spiritualit dans la pratique quotidienne. Cette approche explore la narration comme mode d'expression, sa relation avec l'ergothrapie et son utilit pour aborder la composante spirituelle de la personne. Une tude de cas vient illustrer comment rapproche narrative permet une comprhension de la signification et de la finalit de sa propre vie.
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Spirituality has been recognized as an essential component of the individual within the model of occupational performance (Canadian Association of Occupational Therapists (CAOT), 1991). As such, efforts to clarify spirituality as a term and a concept have been undertaken (Egan Bz DeLaat, 1994; Urbanowski tk Vargo, 1994) and occupational therapists have articulated their views around ways in which the spiritual component influences occupational performance (Townsend, Krefting Burwash, 1991). However, methods of integrating this performance component into daily practice remain elusive, largely due to our limited knowledge in this area as well as a lack of clarity around methods to assess and address spiritual health. This paper will discuss the use of narrative approaches in occupational therapy to address the spiritual component of the individual, that is, to facilitate the exploration of meaning and purpose in one's life.

creation of individual narratives represents a primary means by which individuals make sense of their experiences.

NARRATIVES AND OCCUPATIONAL THERAPY

Recently, interest in eliciting stories from clients around the experience of illness and disability has grown in the health professions (Coles, 1989; Kleinman, 1988). Although occupational therapists have always drawn informally on clients' personal stories to develop goals and plan intervention strategies, the profession is now recognizing and utilizing narrative in a more formal way. The consistency of this approach with occupational therapy philosophy and values makes it an appealing choice. Eliciting narratives, or facilitating the emplotment of one's life, is an approach directed at the individual as a whole - his or her feelings, thoughts, perceptions and beliefs rather than the pathology itself. It places the narrator or client at the centre of the process, empowering him or her to voice himself or herself as he or she chooses. Narrative as a cognitive scheme is actively used to organize and interpret a person's encounter with the environment; it presents an awareness of a world in which human actions are linked together according to their effect on the attainment of individual desires and goals (Polkinghorne, 1988). As such, the narrative approach embodies the values and principles upon which our profession is built: holism, client-centredness, and the significance of person-environment interaction. Some documentation of narrative as a form of hermeneutic expression in which human action is understood and made meaningful can be found in the occupational therapy literature, though it is written primarily from the point of view of finding meaning in the therapeutic encounter itself. Hasselkus and Dickie (1994) elicited experiential narratives from practising occupational therapists to derive dimensions of the lived experience of doing occupational therapy. Helfrich, Kielhofner and Mattingly (1994) illustrated how volition is embedded in personal

NARRATIVE EXPRESSION
Narratives are fundamental and universal ways of interpretation in which humans make sense of their life experience through stories and metaphors (Spencer, 1993, p.120). The cognitive psychologist Bruner (1990) describes human nature as deriving meaning through story: "our capacity to render experience in terms of narrative is an instrument for making meaning that dominates much of life in culture - from soliloquies at bedtime to the weighing of testimony in our legal system... our sense of the normative is nourished in narrative but so is our sense of breach and exception. Stories make reality a mitigated reality (p.97). Narrative recreates experience through the eyes of the experienced, and brings with it the richness of personal and social history. It tells not only of past actions and events but how individuals understand those actions, that is, meaning. Individual realities are created based on subjective experiences of the objective, and narrative structures provide a format into which "experienced events can be cast in an attempt to make them comprehensible, memorable, and shareable" (Olson, 1990, p.100). The

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narratives, explaining that motivation to choose and act results from the context and meaning uncovered. Helfrich and Kielhofner (1994) examined life experiences as they impact on the meaning derived from therapy and advised: c'occupational therapy can only transform lives if patients see meaning and relevance to their own life stories. The task of occupational therapy is to become an episode in the patient's narrative" (p.324). Mattingly (1991), in her article on clinical reasoning, echoed this theme as she stated: "the therapist and patient must come to share a story about the therapeutic process: they must come to see themselves as in the same story...an as yet unfinished story" (p.1002). Accounts of employing narrative approaches for therapeutic purposes are limited in the occupational therapy literature, although some research around the therapeutic value of life review does exist. For example, Froehlich and Nelson (1986) studied the affective meanings of life review in a geriatric population and reported that expression of positive life events appeared to be a positive experience for elderly individuals. McQuaig and Frank (1991) described a narrative process in which meaning was attributed by a woman with cerebral palsy to her own personal competence through a series of interviews. This kind of transformative process is evidenced in Murphy's (1990) account of his own experience with disability and the value of continued engagement in work in maintaining a sense of meaning in his life. It is this emphasis on discovering personal meaning and purpose in life through narrative that holds promise for the practice of occupational therapy.

NARRATIVE AND SPIRITUALITY

The Occupational Therapy Guidelines for Client-Centred Practice (CAOT, 1991) state that t'as spiritual beings, individuals are concerned with the nature, the meaning of life and their purpose and place in the universe" (p.18). Subsequent Occupational Therapy Guidelines For Client-Centred Mental Health Practice (CAOT, 1993) describe spirituality as a critical element
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underpinning occupational therapy intervention, and acknowledge that clients' personal knowledge and experience of living with disability enables them to "seek personal meaning and purpose (a personal sense of spirituality)" (p.6). Egan and DeLaat (1994) define the spirit as "our truest selves which we attempt to express in all of our actions" (p.96) and suggest that each individual's spirit is expressed through engagement in everyday life, that is, through occupational performance in self-care, productivity and leisure. Similarly, Urbanowski and Vargo (1994) define spirituality as the experience of meaning in everyday life activities (a here-and-now event) and carefully distinguish this definition from the meaning of life which, they state, is a level of philosophical reflection which escapes the conscious awareness of most people. It is argued in this paper, however, that reflection upon one's life, the path it has taken, and the road ahead is an important process in meaning-making, and the basis for a narrative approach to addressing spirituality in occupational therapy. As stated by Muldoon and King (1991): "Every human being has a spirituality. The direction one gives to one's life, the story one tells with one's life, is itself rooted in and embodies a certain way of looking at life" (pp.100-101). Through stories we attempt to clarify and understand what life is about; we try to make sense out of life, in the same way we try to make sense of a text when we interpret it. Drawing on previously cited concepts around spirituality which emphasize personal meaning and purpose as core issues in defining the term, the appropriateness of utilizing narrative approaches to enhance the spiritual component of the individual emerges. The power of narrative in the search for personal meaning and purpose is stated by Polkinghorne (1988) "Through the action of emplotment, the narrative form constitutes human reality into wholes, manifests human values, and bestows meaning on life" (p.159). The meaningfulness and sense of purpose of one's life can be reflected in one's narrative identity: the unity of a person's life is expeAPRIL 1996 * 57

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rienced and articulated in stories that express this experience (Widdershoven, 1993). Spiritual enrichment may occur through narrative as one frames and reframes actions and events and retrospectively revises, selects and orders past details in order to justify and find purpose in one's current life situation. Furthermore, this process may help individuals in the construction of future stories, projecting hopefulness and a sense of purpose to their futures. As stated by Polkinghorne (1988), "If a person fails to project a hopeful story about the future, he or she undergoes a certain kind of unhappiness, a life without hope ... there needs to be some continuity between past and future stories ... as narrative forms, these stories draw together and configure the events of one's life into a coherent and basic theme"(p.107).

NARRATIVE METHOD Occupational therapists are, for the most part, highly skilled in eliciting historical and contextual information about a person's life. Interviews, observation, reports from significant others and related activities have held a prominent place in the ongoing assessment and information-gathering stage of the occupational therapy process. The purpose of these activities has been to gain historical information to be used in planning and implementing appropriate occupational therapy programmes. In most cases, the emphasis is on reliability of information, observable behaviour and consistency between the clients' and others' perspectives. However, a narrative approach to looking at one's life deals with the issue of truth differently. Narrative analysts take the position that narrative constitutes reality: it is in the telling that one makes real phenomena in the stream of consciousness (Young, 1987). As stated by the Personal Narratives Group (1989): When talking about their lives, people lie sometimes, forget a lot, exaggerate, become confused, and get things wrong. Yet they are revealing truths. These truths don't reveal the past as it actually was, aspiring to a standard of objectivity. They give us instead the
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truths of our experiences...Unlike the truth of the scientific ideal, the truths of personal narratives are neither open to proof nor selfevident. We come to understand them only through interpretation, paying careful attention to the contexts that shape their creation and to the world views that inform them (p.261). Narratives are dynamiC, ever-changing reconstructions of life which are themselves the products of psychological, sociological and historical influence. The life story itself is seen as a social construct in its own right. This view of truth as a concept separate from that defined by formal science, impacts upon methods employed to facilitate spiritual exploration through narrative as well as the relationship between the therapist and the narrator. Narrators do not simply reproduce prefabricated stories regardless of the interactional situation, but rather create their stories within the "social process of mutual orientation" (Rosenthal, 1993, p.64) according to their perception of the interview situation. The narrative presentation is, in part, a product of the interaction between therapist and client. The adoption, on the part of the therapist, of a role of one who interacts with clients to understand their social constructions, is consistent with the view of reality as an everchanging, socially constructed phenomenon. Unlike a traditional information-gathering session, the therapist will not be following a specific interview format nor seeking out predetermined categories. Interviews should be "discovery-oriented" (Van Manen, 1990, p.29), that is, they should attempt to reveal the experiences and meanings attached to the world they explore. The therapist must be open to the unexpected, and must listen carefully, giving the narrator or client scope to develop his or her train of thought. Freedom to pursue topics of his or her choice may foster the process by which a client constructs an identity and makes meaning through his or her stories. Material which may, at the time, seem to be disconnected or irrelevant may connect with the broader picture as the story
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unfolds or as further reflection takes place. To the client, such accounts may help to fit the pieces together, to draw conclusions, and to give continuity to the story so that it remains a comprehensible whole. Hankiss (1981), a researcher who uses the life history approach in gathering data, describes this process: "Human memory selects, emphasizes, rearranges and gives new colour to everything that happened in reality; and, more important, it endows certain fundamental episodes with symbolic meaning, often turning them almost into myths, by locating them at a focal point of the explanatory system of the self" (p.203).

CAS E STU DY
Don (not his real name) is a 29 year old male, who has been involved in the mental health system for a period of ten years and who is working full time as a mail clerk for a large corporation. He regularly attends a community mental health programme during his non-working hours and sees his psychiatrist monthly. During a lengthy session, Don told his story using a plot that consisted of several chapters and themes. Don's story begins at a critical time in his life, a series of chapters describing his entry into mental illness, his changing self-perceptions, and the subsequent struggles in his life. I was at university studying to be an accountant, and a simple balance sheet was no longer easy for me to do ... I had 90s going into university in accounting and I won a stock market championship held across the province and my research skills were high above anyone else at school and when I came to university I couldn't even get a C average in my best subject, I became very angry and frustrated. And instead of being able to hit the books basically I started reading books on mental illness, wondering what was wrong. Having set the scene, Don identifies the day, in fact the moment at which his identity and life course changed:

One night I was at an exam and I couldn't concentrate...I talked to the teacher and I told her some of the problems I was encountering, she said maybe we should go over to the hospital and get some help. She stayed with me for nearly two hours in the emergency room while the doctors interviewed me and realized that I needed help. I was away from home and I was admitted that night and I began my treatment for schizophrenia. In constructing his story and developing his own personal identity Don explores the many character roles he has fulfilled, one of which is that of patient. It is a part of his history, and he frames it as such. He is able to do so, as it now has its place as a piece of this single unfolding and developing story. As stated by Sarbin (1986): "one may play different characters which give temporary periods of identity during one's life span. But these various roles - the precious child, the good student, the fast tracker, and so on - all take on meaning from the single perspective that is one person, as defined by the life plot" (p.17). Hence we see Don's ability to use the chapter in which his character is one of patient as a place from which to construct a subsequent chapter describing his character as worker, thereby defining further his own self and the meaning to his life. When I got a job, I told the interviewer then that I had a mental health problem, I told him up front, and he said,look, as long as I know that you're getting treatment we'll give it a shot...[work] occupies my time, it focuses my mind on other things besides my illness, the thoughts that disturb the way I think are not as prevalent when I'm working as when I'm unemployed... when I'm working I'm in a structured environment, I am contributing to society, I feel I'm doing something good not only for myself but for society as a whole...the job provides structure to my day. It makes me feel as if I'm important. I'm not just another statistic. I'm doing something productive with my life.
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It is this theme of productivity and self efficacy that now pervades Don's reality. Carr (1985) tells us that narration is an extension and confirmation of the primary features of one's reality. He notes that everything that happens to a person is part of his or her life; however in one's self-stories the extraneous details are pushed into the background through the capacity of selection: "In planning our days and our lives we are composing the stories or the dramas we will act out and which will determine the focus of our attention and our endeavours, which will provide the principles for distinguishing foreground from background" (p.117). Clearly, in telling his story, Don does not deny his status as a person with a major mental illness, but carefully places it in the background, allowing other roles and capabilities to flourish: It's not hard for people to see that I have a physical disability. It's harder for them to know I have a mental disability, because it's not as apparent...But people respect me...it's nothing to be ashamed of to say you suffer from a mental health problem...people know who I am and they know I put in an honest day's work and people, not just the average employee but the people at the top, actually care about me. I can honestly say that my firm has gone the extra mile for me and I continue to go the extra mile for them... The narrative approach within psychology is often seen as a process of redefinition (Widdershoven, 1993). Through his narrative, Don is able to redefine his own identity from one in need of help to one who helps others: My mother was dying of lung cancer and so I bought a car to get her to and from the hospital for chemotherapy...the increased salary led to being able to do things for my Mom and Dad who had done literally millions of things for me before...it felt very good. My Mom was dying and here was I, her son, making the effort to help her when she needed it most.

Through the narrative process Don was able to realize how his acts of kindness brought meaning, a sense of purpose and fulfilment to his life, resulting in a deepened sense of spirituality and a strengthened identity as a productive and humane individual. The process of emplotting his life enabled Don to configure the events of his life into a story with themes around productivity, humanity, personal efficacy and identity as a person other than a patient. He was able to connect with the meaning and purpose in his life, to enhance his own spiritual self so that he experienced a sense of selfactualization and hope for the future.

CONCLUSION
This paper has discussed the use of narrative in occupational therapy as a method of addressing meaning and purpose in one's life, thereby exploring one's spiritual self The essence and identity of one's self can be achieved through narrative, as can the process of realizing the possiblities in one's life. Meaning and purpose in one's life are linked to a person's life story, which connects up the actions into an integrating plot. "The realization of self as a narrative in process serves to gather together what one has been, in order to imagine what one will be, and to judge whether this is what one wants to become" (Polkinghorne, 1988, p.154) It is a method which holds promise for the practice of occupational therapy, as the profession embarks upon understanding and enhancing spirituality amongst its clients.
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Carr, D. (1985). Life and the narrator's art. In J. Silverman, & D. Idhe. (Eds.). Hermeneutics and Deconstruction. (pp.108121). Albany, NY: State University of New York Press.

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