Eudaimonic Well-being: Its Importance and Relevance to Occupational Therapy for Humanity
Claire Hayward, Access to Communication and Technology, South Birmingham Community Health, West Midlands Rehabilitation Centre, 91 Oak Tree Lane, Selly Oak, Birmingham B29 6JA, UK.
Contemporary critique of the philosophy and theory of occupational therapy has asserted that the mainstream of the profession holds a westernized view of the world and that occupational therapy has been shackled to notions of health/illness and the medical establishment for too long, hampering movement into social and political spheres. Strategies and developments have been proposed to combat these biases, which have included increased cultural relativism and a re-focus on the subjective experience of occupation. The value placed on “being” in occupational therapy philosophy is described alongside the related terms of occupational integrity and spirituality. Drawing on theory and research from psychology, this paper proposes the construct of eudaimonic well-being as both relevant and valuable to occupational therapy in re-conceptualizing the profession, countering some of the central tensions in the identity of the profession and re-asserting that well-being through occupation is for all and for humanity. Finally, the paper proposes that well-being, in a eudaimonic sense, should be advertised and evidenced as a routine outcome of occupational therapy and consolidated into occupational therapy models as a relevant and meaningful concept. Copyright © 2011 John Wiley & Sons, Ltd.
Wilcock, the influential occupational therapist and scientist, described the currency of occupational therapy as Doing, Being, Becoming and Belonging (Wilcock, 2007). Wilcock's dimensions are the result of her in-depth critical appraisal of and vision for occupational therapy and occupational science. However, an occupational therapist's understanding of occupation differs from that of the general public (McAvoy, 1992; Chow and Chung, 1996; Creek, 2003). So which dimensions of occupational therapy are most apparent to the general public and other stakeholders?
Occupational therapists' most visible work and outcomes are often involved with “doing” (Creek, 2003; Perrin et al., 2008). However, if occupational therapists' prime concern is understood to be function (doing), we risk losing focus on being (Rowles, 1991; Hammell, 2004, 2007; Perrin et al., 2008). This could contradict the complex and multidimensional nature of occupational therapy (Creek, 2003) and risk compromising the practice of authentic occupational therapy (Yerxa, 1966). This also creates a potential misunderstanding of the profession, for others to conclude as some occupational therapists do (Wilding and Whiteford, 2009) that the end of occupational therapy is what is performed rather than why it is performed or the experience of doing (Doble and Santha, 2008), in turn misconstruing occupational therapy as being simply task focused.
The way in which the relevance and utility of occupational therapy is understood and evaluated by the individuals and populations it is intended to benefit is also of critical importance (Royeen, 2002). A poorly rounded perception of occupational therapy places the profession in jeopardy, especially in times of global economic pressure (Clouston and Whitcombe, 2008).
If being is a core construct of occupational therapy theory, then a positive experience of being, that is to say “well” being, must also be a key aim for occupational therapy practice. “Being” as it relates to occupation incorporates many elements and is indeed difficult to define (Wilcock, 2006), although in essence, in an occupational therapy context, it relates to the subjective experience of occupation (Doble and Santha, 2008). This is a view echoed by George Berkeley, the American philosopher who considered subjectivity the primary activist in being (Berkeley, 1713). Dige (2009) proposes an occupational therapy interpretation of well-being as “[that] which consists of the wholehearted and successful carrying out of valuable activities”.
Doble and Santha (2008) also cite an imbalance between doing and being and suggest that the focus of occupational therapists on occupational performance detracts from concepts of occupational satisfaction and fulfilment. They argue that the subjective experience of occupation has been marginalized. Although the call to re-focus on the subjective experience of occupation is not new, it appears to have been overshadowed by the health and illness agenda (Hammell, 2007). This may be in part due to the modern medical focus on the measurable and finite (Wilcock, 2006). In may also be due to the impenetrability of our professional terminology. While the words “occupational satisfaction” for occupational therapists may clearly suggest the positive subjective experience of occupation, these words may have little if any meaning for those outside the culture of occupational therapy. In contrast, well-being is a term widely used and valued in contemporary society (Godfrey, 2000; Carlisle et al., 2009) and has resonance for many stakeholders of occupational therapy and those we serve. Evidence for this includes the recently unveiled plans by the British government to measure and collect data on national levels of well-being (Stratton, 2010), with other countries considering similar proposals to direct government policy as part of a global shift away from measures of wealth (Bok, 2010; Stratton, 2010).
But what is well-being? How does it map to occupational therapy philosophy and terminology? Occupational therapy theorists have developed models over time that aim to capture the belief system and skills of the profession (Duncan, 2005; Boniface et al., 2008). Despite the lack of priority accorded to “being” in occupational therapy practice as previously contended, occupational therapy theory, philosophy and models do consistently include the role that the concept of being plays in occupation and health using the language and constructs of the author(s). Indeed Imperatore Blanche and Henry-Kohler (2000) state that “The cosmovision of occupational therapy philosophy is that occupation is important to the health and well-being of the individual.”
Occupational therapy has explored some of the constructs that comprise being: integrity, spirituality, identity, personal causation, motivation, volition, satisfaction and the subjective experience of occupation are some examples of these. However, the explicit use of the term “well-being” does not feature within the primary occupational therapy models.
The belief, widely accepted by occupational therapists (Ivarsson and Müllersdorf, 2009), that the relationship between occupation and well-being is strong and proven (Pentland and McColl, 2008; Perrin et al., 2008) has been challenged (Hammell, 2009a). Hammell asserts that occupational therapy must critically appraise its long-held assumptions and begin to develop models that reflect the diverse populations facing occupational challenges. As one illustration of this, Hammell gives the example of a man caring for his dying wife and asks the question: what occupational subset is this contributing to – self-care, leisure or productivity? Occupational therapy divided into these domains can be seen to be in direct opposition to the client-centred approach that occupational therapists espouse (Pierce, 2001; Hammell, 2009a, 2009b) This argument links back to the excessive focus of domains of occupation which are doing-centric (Hammell, 2003; Corr et al., 2005). The notion of well-being as a means of conceptualizing occupational therapy outcomes could be useful in this context and could offer a foil both to the arguments against task-focused domains and the “doing” focus. Taylor (2008) surmised that “Subjective experience and the personal meaning of an occupation may defy the rigidity of commonly employed categories” (p. 18).
Occupational therapists' interpretations of well-being allow for many complex and competing factors and influences. Hocking notes that one occupation in itself may have both positive and negative outcomes for the individual but yet still be seen as enhancing well-being. In this way, an occupation may, at face value, be detrimental to well-being (for example, many hours of caring for an ill relative), but when seen in the context of the values of that person, it may actually engender a sense of well-being in spite of those superficial detractors (Hammell, 2009b; Poulin et al., 2010). The somewhat paradoxical effect of experiencing well-being despite what can be considered as barriers to health or wellness is noted by other disciplines and researchers (Albrecht and Devlieger, 1999; Seligman et al., 2004; Dolan et al., 2008).
Well-being has been described as having a spiritual dimension (Hammell, 2001; Egan and Swedersky, 2003; Kang, 2003; Morris, 2007). Spirituality in occupational therapy has long been seen as an important consideration in occupational theory and has been conceptualized as separate from religion (Kang, 2003). Hammell (2001) defines the notion of spirituality (which Hammell terms “intrinsicality”) as “philosophy of meaning that informs life choices and life satisfaction”.
Being can be seen to offer opportunities for client centredness. It has been noted that whilst the “doing” aspect of an occupation may be conducted in a remarkably similar way from one individual to another, the subjective experience of that doing (i.e. the “being”) will always be unique. In this sense, it can be argued that a focus on being demands the therapist to recognize the individual experience of each client (Hammell, 2007).
Occupational outcomes re-considered
There is a significant risk that, without the adequate consideration for “being” in occupational therapy, important benefits to clients are overlooked and undervalued. Corr et al. (2005), in their study comparing definitions of occupational therapy and the reported experiences of consumers, confirmed that those who receive occupational therapy also define the outcome of that intervention as more than mere doing and identified results which encompass many dimensions of being.
“It is the definition of ‘purposeful’ and ‘activity’ that is crucial here: the meaning and action taken will be different for each individual and success may lie not in terms of measurable outcomes but in the client's perception that his or her quality of life has improved. There may be no physical signs that any measurable improvement has taken place, but the client, nevertheless, may feel that his or her journey has taken a more favourable path and that life has a meaning that cannot be expressed in purely logical terms.” (Kelly and McFarlane, 2007).
This suggests that the subjective, well-being output of occupation should be both highlighted and evaluated. Reflecting this, Doble and Santha (2008) propose the use of well-being as the product of occupational therapy intervention, in part as a countermeasure to the use of the terms of participation and activity, given credence by the International Classification of Functioning, Disability and Health (WHO, 2001), which lacks the subjective experience of occupation (Borell et al., 2006; Polatajko et al., 2007; Doble and Santha, 2008).
The impact of a shift to well-being as an end product of occupational therapy could be significant and positive. If well-being was recognized as an outcome, occupational therapists would need to re-consider outcome measures and how interventions are evaluated.
Occupational therapy and eudaimonic well-being
Occupational therapy and occupational science draw from a range of related disciplines (Wilcock, 2006) including psychology (Creek and Hughes, 2008). Concluding a review of literature relating to the link between health and occupation, Creek and Hughes (2008) underlined the need for occupational therapists to use the evidence from these knowledge bases to underpin the profession. Hesse (2009) contends that occupational therapy should embrace the research base of psychology to better inform and professionalize its practice. The relevance of well-being to occupational therapy has been outlined; occupational therapists should therefore utilize the “body of internationally relevant theory and evidence” (Carlisle et al., 2009) from psychology which exists around the science of well-being to further explore this construct.
Psychology literature describes two main traditions in the study of well-being: hedonic and eudaimonic well-being (Deci and Ryan, 2008; Dolan et al., 2008). Hedonic well-being primarily relates to the experience of happiness through the attainment of pleasure and the avoidance of pain (Kahneman et al., 1999). This understanding of well-being has been critiqued by many academics, religious leaders and philosophers throughout the ages; indeed, Aristotle found hedonic well-being “to be a vulgar ideal, making humans slavish followers of desires. He posited, instead, that true happiness is found in the expression of virtue” (Ryan and Deci, 2001, p. 145).
Eudaimonic well-being occurs “when people's life activities are most congruent or meshing with deeply held values and are holistically or fully engaged” (Ryan and Deci, 2001) and is associated with a sense of an authentic existence, which may involve meeting challenges and feeling stretched in one's skills and abilities. Waterman et al. (2008) assert that eudaimonic well-being is fostered by “doing what is worth doing”, which may or may not engender happiness. Eudaimonic experience is seen to be a dynamic process, aimed at achieving self actualization through engaging in activities. This poses the question for occupational therapists: if a person is doing what is not worth doing (i.e. not congruent with one's values and beliefs), then is this occupation?
Spirituality, a familiar and important area of inquiry and practice for occupational therapists, is seen as a dimension within eudaimonic well-being (van Direndonck and Mohan, 2006). This interpretation of spirituality as an inner resource, independent of religion or denomination, is comparable with the definitions proposed by occupational therapy researchers. Its inclusion within the landscape of eudaimonic well-being serves to underline the relevance of the concept for the occupational therapy professionals.
Eudaimonic well-being provides a framework of understanding for those activities that we may value and desire, which may even bring happiness but may not promote wellness. This can provide a useful construct to occupational therapists, considering the concept of occupations, such as producing illegal graffiti, that may produce apparently contradictory outcomes (e.g. producing graffiti may bring happiness for the individual but may have a negative impact on others in the community or may be considered a criminal offence). This duality also allows for those occupations, like caring for a sick relative as mentioned previously, that present both health-promoting and health-inhibiting consequences but are ultimately deemed as producing well-being. Ryff and Keyes (1995) and Ryff and Singer (1996) contend that eudaimonic living creates psychological well-being and offers evidence to suggest that this creates physical health. Psychological well-being is seen as having the following dimensions: autonomy, personal growth, self-acceptance, life purpose, mastery and positive relatedness (Deci and Ryan, 2008). Bauer et al. (2006) explored eudaimonic well-being and its relationship to narrative identity; they concluded that people who are able to experience higher levels of eudaimonic well-being view challenging life experiences, which include significant pain and adversity, as transformational opportunities. Indeed experiences of hardship, trauma and grief are considered an integral part of living through eudaimonic lifespan, a view reflected by Joseph Campbell, the comparative mythologist who suggested that to find life's meaning we should be “participating joyfully in the sorrows of the world” (Campbell, 2008). This consolidatory approach which considers the challenges of life as integral to it brings the utility of the psychology theory base further into the realm of occupational therapy.
In discussing what promotes or engenders well-being, consideration of that which restricts it is also necessary. To the eye of an occupational therapist, barriers to well-being may also present barriers to occupation. However, this is a dangerous link to automatically make. Equating reduced occupational performance with reduced well-being of either tradition, hedonistic or eudaimonic, is a potential trap propagated by the mainstream occupational therapy focus on “doing”. Research certainly suggests that people with restricted occupations in terms of function, doing and activity often report high levels of well-being (Albrecht and Devlieger, 1999). Hammell (2004) references a wealth of disability research which shows that physical disability and/or illness (and consequent disruption or reduction in “doing”) can lead to a re-evaluation of the meanings subscribed to occupations and to experiencing higher levels of well-being than when previously “well” or non-disabled In a later paper, Hammell (2008) warned against occupational therapy's preoccupation with health, illness and impairment, a call echoed by many others, and proposed that occupational therapists move to consider the well-being of all. A focus on those who live in poverty and oppression, those who are migrants and those who are homeless has been some suggestions for areas of practice (Kronenberg et al., 2005). These groups again may be perceived, when the westernized viewpoint is continued, to be lacking in their ability to do, to perform activities and to function. As such, the risk exists that we perpetuate in ascribing a potentially alien value base to these groups to assume that they are in “need” of occupational therapy based on their ability to participate in leisure, self-care and productivity. When the literature base of psychology is consulted, there are many examples of people living in poverty (for example) who report higher levels of well-being than those in more affluent, western environments (Seligman et al., 2004; Waterman et al., 2008). A key challenge for occupational therapy, then, is not to replace the focus of the recent past on health and illness with other “causes”.
Eudaimonic well-being for humanity
The notion of eudaimonic well-being provides fresh impetus and direction towards a future state of occupational therapy which is owned by its recipients rather than tethered by its historical past. The inclusion of eudaimonic well-being provides a vision for occupational therapy which is for humanity, for all, allowing occupational therapy to be defined by those who may benefit from it, not its practitioners. Perhaps, the key question we should be asking this century is “Does this person experience optimum eudaimonic well-being through occupation?” It demands that we recognize that eudaimonic well-being may thrive in lives where disease or injury reside or where social, financial or political limitations exist. It challenges us to make the deeply personal and subjective experience of occupation our keystone. Such steps may feel counterintuitive; in times of international financial austerity, we may wish to court those who commission our services, focusing on the tangible, the traditional and the more easily demonstrable. Voices from mainstream medical groups have argued that, despite the frequent use, the term well-being, meeting the well-being needs of populations, should not be the central focus of health care (Fitzpatrick, 2010). Occupational therapy re-focused on eudaimonic well-being may turn away from those medical establishments and organizations that have for so long been both the hand that feeds us and the arm that holds us back.
Pentland and McColl (2008) introduced the notion of “occupational integrity”; this concept underlines the importance of the subjective experience of occupation and embodies the values-based concept of eudaimonic well-being:
“Occupational integrity expands the focus of therapy beyond “doing” to interventions at the level of the person and identity, helping clients to identify their strengths, values and purpose, what is meaningful and satisfying for them, and then designing and living their lives in congruence with that” (p. 138).
Occupational integrity aligns the notion of occupation within the context of cultural, political, moral, social and spiritual influences and moves occupational therapy theory beyond occupational performance and therefore towards the pursuit of eudaimonic well-being. This is crucial if occupational therapists are to realize the profession's vision of a just and inclusive society (Kronenberg et al., 2005). Well-being in general terms has also been clearly linked to this new political and rights-based occupational therapy movement (Hammell, 2007) and has been shown to be sensitive to cultural influences (Piškur et al., 2002; Wilcock, 2006).
Eudaimonic well-being, it is contended, can be derived not simply from participation in occupation, or from occupational balance, but from the lived experience of occupational integrity. Occupational integrity asks the questions: “What do I really value, and how do my occupational choices reflect those values? How can I put my life together in a way that honours my values?” (Pentland and McColl, 2008, p. 137).
Carlisle et al. (2009) equate the negative elements of westernized culture to modernity and propose eudaimonic well-being as an antidote to modernity, defining modernity as the following:
“a worldview that tends towards objectification, reductionism and materialism: a view of the world as lacking in any inherent meaning, design or purpose; and a view of the person as fundamentally separate, unique and alone.” (p. 1577).
They suggest, as do Ryan and Deci (2001) and Csikszentmihayli (1993), that eudaimonic well-being must be defined in a global context, considering the well-being of all humanity. This opportunity to recognize and renew connections to others, to values and to spiritual beliefs has been described as offering a renewed sense of connectivism (Arai and Pedlar, 2003; Carlisle et al., 2009).
The eudaimonic interpretation of well-being can be seen to reflect the post-modernist perspective which values local narratives (Mitchell, 1996), prioritizes subjectivity and temporality (Weinblatt and Avrecht-Bar, 2001) and rejects universality. Weinblatt and Avrecht-Bar (2001) state that the term “subjective meaning” is in itself a post-modern term and asserts the utility of a post-modern perspective in enabling an occupational therapist to provide functional interventions which are practical for the client.
One of the central criticisms of the current occupational therapy theory is that it represents a westernized perspective, where a universal and singular truth external to the self is predominant (Iwama, 2005, 2006; Hammell, 2009a). In contrast, many other cultures value instead the interrelatedness of life and the success of the collective (Iwama et al., 2009). Iwama advocates that a position of cultural relativism (i.e. truth relative to each individual) is essential for the genuine cultural competence of the occupational therapy profession. The dimension of connectivism, also apparent in eudaimonic well-being, has been described as mythic (Kelly and McFarlane, 2007) and an antidote to the “cult” of westernized occupational therapy (Iwama, 2006; Kelly and McFarlane, 2007; Hammell, 2009b). The inherent respect for, and impact of, values and culture in eudaimonic well-being (Ryan and Deci, 2000; Dolan et al., 2008) therefore supports Iwama's (2005) recommendation of cultural relativism. This link between cultural sensitivity and the subjectivity of well-being has also been made in occupational therapy literature (Piškur et al., 2002; Watson, 2006; Wilcock, 2006).
As well as providing a mechanism for improved cultural relevance, moving away from hedonic notions of eudaimonic well-being has been proposed as a catalyst for change from social ills such as overly consumerist attitudes and the apparent decline in life satisfaction in the west (Carlisle et al., 2009).
However, there is also a critical tension here; in the eudaimonic tradition, the definition of well-being is subjective and unique to each person, achieved only when living a life representative of one's values and culture. However, the occupations that satisfy the eudaimonic well-being of one person or group may negatively affect that of another (Carlisle et al., 2009). These two notions of sustainable ecology and sustainable communities are brought together by Wilcock (2006) in the “Occupation-focused Eco-sustainable Community Development Approach” (OESCD). Wilcock highlighted that occupational therapists have a key role to play in authentic moves to promote communal occupation-focused initiatives but recognized that “Occupational therapists … who chose to take an OESCD approach need, initially, to enable people to recognize the impact of what they do, be, and become in communal and environmental terms” (p. 220).
In other words, it is important to consider the macro level of well-being and to engage the “being” before the “doing”. Therefore, occupational therapists have a significant potential role to play both in considering the occupations which engender eudaimonic well-being for individuals and communities and in considering the impact on wider communities.
The current climate of occupational therapy is one of lively discourse, change, threats and opportunities. Prominent occupational therapists have called for a re-conceptualization of occupational therapy that aims to benefit all. Hammell (2009a) asserts that occupational therapy must critically appraise its long-held assumptions and begin to develop models that reflect the diverse populations facing occupational challenges (Imperatore Blanche and Henry-Kohler, 2000).
If we consider “being” in occupational therapy as the subjective experience of occupation, (eudaimonic) well-being can be seen as the expression of occupational integrity. In this way, occupation could be defined as “doing” which engenders eudaimonic well-being, reflective of culture and values. If we therefore re-frame the goal of occupational therapy as achieving eudaimonic well-being, we may be able to mitigate the imperialist, westernized and ablest bias levelled at the occupational therapy profession by some (Kronenberg et al., 2005; Pentland and McColl, 2008; Hammell, 2009a, 2009b) and move wholeheartedly towards a professional theoretical base which is for all humanity. This shift in focus could continue the renaissance in occupation as a means (Pollock and McColl, 2003) but allow for a more critical appraisal of the utility of the term occupation (or occupational satisfaction or balance) as an end. Well-being, internationally recognized as vital to human experience (World Health Organization, 1946), more specifically eudaimonic well-being, offers a new way of conceptualizing the outcome of occupational therapy, which allows practitioners to be inclusive of our new politicized and rights-based practice agenda (Creek and Hughes, 2008), giving recognition to the importance of considering the sustainability of our social and natural environment.
The call for a renewed exploration of occupation and well-being in a contemporary world is not new (Rowles, 1991; Wilcock et al., 1998; Hammell 2004; Doble and Santha, 2008; Hammell, 2008; Taylor, 2008). However, this paper has made links between current thinking in psychology and modern occupational therapy theory and research. Eudaimonic well-being is proposed as a key concept for occupational therapy but one that is currently missing from the debate, literature and research of our profession. The opportunities offered by such a current (Bauer and McAdams, 2010), well-described and evidenced concept should be seized by occupational therapists. In considering who might benefit from the skills of occupational therapists in using occupation as a means, we should start by exploring those people or groups who experience a lack of self-defined eudaimonic well-being.
Well-being has been shown to transcend traditional boundaries of physical and mental health and societal and cultural norms and reflects the aspirations of international agencies such as the World Health Organization. This construct therefore has much to offer to an internationalized community of occupational therapists, going beyond the borders of the previously sacred domains of occupational therapy.