Health and the Human

Spirit for Occupation

Elizabeth J. Yerxa
Key Words: chronic disease health human
activities and occupations
The relationship between engagement in occupation and
healthfUlness is explored Health is viewed not as the ab-
sence oforgan pathology, but as possession ofa repertoire of
skills that enables people to achieve their vital goals in their
own environments. This sort ofhealth, reflecting adapt-
ability anda good quality oflife, is possiblefor all people,
including those with chronic impairments.
Theoretical and research literature from an array of
disciplines explores the influences ofoccupation on various
aspects ofhealth. These include interests, satisftction in
everyday doing, balance, the latent consequences ofwork,
and transcendence. Support is providedfor a relationship
between activity level and survival. To improve the life
opportunities ofthose they serve, occupational therapists
need to become ardent students oflife's daily activities,
grappling with the ambiguity and complexity ofoccupa-
tion, the occupational human, and the contexts in which
occupation takes place.
Elizabeth]. Ywca, EdD, LHD (Han), SeD (Han), OTR, FAOTA, is
Discinguished Professoc Emerita, Departmenc of Occupacion-
al Therapy, University of Southern California, Los Angeles,
California. (Mailing address: Route 1, 196 Columbine,
Bishop, California 93514)
This article was acceptedfor pub/icati.on March 17, 1998.
R
eilly's (1962) fundamental hypothesis "that man,
through the use of his hands as energized by
mind and will, can influence the state of his own
health" (p. 2) proposes a significant relationship between
engagement in activiry, as dictated by the human spirit
for occupation, and healthfulness. I shall explore that
connection by describing my views of occupation and
health, sharing some assumptions, reviewing relevant
ideas from an array of disciplines, and drawing implica-
tions for occupational science and its application in occu-
pational therapy.
This article is based on my continuous search for
ideas from other disciplines, a synthesis of which may
contribute to the scholarly foundations of occupational
therapy (occupational science) and should therefore be
seen as a work in progress.
Views of Occupation and Health
The human spirit for activiry is actualized, in a healthy
way, through engagement in occupation: self-initiated,
self-directed activiry that is productive for the person
(even if the product is fun) and contributes to others.
Occupations are organized into patterns or the "elemen-
tal routines that occupy people" (Beisser, 1989, p. 166).
These activities of daily living (ADL) are categorized by
our culture as play, work, rest, leisure, creative pursuits,
and other ADL that enable us to adapt to environmental
demands. Dewey's (1910) criteria for a child's occupa-
tion were that it be of interest, be intrinsically worth-
while (relevant personally and socially), awaken curiosiry,
and lead to development. Engagement in occupation
enables humans to learn competency.
I shall view health, not as the absence of organ pa-
thology, but as an encompassing, positive, dynamic state
of "well-beingness," reflecting adaptabiliry, a good quali-
ry of life, and satisfaction in one's own activities. Notice
that this perspective of health does not exclude persons
with disabilities. They may have irremediable impair-
ments but still possess the potential to be healthy, for
example, by developing and using skills to achieve their
vital goals (Porn, 1993).
What is the connection between engagement in
occupation and health? This question is crucial for
humankind in the new millennium, for the 21st century
will certainly usher in an unprecedented "era of chronici-
ry" due to advances in medicine's abiliry to preserve life.
What is thought about how people, including those with
chronic impairments, achieve healthfulness through the
use of their hands, minds, and will?
Assumptions
I always urge my graduate students to make their as-
june 1998, Volume 52, Number 6 412
sumptions explicit, so I have to follow my own advice:
1. I shall view people as complex, multileveled (bio-
logical, psychological, social, spiritual), open sys-
tems who interact with their environments (Kagan,
1996) by using occupation to make an adaptive
response to its demands. Consequently, human
beings cannot be reduced to a single level, say that
of the motor system, and retain their richness or
identity. Similarly, water cannot be reduced to hy-
drogen and oxygen and still be wet and drinkable.
2. The occupational therapy profession is founded on
an optimistic view of human nature (Reilly, 1962).
Occupational therapists discover a person's resources
and emphasize what that person can or might be
able to do instead of the person's incapacities;
what's right instead of what's wrong. We are "search
engines" for potential. Our profession is commit-
ted to improving life opportunities for all people,
including those with so-called chronic impair-
ments, a category that includes most of the per-
sons we serve.
3. The postindustrial society is in danger of creating
masses of throw-away people, a burgeoning under-
class whose chronic impairments, homelessness,
mental illness, and inadequate education and skills
leave them outsiders in an increasingly technical,
complex, and fast-paced society. In important
respects, most of society, except for an elite super-
class, may become an endangered species occupa-
tionally. As Beisser (1989) said when he lost the
ability to work as a physician due to paralysis, "My
place in the culture was gone" (p. 167). Similarly,
for large segments of society, Rifkin (1995), an
economist, predicted the "end of work." Work as
we have known it may be replaced by a "technop-
oly" managed by an elite class who keeps the robots
and computers operating, leaving millions without
a job or a place in society. This endangerment to
health and well-being is profound because our soci-
ety lacks an agreed-upon, valued substitute for
work. Because we often view work as an economic
necessity rather than a biological, moral, and social
imperative, we frequently fail to recognize the po-
tential impact of unemployment and loss of occu-
pational role on human health. The more than
70% of working-age persons with disabilities who
are currently unemployed provides a window into
the future (Bickenbach, 1993).
Relation of Engagement in Occupation to Health
Interests
Storr (1988), a British psychiatrist, proposed that our so-
ciety has overvalued intimate relationships while paying
The American Jou,.naL ofOccupationaL Therapy
too little attention to "work in solitude" as a source of
health and happiness. Two opposing motives operate
throughout life, one to bring us closer to people and
another for autonomy. The second is as important as the
first.
Creative persons classed among the world's great
thinkers often lacked close personal ties. For example,
Descartes, Newton, Kant, Nietzche, Kierkegaard, and
Wittgenstein lived alone for most of their lives, finding
their chief value in the "impersonal" (Storr, 1988). The
impersonal includes interest in doing almost anything from
breeding carrier pigeons to designing aircraft. Such interest
contributes to the economy of human happiness by fulfill-
ing the need for autonomy, leading to both adaptation
and creativity.
Storr (1988) criticized psychiatry and the social sci-
ences for overlooking the importance of pursuing inter-
ests to meaning, happiness, discovery, creative contribu-
tion, and the human search for some pattern that makes
sense out of life. Such pursuits can be a matter of life and
death. Acting on interests may prevent mental collapse
and subsequent death for persons in states of extreme
deprivation. The capacity to be alone while pursuing one's
unique interests is a valuable health resource, fulfilling the
need for autonomy and achieving personal integration
through activity one believes is worth doing. Interests
energize occupation.
Satisftction in Everyday Doing
When I become discouraged by the high-tech, business-
oriented, specialist trajectory of our culture, I read Adolph
Meyer (1931/1957). He never fails to revitalize my enthu-
siastic respect for the idea of occupation. Meyer (1922/1977)
focused on the person's everyday doings and actual experi-
ences as primary resources for health. Health was assessed
by one's relative capacity for satisfaction, "doing and getting
enough" in those cycles of activity and composure that mark
the rhythms of life. Meyer's (1931/ 1957) formula for satis-
faction included the components shown in Figure 1. His
view of satisfaction and health suggests major concepts
for investigation by occupational scientists. For example,
capacity implies that people be viewed as individuals who
PERFORMANCE AND MOOD
SATISFACTION =
CAPACITY; OPPORTUNITY; AMBITION
= (in the light of) AVISION OF ULTIMATE ATIAINMENT
AND APPRECIATION BY OTHERS
Figure 1. Formula for satisfaction (Meyer, 1931/1957, p.
81 ).
413
have unique skills and resources; opportunity requires
attention to environmental qualities such as novelry, affor-
dances, attractors, and challenges that will stimulate activ-
iry; and ambition involves energizers of action as
interest, curiosiry, will, desire, and personal perceptions of
skills. In interaction, these contribute to satisfaction by
influencing both performance (generating feedback) and
mood (encompassing one's being).
Meyer (1931/1957) placed this dynamic relationship
within a cultural context, showing that both other peo-
ple's appreciation of what we do and our own expecta-
tions of ourselves contribute to satisfaction. The formula
suggests that health may be influenced by discovering or
developing new capacities, changing the
nurturing ambition, improving performance and modI-
fying mood, all in ways appreciated by one's culture and
acceptable to oneself. Meyer (1922/1977) proposed that
occupational therapists provide opportunities rather than
prescriptions in the spirit of this formula.
His formula applied to aLL people-physicians, psy-
chiatric patients, and the public. Thus, health via satisfac-
tion was possible for all, rather than requiring a special,
separate track for those with psychopathology. Patients
with mental illness were part of the mainstream of sociery,
seeking the same satisfactions as anyone else, capable
thereby of influencing their own health.
Meyer (1931/ 1957) saw potential everywhere; all
people possessed assets and capacities: "A st.udy and of
the assets, at the same time we attempt a dIrect COrrection
of the ills, is the first important condition of a psychobio-
logical therapy" (p. 157). But he was not blind to the
challenge he posed: "To use the patient's assets is a more
difficult problem than using something under our con-
trol" (p. 157). Capabilities discovered and nurtured could
overcome psychiatric problems, which he viewed as prob-
lems of adaptation.
Meyer's (19311 1957) optimistic view of people em-
phasizing their resources, capabilities, habits, and skills
that enable them to adapt to their environments with joy,
satisfaction, and harmony places the spirit for occupation
as central to human healthfulness. It is remarkable that
his philosophy was applied in the early 1900s, long before
the advent of psychotropic medications, because his pa-
tients must have exhibited severe symptoms rarely seen
today. Yet he viewed even these persons as capable of
healthy satisfaction through occupation.
Balance
Activity. Many theorists whose ideas are relevant to occu-
pation and health propose the need for some sort of
"healthy" balance. For example, Meyer (1922/1977) noted
that people organize themselves in a kind of rhythm as
they carry out their daily rounds of activiry. To be healthy,
people needed to be attuned to
the larger rhythms of night and day. of sleep and waking hours, of
hunger and its gratification and finally the big four-work and play
and rest and sleep which our organism must be able to balance even
under difficulty. (p. 641)
Meyer asserted that only by "actual doing" (p. 641) or per-
formance could this balance be obtained. Consequently, all
people needed to be provided with opponunities to work,
to achieve pleasure in their own achievement, and to learn a
happy appreciation of time and the sacredness of the
moment. This balance was learned through organizing one's
own actions.
Porn (1993), a contemporary philosopher, related
health to people's ability to achieve their own goals
through engagement in daily life activities and routines.
He viewed people as acting subjects (not reacting objects).
People, as actors, draw on three essentials: "a repertoire,"
an organized collection of abilities to act; an environment;
and goals. Vital goals are personal objectives necessary for
minimal happiness (p. 303). According to Porn, health
consists of achievement of a complex balance or equilibri-
um between people's environmental circumstances and
the abiliry to realize their goals through a repertoire of
abilities. Health is a kind of wholeness and general adapt-
edness that does not require freedom from pathology.
How could such healthfulness be assessed? We could
look at the adequacy of one's repertoire (organized abili-
ties to act), the appropriateness of one's environment (es-
pecially the opportunities it provides to,
and the extent of realism in the persons goals In relation
to both the environment and the repertoire.
How might health be fostered in a way that preserves
and defends adaptation? This might be accomplished by
addressing the repertoire (e.g., developing new skills for
increased competence), the environment by modifying its
challenges, and the goals by helping the person alter his or
her objectives. All three components need to be balanced
for holistic care directed toward human agency.
Occupational therapists know this in their bones and
hearts. In Sweden, they participated in research that vali-
dated Porn's (1993) theory between persons with and
without impairments. In this research, abiliry to achieve
one's vital goals (via a repertoire of skills) was found to be
more important to life satisfaction than degree of physical
impairment among those with stroke (Bernspang, 1987).
Other theorists who have related balance to health
include Csikszentmihalyi (1975), who posited the need
for a balance between self-perceived skills and environ-
mental demands, and Reilly (1962, 1969, 1974), who
related health to a balance between degree of environ-
mental challenge and capaciry for learning the skills, rules,
june 1998, Volume 52, Number 6 414
and habits necessary to fulfill occupational role expecta-
tions. Offering a "just-right challenge" that enables an
adaptive response promotes a crucial balance for health-
promoting occupational therapy practice.
Inftrmation. Klapp (1986), a sociologist, proposed
the need for another sort of balance concerning informa-
tion and action. Today, health is threatened by the bore-
dom that permeates postmodern life, creating a thick
cloud over people's everyday experience. We feel trapped,
satiated, habituated, and desensitized because we are bom-
barded by meaningless stimuli from the media, "noise"
that requires no response. Listen to the monotonous, ever-
urgent tones used by announcers and observe the sheer
volume of noise created by the endless commercials and
repetitious banality of the media. "Our ears are over-
whelmed while we are denied a voice," Klapp observed
(1986, p. 51). He defined information as "useful knowl-
edge," contrasting it with "entropy" (p. 120), a tendency
to randomness and confusion. When input does not
arouse interest but continues relentlessly, people often
escape into passivity or health-threatening "social place-
bos," such as alcohol, drugs, and other mood-altering
addictions.
The desired balance that buffers boredom and con-
tributes to health consists of "meaningful variety" that
encourages learning and "meaningful redundancy," which
is so familiar, reliable, and reassuring that it contributes to
warm memories and a sense of community (Klapp, 1986,
p. 118). (I think here of cultural rules and rituals.) People
need to develop skill to respond to this overload of mean-
inglessness by learning to view their boredom as a signal
for action. To be healthy, they need to be taught to create
an individualized balance of meaningful variety and re-
dundancy through discovering, developing, and acting on
their own interests and by participating in the rules, hab-
its, and rituals of their cultures.
Meyer's (1922/1977) vision of providing opportuni-
ties rather than prescriptions, contributing to perfor-
mance and mood, offers occupation as an alternative to
this health-threatening imbalance. Instead of escaping
into unhealthy social placebos to alter their moods, peo-
ple could learn to achieve their own balance of meaning-
ful variety and meaningful ritual through engagement in
activity worth doing.
Aristotle might have been right about the golden
mean. Health as adaptation, satisfaction, and quality of
life experience seems to require achievement of a desirable
balance between environmental and personal attributes.
Such a balance is highly individualized and is learned
through opportunities to act on the environment as an
agent. We need to learn much more about such healthy
balances and how they might be fostered.
The American Journal ofOccupational Therapy
The Latent Comequences ofWork
Recently a psychiatrist asked me, "Why is work so im-
portant to our patients? Why can't some other activity
take its place?" Liebow's (1993) anthropological study of
homeless women revealed their obsessive preoccupation
with looking for and finding a job. Our own research
with men who had spinal cord injuries found that they
reserved the category of "work" almost exclusively for paid
employment, even though they were engaged in many
occupations that could have been called work (Yerxa &
Baum, 1986). How is participation in the apparently sig-
nificant occupation of work related to health as adapta-
tion?
In technologically sophisticated societies, work is sep-
arated from other activities, such as leisure. Relationships
that are largely based on work constitute a major source
of societal structure and order (Argyle, 1987). Work ap-
pears to have a psychologically stabilizing effect on peo-
ple. Leisure, to be satisfYing in any important sense, needs
to be viewed as the moral equivalent of work (Argyle,
1972) to fill its culturally significant role. People who are
unemployed and have no organized leisure often become
depressed, losing their sense of identifY and purpose in
life as well as their health.
Jahoda (1981) asked, why is work, as Marx observed,
such a fundamental condition of human existence that
people eat to work, not the other way around? She differ-
entiated the "latent consequences" (p. 188) of work from
its manifest outcome of earning a living. Latency meant
the unintended but significant "by-products" of being
employed (p. 188). Five latent consequences of employ-
ment seem relevant to health:
Employment imposes a time structure on one's day.
Employment implies regularly shared experiences
and contacts with persons outside one's immediate
family.
Employment links persons to goals and purposes
transcending their own.
Employment defines important aspects of personal
status and identity.
Employment enforces activity, providing a predict-
able demand for action. Qahoda, 1981, p. 188)
Jahoda (1981) did not address the experience of "flow,"
that autotelic satisfaction in simply doing the work (Csik-
szentmihalyi, 1975), which is an important product for
many people, nor did she discuss work's latent conse-
quences for social units such as the family. However, her
observations support the importance of work to health.
Remove employment and yOli remove a person's strongest
tie to reality (Freud, 1930), hls or her place in the culture,
threatening healthfulness. Work is supportive of health
415
even under poor conditions. People may dislike their jobs,
bur they often dislike unemployment more (Argyle, 1987).
I still await the predicted utopia in which leisure be-
comes our major occupation. For leisure to be health
promoting, it would have to convey the same latent con-
sequences as work. Instead, the laboratory of unem-
ployed persons with impairments and others who have
lost their jobs due to corporate downsizing demonstrates
the stubborn significance to health and quality of life of
having work worth doing.
In many respects, the desire to engage in the occupa-
tion of work and its significance to human health and
happiness are not fully appreciated until the opportunity
to engage is taken away, whether by revolutionary social
upheaval, as in today's postindustrial, increasingly auto-
mated society, or by the onset of impairment. Vash
(1981), a woman who was severely paralyzed by polio as a
teenager and later became a psychologist, put it this way:
"The impact of disablement is largely contingent on the
extent to which it interferes with what you are doing" (p.
15), not only the actual activities, but also the potential
ones. Beisser (1989), who had been an ardent tennis
player and medical student before he contracted polio,
believed that "my place in the culture was gone" because
he was no longer able to engage in the "elemental rou-
tines that occupy people" (pp. 166-167) and was discon-
nected from the familiar roles he had known in family,
work, and spons. Yet the public, seeing Carolyn Vash
and Arnold Beisser, would probably view inability to
move as their most important characteristic, rendering
them "disabled." Important though such impairment is,
preoccupation with the loss of motor control blinds us to
the signitlcant loss of something important to do, the frus-
trated spirit for occupation, no longer served by their bod-
ies, culture, or environment. Both of these articulate peo-
ple believed that this loss was more important than their
physical impairments. They echo Porn's (1993) theory of
health and Jahoda's (1981) latent consequences of work,
revealing the connection between engagement in occupa-
tion and healthy adaptation.
Transcendence
The experiences of persons incarcerated under extreme
conditions of deprivation and despair support the tran-
scending effects of engagement in occupation that fosters
survival and sanity (Storr, 1988). Frankl (1984), a psychia-
trist who lived through Auschwitz, stated: "In the Nazi
concentration camps, one could have witnessed that those
who knew there was a task waiting for them to fulfill were
most apt to survive" (p. 126). He reported that psychiatric
investigations into Japanese, North Korean, and North
Vietnamese prison camps reached the same conclusions.
The manuscript of Frankl's first book was confiscated
when he was searched before incarceration. He felt this as
a profound loss. His unfulfilled desire to rewrite the book
not only helped him survive the rigors of camp life, but
working on it, reconstructing the manuscript, and scrib-
bling key words in shorthand on tiny scraps of paper, also
enabled him to ward off attacks of delirium. Engagement
in occupation, albeit mental, also enabled him to tran-
scend his immediate disgust and despair. He visualized
himself in a warm lecture room in front of an attractive
audience. He was giving a lecture on the psychology of
the concentration camp. By so doing, he rose above the
suffering of the moment. Occupation enabled him to
objectify and describe his oppressing situation from the
"remote viewpoint of science" (Frankl, 1984, p. 95), trans-
forming his emotions from despair into an interesting
scientific study that he, himself, conducted.
Extreme environmental degradation reveals the po-
tential transcending effects of occupation in stark clarity.
People were more likely to survive such conditions when
they had interests and tasks worth doing and were able to
create transcending experiences that restored their sense of
autonomy (Frankl, 1984).
Relevant Research on Occupation and Health
Hardy Personality
Kobasa (1982), an existentialist, believed that people con-
struct a dynamic personality-"being in the world" (p.
6)-through their own actions. Because their life situa-
tions are always changing, they inevitably encounter stress.
She asked, how do people confront unavoidable stresses
and shape their lives successfully?
Her theory and research supported the idea of a
"hardy personality" that resists stress and remains healthy.
(In contrast to my definition, she defined health as lack of
physical or psychiatric symptoms.) The three characteris-
tics contributing to hardiness should interest occupational
therapists:
Commitment-"ability to believe in the value of
who one is and what one is doing" (Kobasa, 1982,
p. 6) involving oneself fully in life, including work,
family, and social institutions. An overall sense of
purpose, goals, and priorities acts as a buffer to
stress.
Control-"tendency to believe and act as ifone can
influence the course of events" (p. 7). Stress was
viewed as a predictable consequence of one's own
activity and subject to one's own direction.
Challengf.'-a "belief that change rather than stabili-
ty is the normative mode oflife" (p. 7). Stress was
viewed as an opportunity or incentive rather than
as a threat. Hardy people search for new, interest-
June 1998, Volume 52, Number 6 416
ing experiences and know where to turn for
resources.
These three components contribute to "hardiness" or the
ability to resist stress and maintain health. Kobasa hy-
pothesized that when life is stressful, people with such
hardiness would remain healthy. Her hypothesis was sup-
ported by research with male business executives, male
general practice lawyers, and female medical outpatients
in retrospective and prospective studies, using subjective
and objective reports of illness indicators.
Kobasa's (1982) research conneCting commitment,
control, and challenge to hardiness in the face of stress
supports the use of occupation as therapy to prepare peo-
ple for engagement in the practical endeavors of everyday
life. For if Meyer (1931/1957) was correct that people
learn to achieve health in the doing, then such hardiness
may be learned and developed through engagement in
occupation. Gaining a sense of commitment in what one
is doing, a sense of control over the course of events, and
the seeking of challenges as a source of interest are prod-
ucts of one's adaptive responses to a "just-right" degree of
challenge. In Kobasa's (1982) work, these products resist-
ed the inevitable stressors of daily life and enabled people
to maintain health. The most important piece missing
from Kobasa's work is the process by which such character-
istics are constructed by the person's actions in real life. I
propose an important role for occupation.
Mortality
In tOday's world, engagement in some occupations is of-
ten trivialized, sometimes considered merely diversion.
This view may reflect our ignorance of the contribution
of engagement in occupation not only to health, but also
to actual survival.
In an II-year study of the long-term survival of per-
sons with spinal cord injuries, Krause and Crewe (1991)
compared the characteristics of those still alive with those
known to have died. The researchers hypothesized that
the survivors would have superior medical and psychoso-
cial adjustment. "Medical adjustment" measured by non-
routine medical appointments and hospitalizations, was
expected to be the most important predictor of survival.
But neither recent medical histOry nor emotional adjust-
ment predicted survival. Instead, strong suPPOrt was
found for a relationship between activity level and survival.
Those who were more active, vocationally and socially, in
participating in a round of daily occupations were more
likely to have survived. Activity level was more important
than medical history or a mediating emotional state. The
authors, both psychologists, concluded that "counseling
must go beyond facilitating emotional adjustment" (p.
84). Rather, people need to be taught the skills to parrici-
The Amaican journal o/Occupational Therapy
pate in life, skills that might influence survival itself.
In another study (Wright, 1983), 100 patients with
severe disabilities underwent rehabilitation in a hospital
that encouraged their maximum participation. Patients
designed their own schedules and solved problems as they
arose. If a wheelchair needed repair, the patients worked
OUt how to get it done. One year afrer discharge, these more
"occupationally autonomous" patients not only showed a
greater degree of sustained improvement in aCtivities of
daily living, but also a lower mortality rate than did the
control group.
Both theory and research demonstrate that an envi-
ronment that provides opportunities for active engage-
ment in life contributes to health, well-being, indepen-
dence, and survival. We need to take anOther look at the
trivialization of occupation. What could be less trivial than
survival?
Conclusions
An increasing body of knowledge from an array of disci-
plines supports Reilly's (1962) great hypothesis. Humans
can influence the state of their own health, provided that
they are given the opportunity to develop the skills to do
so. The human spirit for occupation, developed through
eons of time in evolution, unfolding through develop-
ment, and actualized through daily learning, needs to be
nurtured to contribute to the health, quality of life, and
survival of persons and society.
Occupational therapistS and occupational scientists
need to reaffirm that engagement in occupation, rather
than being trivial, is an essential mediatOr of healthy adap-
tation and a vital source of joy and happiness in one's daily
life. In the new millennium, the era of chronicity and the
potential "end of work" as we have known it will pose
particularly strenuous challenges: How can our profession
help create an environment in which people have oppor-
tunities to engage in the "moral equivalent of work" and
thus contribute to their own health? How can all people
be provided with opportunities or "just-right challenges"
to discover their interests and potential for something
worth doing?
Occupational therapy could promote a new concept
of health to replace the traditional view. Health, perceived
as possession of a repertoire of skills enabling people to
achieve their valued goals in their own environments,
would then be possible for all people, including those with
chronic impairments. A major objective would be to
achieve "equality of capability" (Bickenbach, 1993). To do
this, we need to learn much, much more about how hu-
man beings develop the adaptive skills, rules, and habits
that enable competence as well as how occupational ther-
apists might create a "just-right environmental challenge"
to enable an adaptive response. Such "coaching" from
417
occupational therapists could benefit all people who need
to develop skills in order to survive, contribute, and achieve
satisfaction in their daily life activities, whether or not they
have impairments.
To serve humankind well requires that we discover
much more knowledge about people as agents, in their
own environments, engaged in daily occupations. We
need to broaden our concept of ADL beyond self-care to
include study of the daily routines that occupy people in
real life contexts. To learn what we need to know requires
that we accept the challenge of becoming ardent students
of life's daily activities, grappling courageously with the
ambiguity and complexity of occupation, the occupational
human, and the contexts in which occupation takes place.
Only then will we fulfill our commitment to persons with
chronic impairments and assure that our humanistic val-
ues are expressed in an occupational therapy practice that
contributes to life opportunities and health for a new mil-
lennium. .A.
Acknowledgments
A major portion of this article was presented as the Wilma West
Lecture at rhe Ninrh Occupational Science Symposium at rhe Uni-
versiry of Southern California on April 12, 1996. It is respectfully
dedicated to rhe memory of Wilma West, MA, OTR. FAOTA, who con-
tributed so much of her spirit to occupational rherapy.
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