The Meaning of Occupation, Occupational Need, and Occupational Therapy in a Military Context

An Outline of Occupational Therapy Practice

Occupational therapy is a health care profession founded on the knowledge that engaging in meaningful occupations promotes health and well-being. It is “the art and science of helping people do the day-to-day activities that are important and meaningful to their health and well-being through engagement in valued occupations.”^4(p28) According to Townsend and Polatajko, “Occupational therapy enables a just and inclusive society so that all people may participate to their potential in the daily occupations of life.”^5(p372)

Occupational therapy crosses physical-mental health boundaries. Occupational therapists work to a biopsychosocial model providing holistic care management and interventions for physical, psychological, emotional, and social issues associated with disability and functioning. Spirituality, finding meaning in everyday life, is an integral part of the holistic model^1,6 because many people begin searching for spiritual support during a personal crisis, illness, loss, or trauma.⁷

Employment with public and private organizations means occupational therapists work in a variety of nonmilitary settings, including hospitals, the community, long-term care facilities, and rehabilitation clinics. Many are self-employed.⁸ Collaborating with individuals, families, groups, and communities to assess degrees of engagement in everyday occupations, occupational therapists work with all age groups, from neonatal to elderly, providing long-term care, subacute care, and acute care, including input to emergency clinics.

Work in acute care includes postsurgical interventions, hand and upper-limb rehabilitation, and sensory, perceptual, and cognitive retraining. In emergency departments, occupational therapists' help prevent unnecessary admission to acute beds often through equipment and orthotic provision, referral to community support, and mobility and transfers education.

In psychiatric units, occupational therapists might focus on successful community integration by teaching new strategies and providing graded activities. Attention might be directed to: (1) increasing energy; (2) finding a balance among self-care, productivity, and leisure; (3) social participation; (4) decision making and priority setting; and (5) productivity options that decrease stress.⁹

The Concept of Occupation

In lay language, “occupation” is understood as paid work. Occupational therapists recognize occupation in a broader sense. Crepeau et al stated that occupations “include the day-to-day activities that enable people to sustain themselves, to contribute to the life of their family, and to participate in the broader society.”^4(p28) Thus, occupations are multifaceted phenomena going beyond CF members' everyday work. Occupations are fundamental to human health and well-being because they provide meaning, identity, and structure to people's lives and reflect society's values and culture.¹⁰ Because humans are occupational beings,⁵ occupations have therapeutic potential.

Occupational therapists categorize occupations as self-care, productivity, and leisure.⁴ Self-care can be functional mobility and communication, home management, personal hygiene, or community activity such as grocery shopping. Self-care examples are a CF member dressing himself or herself in uniform or walking to the cafeteria or mess hall to eat. Productivity includes paid and unpaid work. Listening to sonar for enemy submarine or physical fitness training at the base gym are CF examples. Leisure activities include socializing, outdoor activities, games, and sports. An example of a leisure activity might be 2 infantrymen playing cards in the back of their light armored vehicle. The term “occupation,” as used in occupational therapy, is defined in Table 1.

An important skill of occupational therapists is the ability to analyze tasks, analyze members' performance in those tasks, and plan interventions that have a direct effect on the occupations. Almost every occupation requires a combination of voluntary movements and mental processes to perform tasks.⁵

A battle tank driver in Afghanistan is an example of a CF member who must execute combinations of psychological and physical processes required in a complex CF occupation. A simplified task analysis of 1 aspect of this occupation is the driver's need to: (1) listen and understand the crew commander's direction (psychosocial and cognitive skills) while staying vigilant for pedestrians and other vehicles (sensory and cognitive skills), and (2) look through the episcope to estimate distances of buildings from the tank (sensory and perception skills) while manipulating the brake and throttle and steering the yoke (physical skills).

The Person-Environment-Occupation Relationship

Notwithstanding a member's abilities prior to and following trauma, engagement in occupations is affected by the individual's or population's environment (physical, institutional, cultural, and social). The environment can facilitate or create barriers to participating in society. Steep slopes and steps in the built environment can create access barriers. Inadequate policies, procedures, and standards can create barriers to services. Social barriers, such as negative attitudes to disability, can isolate people with disabilities.¹¹

Occupation is a function of the fit, or lack of fit, among the person's skills and abilities, the demands of a particular occupation, and the environment in which the occupation is performed.¹² In addressing occupation, occupational therapists, therefore, must attend to the complex dynamic relationships among a person, his or her occupation, and his or her environment.

Occupational Need

Everyone has occupational needs to: (1) choose daily occupations, (2) participate in occupations, (3) have a balance of various occupations in his or her life (eg, self-care, productivity, leisure), and (4) engage in personally meaningful occupations.^5,10,13 Unmet occupational needs occur when an individual or group is unable to engage in daily occupations. Unmet needs can lead to occupational disruption, deprivation, or imbalance.^5,10,13

Occupational Disruption, Deprivation, and Imbalance and the Canadian Forces

Occupational disruption “occurs when a person's normal pattern of occupational engagement is disrupted due to significant life events.”^14(p201) Being posted to a new military base, preparing for war, changing military positions, becoming ill, or grieving over the loss of a comrade are CF examples of occupational disruption. Occupational disruptions are, typically, temporary and transient interruptions to a CF member's normal engagement in daily occupations.⁵

When medical conditions have long-term consequences, occupations can have a mediating effect. With appropriate rehabilitation supports and resources, the interruptions and consequences can be corrected, and the person may even have an improved level of occupational functioning.¹⁰ Retired Master Corporal Paul Franklin is an example of how CF members overcome and excel after occupational disruption. Master Corporal Franklin severed both legs during an explosive device strike in Afghanistan in 2006. After tremendous efforts by Master Corporal Franklin and involving rehabilitation specialists, psychological counselors, administrative staff, he co-founded the Northern Alberta Amputee Program and the Franklin Foundation. He is a motivational speaker and has a book published regarding his struggles and successes titled The Long Walk Home: Paul Franklin's Journey From Afghanistan.¹⁵

Occupational deprivation is the “state in which a person or group of people are unable to do what is necessary and meaningful in their lives due to external restrictions. It is a state in which the opportunity to perform those occupations that have social, cultural, and personal relevance is rendered difficult if not impossible.”^14(p200) At times, regular and reserve CF members with severe physical and psychological issues are left in a “state of preclusion from engagement in occupations…due to factors that stand outside the immediate control of the individual.”^14(p201) A minority of severely injured CF members (often reserve members or regular members posted away from large military bases) who are located in rural areas, are underemployed or unemployed due to lengthy disability, and perceive themselves as not having a “voice” in mainstream society may be prone to occupational deprivation.¹⁴ Left unresolved, occupational deprivation and disruption can result in secondary psychosocial issues such as depression and maladaptive behaviors¹⁴ such as excessive drinking.

Occupational imbalance occurs when a person is unoccupied, underoccupied, or overoccupied.¹³ According to Molineux, “the loss of a balance of engagement in occupations” affects health and well-being.^16(p173) Townsend and Wilcock stated, “Underemployed people are at risk for ill health because they are less likely to experience sufficient mental, physical and social exercise that provides meaning and enrichment…over-employed people are also at risk for ill health because they are too busy to look after themselves, their families, or their community.”^13(p82)

Lack of opportunities to participate in leisure or productivity occupations also causes occupational imbalance. The effect of impairment or injury on availability of CF members' time for elective occupations has not been researched. However, experience and research from other groups indicate that people with disabilities and functional limitations spend more time in self-care and passive activities within their home environment than people who are nondisabled, leaving less time for discretionary activities.^17,18

Canadian Forces members who have mental or physical injuries may experience an over-engagement in “health work” (a range of intentional, yet institutionally prescribed, practices in which people must engage when they are ill or injured)¹⁹ to the detriment of other occupations. Experience with military members severely injured by explosives, resulting in amputations, burns, shrapnel residue, brain injury, hearing loss, and anxiety, indicates injured military members spend much of their day “getting better.” These severely injured members are seen by different specialists in various locations, are engaged in diverse therapeutic “homework” over months or even years, and are taking numerous medications.

Extensive health work involves tremendous effort, endurance, organization, and motivation, often leaving little energy or time for other types of meaningful occupations. Health work becomes more complex when injured CF members experience barriers such as complicated health policies and procedures that interrupt the rigorous health work routine. Refer to Table 1 for a summary.

Current Status of Occupational Therapy Within the Canadian Forces Rehabilitation Services

Occupational therapists are categorized in CF as “Role Four” care providers, meaning occupational therapy is viewed as a specialized profession in which care is delivered over a protracted period of time. The military does not typically deploy Role Four health care professions, “therefore, OTs [occupational therapists] would not be called upon to deploy into mission areas, and that means there is no requirement for OTs to be CF members” (Brigadier-General D.E. Martin, written communication, August 2008). Canadian Forces occupational therapy differs from the small but influential US Occupational Therapy Army Medical Specialist Corps, which deploys with combat units and is charged with a variety of responsibilities,²⁰ including running a post-blast concussion and mild traumatic brain injury (TBI) clinic.^20,21

At present, CF military members requiring occupational therapy are referred to civilian businesses that offer private, contracted short-term occupational therapy services or to civilian rehabilitation centers. Private occupational therapists from civilian businesses may be contracted to provide services such as home modifications and prescription of medical equipment and may not assess the occupational needs of CF members who are their patients.

Canadian Forces occupational therapists are now employed in posts on some military bases across Canada (ie, in Edmonton, Alberta; Ottawa, Ontario; Valcartier, Quebec City; and Halifax, Nova Scotia). Most work within rehabilitation clinics, alongside physical therapists. The CF's intent is to expand CF occupational therapy to every military base in Canada.²² The expectation is that by connecting CF occupational therapists with the numerous civilian occupational therapists, there will be increased focus on the occupational needs of the CF members.

Canadian Forces Health Culture: Critical Issues for Occupational Therapy

Culture is defined as “the attitudes, feelings, values, and behaviours that characterize and inform society as a whole or any social group within it.”²³ Culture is typically understood as national or ethnographic, but businesses and industry have particular corporate cultures that distinguish each from others.²⁴ The CF is one particular cultural group.

Of particular interest to occupational therapists are 4 issues: (1) the mandate for occupational therapists, (2) the priority to rehabilitate those who are injured to retain them and ensure they are physically and mentally fit throughout their military career, (3) the tenet of universality of service, and (4) the expectation that those injured will work at their rehabilitation as if it were their job.

Some cultural issues limit occupational therapy practice in the CF. Others provide insight into the range of CF “insider” knowledge required by occupational therapists for successful contribution to injured CF members' rehabilitation.

Canada's Department of Defence states the role of occupational therapists as: Occupational therapists (OTs) assess an individual's functional abilities, determine a treatment and intervention plan and put it into place; develop, restore, or maintain skills; deal with disabilities; attenuate challenging situations; and adapt the environment to promote optimal autonomy in the patient's daily, family, social, and professional lives. Concretely, OTs seek to assist the individual in recovering from impaired functions and strengthening those that are still intact, while teaching the patient how to deal with the disability and do things differently. They introduce technical aids such as wheelchairs, create and fit orthotic devices, and adapt ill and injured CF personnel's environment, including their home, vehicle, and workstation.²⁵

Assessment and intervention targeting occupational need are absent from, or not explicitly stated in, the CF occupational therapists' mandate. There is, thus, the potential to overlook or not deal in detail with the factors that limit CF members' progress.

The CF's priority is to rehabilitate those who are injured to retain them²² and ensure they are physically and mentally fit throughout their military career.^26,27 Occupational therapists can work across physical injury into emotional and psychological health for maximum rehabilitation. Civilian occupational therapists limited by contractual agreements that focus on aids and adaptations will not be able to offer the broad range of interventions to meet the needs of injured members. Canadian Forces occupational therapists are better situated to ensure individuals' successful adaptation to the range of demands and situations for military readiness and safe return to duty.

The “principle of universality of service” states, “Canadian Force members are liable to perform general military duties and common defence and security duties, not just the duties of their military occupation.”²⁸ To ensure effectiveness of CF, this principle overrides that of the Canadian Human Rights Act section 15(2) “duty to accommodate” those with injury, illness, or disability.²⁸ Every civilian occupational therapist receiving a referral for return-to-work rehabilitation would necessarily need to spend quite some time researching the spectrum of duties expected of injured members. Canadian Forces occupational therapists would have knowledge of the range of general military, defense, and security duties that an injured member might be required to carry out so as to undertake a thorough vocational assessment and return-to-work plan.

As in the past, injured military personnel must remain “military obligated to do their duty,”^1(p91) which, in this case, is to become rehabilitated. The expectation is that injured members will work at their rehabilitation as if it were their job. Although rehabilitation is usually a priority for civilians with trauma, it does not always carry the same crucial focus as it does for CF members. Canadian Forces occupational therapists have a tacit understanding of the CF and members' obligation so as to provide timely, military-focused rehabilitation interspersed with discretionary occupations that meet members' occupational needs.

According to Besemann, “Most soldiers…start their rehabilitation at the level of function that exceeds the end-state among civilians.”^22(pS140) The seriousness of some injuries means rehabilitation can be a long process requiring determination of the injured member, continuity of rehabilitation, health team cohesion for comprehensiveness, and the specialist skills of a CF occupational therapist.

Future Occupational Therapy and the Canadian Forces

Program effectiveness and efficiency studies would help with decisions about service provision, but the small number of CF occupational therapists makes specific CF occupational therapy program evaluations and research unfeasible. There are, however, American clinical studies and reports that can inform practice.

American military occupational therapy evidence-based clinical practice guidelines are available in areas such as mild TBI.²⁹ Research studies have been conducted on various specialties, such as burns.³⁰ Reports of polytrauma³¹ and combat stress casualties³² show the complexity of rehabilitation and demonstrate the adaptability of military occupational therapists and the range of expertise needed.

Notwithstanding the quality of CF health care, there are gaps. A report on national defense stated: As effective as current Canadian Forces health care and social support programs are, there is room for improvement. Concern has been expressed over the ability of the Canadian Forces to meet the needs of soldiers recovering after being injured in combat in Afghanistan and in other operations. Of particular worry is the ability of the military health care system to care for the growing number of those suffering operational stress injuries (OSI), including post-traumatic stress disorder (PTSD).^33(p1)

Psychosocial interventions for addressing OSI and PTSD are interwoven within the biopsychosocial model for populations of injured CF members: (1) those with transient, intermittent injuries; (2) those returning from overseas missions with very serious injuries or severe injuries; and (3) those with permanent injuries who are transitioning from the CF into civilian life. These categories are informal, with no clear boundary regarding the type of injuries or the degree of injury severity for each. The information is summarized in Table 2.

Interventions are related to eliminating or minimizing barriers to the person, the environment, or the occupation to reduce occupational disruption, deprivation, and imbalance and improve chances of successful occupational engagement.

Members With Transient and Intermittent Injuries: Promoting Military Readiness Through Occupation

Occupational therapy assessment of those experiencing short-term injuries or illness (eg, postsurgery, pain, strains and sprains, mental and physical fatigue—the bulk of those seen in the CF rehabilitation clinics) determines the impact of the injury or illness on CF members' occupations.

Mental and physical abilities can be improved by a schedule of graded activities (person). In-garrison assessment might focus on the workspace, such as maintenance hangers, workshops, gymnasiums, classrooms, and office settings, for ergonomic modifications, provision of specialist equipment, or environmental alterations (environment). Insider CF knowledge of the fundamentals of high-risk CF trades, including the essential components of jobs and minimal operational and physical fitness standards, facilitates intervention planning that targets adaptation of the trades tasks (occupation), making them simpler or less demanding and promoting greater success.⁴

Canadian Forces occupational therapists can assist in assessing whether injured CF members will return safely to their position in a modified fashion or be transferred for a limited time to another position that is both meaningful and essential to the mission at hand. For instance, a CF occupational therapist would assess the work capacity of an injured member in CF duties requiring lifting, pushing, pulling, work tolerance, and psychosocial areas such as maintaining attention, concentration, and memory.

Critically, CF members' sensory processing, cognition, and ability to regulate emotions can be impaired after a traumatic event, affecting their ability to engage in social situations and participate in self-care and work tasks. Enabling CF members to re-engage in tasks by supporting them in planning and initiating daily schedules and in organizing their own contacts and associations is an important contribution of CF occupational therapists.

Members Who Are Severely Injured: Promoting Timely Progress Through Occupation

Those identified as being very seriously injured or severely injured because of military mission injuries are top priority for CF rehabilitation. During acute and subacute phases of very serious and severe injury, and before the option of preparing to return to work, the road to full recovery is long, often isolating, frustrating, and painful and can be filled with months and years of health work. Canadian Forces occupational therapists can assess and treat personnel who are very seriously injured or severely injured at various stages of recovery, agreeing on a plan for amelioration of limitations to engagement in occupations.

Hospital and home visits during the acute phase may place priority on the environment and occupation. In addition to determining and ordering essential equipment such as wheelchairs to lessen dependency and coordinating work for home modifications such as ramps and stair lifts to reduce lengthy wait times, CF occupational therapists can provide ongoing support for the CF member and family to ensure success. A graded program of occupation focusing on early self-care intervention establishes the expectation and possibility of independence in bathing, toileting, and dressing and supports caregivers through education, in particular therapy strategies, handling techniques, and coping mechanisms. Home discharge planning involving the injured military member and family and rehabilitation professionals starts early to accommodate the person's functional level.

Issues related to the person may begin at the subacute stage. Outpatient occupational therapy rehabilitation, preferably in-garrison to maintain military bonds and associations, enables new or existing skills to be developed through: (1) relaxation techniques, (2) problem solving on home-front issues, (3) stress and anger management classes, (4) assertiveness training, and (5) cognitive-behavioral training. Pain and sleep would be monitored, advice provided, and habit training initiated.³⁴ These life strategies are valued and used by military members when faced with exceptional circumstances³⁵ and show the potential for helping those returning from the Gulf War and experiencing mental and physical health issues.³⁶

The ultimate outcome of occupational therapy for military personnel with very serious and severe injuries is to decrease occupational deprivation and imbalance and promote full occupational recovery in personal and military lives. In essence, occupational therapists assist the injured person to either return to the military (and, therefore, prepared for military readiness) or begin transitioning to a full and active civilian life.

Members With Permanent Injuries: Transitioning Into Civilian Life

Once CF members fully transfer from the CF, they are often titled veteran. If injured CF members do not return to their former, or an alternative, military position (due to institutional barriers or personal choice), CF occupational therapists can augment existing military transitioning services. The stress of combat and returning home can cause maladaptive behaviors. One veteran research participant stated that within 2 weeks post-deployment, he was drinking every night. He stated, “[Was I] drinking every night because [I] am glad to be home, or have a problem?” Another veteran reported, “A lot of people binge drink…because of some of the stuff that they see over there, too.”^35(p26) Early intervention helps prevent maladaptive behaviors such as alcohol and substance abuse.³⁷

Early intervention for veterans with anger, anxiety, depression, and insomnia might focus on the person, helping veterans understand and take control of their health by providing insight to triggers and using relaxation and visualization techniques. The CF occupational therapist also might advise on sleep hygiene, be a resource for community services,³⁵ facilitate goal planning, and provide skills in conflict resolution, communication, financial and time management, and methods of solving specific problems.³⁸

Veterans' families, concerned with what to expect after the serviceman or servicewoman leaves the military, benefit from knowledge of positive and productive interactions that respect individual family members' roles. Canadian Forces occupational therapists also might offer advice on community resources such as social supports, child care, and family counseling.³⁵ These interventions focus on the family environment.

Vocational and leisure occupations are of critical importance to veterans as they transition into civilian life. Many military specialties (eg, machine gunner) are not transferable to civilian life.³⁵ Canadian Forces occupational therapists undertake vocational assessments to evaluate aptitudes, interests, and work skills to identify suitable employment. A functional capacity evaluation (FCE) is a battery of tests, using questionnaires, real and simulated workstations, and standardized tests, to evaluate capacity in aspects of functioning such as bending, fine and gross dexterity, reaching, crouching, lifting, carrying, walking, stamina, speed, flexibility, and endurance.³⁹

Results of an FCE may be used for planning in-garrison rehabilitation, or to determine whether a CF member has the aptitude and skill necessary for a particular job or whether retraining or further education is required.⁴⁰ Veterans often exhibit high motivation to succeed in retraining²² and education.⁴¹ However, they also may face barriers such as physical limitation, symptoms associated with OSI and PTSD, and academic challenges associated with TBI. A CF occupational therapist can work with student veterans to overcome these issues.³⁵

Although not all returning veterans have physical or mental difficulties, many face challenges in the transition from military to civilian life.^35,42 A survey of 1,853 veterans showed returning to civilian life creates dilemmas.⁴²

Conclusion and Recommendations

This article summarizes occupational therapy practice in long-term and short-term settings, drawing attention to occupational therapists' expertise in acute care and emergency department settings, a wider application than currently used by CF Physical Medicine and Rehabilitation Services. Occupational therapy for individuals with symptoms of OSI or PTSD is highlighted.

The term “occupation” is categorized as self-care, productivity, and leisure, and occupation is identified as the therapeutic medium. If left unaddressed, occupational needs can lead to occupational disruption, deprivation, and imbalance, producing or exacerbating secondary health issues for CF members.

There is a clear link between physical and mental health issues. Occupational therapists are an important part of the health care team because they focus on the potential relationships among all aspects of functioning as they affect CF members' performance. Occupational therapy skills of home modifications and provision of aids such as wheelchairs and orthotic devices are well accepted by Physical Medicine and Rehabilitation Services. This understanding can be expanded to include: (1) occupational therapy assessment of dynamic relationships among people, occupations, and their environments and the amelioration or reduction of barriers; (2) the ability to analyze tasks, analyze members' performance in tasks, and the planning of interventions that have a direct effect on the occupations; and (3) return-to-work assessment and graded tasks and schedules to facilitate safe and efficient return to duty.

Occupational therapists provide interventions that address not only the body but also the mind and spirit of injured servicemen and servicewomen. A range of interventions is available for those with transient, intermittent injuries; those returning from overseas missions with very serious injuries or severe injuries; and those with permanent injuries transitioning from the Canadian Forces into civilian life.

Most occupational therapy services are supplied by civilian occupational therapists. This article points out that occupational therapists in civilian practice are not necessarily able to provide the range or depth of interventions necessary for CF members. Canadian Forces members, therefore, may not be receiving the care they need to meet their obligations to return to duty.

Four CF occupational therapists are currently employed with Physical Medicine and Rehabilitation Services. Employing a CF occupational therapist on every Canadian military base to liaise with civilian occupational therapists will improve the quality of military member care. However, directly employing more CF occupational therapists to take responsibility for the total rehabilitation of injured military members has the potential to provide a more comprehensive and cohesive occupational therapy service.