The Power and Flow of Occupation Illustrated Through Scrapbooking

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Anne E. Dickerson, PhD, OTR/L, FAOTA

ABSTRACT. This paper discusses the concept of occupation by summarizing the theoretical work of Wilcock, the recent discussions of the power of occupation by Pierce, and the by-products of occupation by Crabtree. Tying the idea of optimal experiences to occupation, photo scrapbooking is used as an illustration of the power and flow of occupation by using excerpts of individuals enjoying scrapbooking. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: [email protected] haworthpressinc.com ]

KEYWORDS. Scrapbooking, meaning making, occupational intactness

INTRODUCTION The purpose of this paper is to question occupational therapists’ belief and depth of understanding about the power of occupation. Only with a deep understanding of occupation, can we survive as a profession and promote ourselves within this changing health care environment. I will start by telling a story. I was an occupational therapist for 15 years before a particular event offered me the opportunity to truly understand the power of our profession. I lost my ‘‘occupations.’’ In August, 1992, I was living with my husband and new baby at Homestead Air Force Base about to be hit by Hurricane Andrew. Although a terrifying experience, we Anne E. Dickerson is Professor and Chair, Department of Occupational Therapy, East Carolina University, Greenville, NC 27858 (e-mail: [email protected]). Occupational Therapy in Health Care, Vol. 12(2/3) 2000 E 2000 by The Haworth Press, Inc. All rights reserved.

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survived the hurricane and the immediate aftermath. We were very lucky, we were able to salvage our most important possessions and actually leave the area a week later. It was not until we were regrouping at a relative’s home that I felt the impact of the event. Although I cared for my baby, I spent the next few days full of anxiety and a sense of worthlessness. I became resentful of my husband as he dealt with the details of moving while I remained ‘‘trapped’’ in someone else’s home. I wandered around, unable to concentrate, lamenting that I was ‘‘unable to do anything.’’ I had lost my occupations. What are occupations? Occupations are human pursuits that are goal directed for a purpose. They are performed in situations and contexts that influence the activities and can be identified by the doer as meaningful. They are the activities that we do for a reason and have meaning to us (Christiansen & Baum, 1997). I had lost those. I was no longer an educator, home maker, student, friend, and all the leisure activities I normally engaged in seemed gone. I felt powerless and unable to initiate action. However, my story ends well. I did have my baby to take care of and my husband helped me change my outlook. I recognized that I needed something to do that was meaningful and goal directed; I taught myself how to use my new computer. I began to fulfill my other occupations and feel good about what I was accomplishing. This experience was a powerful lesson, although it really wasn’t until a year or so later that I could reflect back and be able to understand what occurred within me. I do not think I was able to frame it within the construct of occupation until others in our profession had written more about the theoretical conceptualization of occupation. However, because of this experience, my understanding of the power of our profession has been greatly enriched. One of those individuals, Ann Wilcock (1993), discusses occupation as a central aspect of the human experience. Through a study of human occupational behavior throughout history, she developed a theory proposing that there is a human need for occupation. She argues the premise that there is a strong biological basis of the need for occupation which brings order and growth in our lives. Wood’s (1996) work with chimpanzees supports this biological basis. Her observation of chimpanzee behavior strongly suggests that there is an innate need for occupation. She found that when she enhanced the environment and gave novel and meaningful occupations to the chimps, they partic-

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ipated in the normal routines and behavior that chimps would in the wild. But when the chimps were restricted by the environment to participate in no occupations they quickly degraded to participating in deviant behavior. Furthermore, when they were given occupations that were initially motivating, but then were given the same activities over and over again, that is, they learned the activities, they also began to participate in deviant behaviors-- much like I did when I lost my occupations. Wilcock (1993) also discusses how the socio-cultural forces and values that have added increasing complexity to the relationship between biological needs and human occupation. Although an individual’s conception, expression, and execution of the occupation is unique and motivated by socio-cultural values and beliefs, there is a basic underlying human need to engage in occupation which is innate and related to health and survival. Wilcock contends that the current complexity of occupational technology and economy and the social structures, divisions, and values which have been established over time has obscured these basic occupational needs of individuals. In this increasingly complex world, particularly in the medical community, it became easy for our profession to lose its touch with our basic tenets of occupation. Wilcock’s (1993) theoretical framework identified three major functions of occupation for maintaining and enabling the health of individuals and the survival of the species. They include: (1) to provide for immediate bodily needs of sustenance, self care, shelter, and safety, (2) to develop skills, social structures and technology aimed at safety and superiority over predators and the environment, and (3) to exercise and develop personal capacities enabling the organism to be maintained and to flourish. If you consider what occurs in occupational therapy clinics, we do try to meet these basic needs of our clients. For example, when a client has a spinal cord injury, we teach them how to provide for their self care, teach them skills so they can manipulate and have control over their environment. We also try to develop knowledge, skills, and abilities so that individuals can maintain and flourish in their environment. The interesting aspect to this theoretical model is the argument that individuals have innate occupational needs that have to be met. In my opinion, if we can structure our therapy to meet those needs appropriately, we are using the power of occupation.

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PURPOSE OF THIS PAPER Recently, I have discovered an activity that I think is one of the most promising activities for demonstrating the power of occupation and providing a ‘‘flow’’ experience for individuals. A flow experience is an optimal experience in which one experiences intense concentration and deep enjoyment, often associated with athletes and artists (Csikszentmihalyi, 1990, 1997). The activity is photo scrapbooking. Photo scrapbooking is selecting your best photographs and using paper, stickers, and journaling to create a unique chronicle of your life and family’s life that will be a priceless keepsake. Engaging in this occupation has made me want to explore this idea of the innate need for occupation and flow. This exploration, doing scrapbooking, and more than anything, teaching scrapbooking to others while observing their response has reinforced my belief about the power of occupation and that the experience of flow is available to anyone. The remainder of this paper discusses components of occupation and flow. To illustrate the concepts, I will offer comments by individuals who have responded to the question of ‘‘why you like scrapbooking?’’ THE POWER OF OCCUPATION Recently, Doris Pierce (1998) identified what she considers the source of power of occupation as its appeal, intactness, and its goal fit. First, the occupational appeal is the degree to which the client sees the occupation as desirable or attractive. The therapeutic activity has to be perceived as offering pleasure, productivity, and restoration. In other words, it has to be meeting the person’s innate occupational needs. MC speaks to this appeal in the following statement. MC: Scrapbooking is a creative exercise. It allows you to relive pleasant events, and, at the same time, exercise creativity in how you present the materials you are using. It gives a way of capturing and reliving important events in your life in a more satisfying manner than simply putting photos in an album-- it is more complete and the act of compiling a scrapbook is a creative one, adding to the pleasure. The second characteristic is occupational intactness (Pierce, 1998). The person needs to be able to see the occupation being used in its

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usual, nontreatment context. We need to use occupations that are spatially, temporally, and socioculturaly natural for each person. The move to do activities of daily living in the morning when the patient is getting dressed was a move to make sure our treatments are occupationally intact. Working with clients in the community is the ultimate goal to meet the occupational intactness. PW illustrates intactness with the following: PW: As a surprise high school graduation gift for my daughter I made her a scrapbook which includes pictures from her 18 years of growing up. Working on the book helped me deal with her graduation and ensuing life changes as we prepared for her to leave home for college. I laughed and cried as I reminisced about her growing up years and found that scrapbooking was a wonderful way to ‘‘deal with’’ my feelings. By the time her actual graduation arrived, I felt much calmer and in control of this major life change. Finally, Pierce (1998) states that the power of occupation is in the goal fit. The degree to which the occupation matches the patient’s goal will determine the power of your treatment. This is not always easy and demands consistent creativity and energy, but when we have it right, we can see the power of occupation work wonders. Both excerpts below describe scrapbooking as an occupation that has goal fit. PW: I really enjoy the creative part of designing each page to fit the photos. I love the stickers, design lines, and borders because no page is ever alike; they can be used in such a variety of ways to create new looks. I find that scrapbooking meets my need to remember the past in a fun, creative, and personal way. AM: I enjoy scrapbooking because it is down right fun. Being able to design and arrange your pictures and decorate them with stickers and journaling is a lot of fun. I have discovered a creative side that I never knew existed! I have fun planning my page and ‘‘taking the trip down memory lane’’ as I journal all the details in. I have never known myself to be a creative person, and with the field I am going into-- Elementary Education-- I need to get better in touch with my creative side, and scrapbooking helps me do that!

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The three characteristics of appeal, intactness, and goal fit, align well with Ann Wilcock’s theory that occupation is innate for humans. What it means is that humans are forced to seek what they need for health and survival and only when we offer what is essential for that person, will occupational therapy work. The well elderly study (Clark, 1997) clearly exemplifies this power. The implication of the study is that although activities may be good for people generally, to make significant differences, an occupational therapist, who understands the power of occupation, is necessary to make a significant difference. In other words, if individuals engage in meaningful occupations, they will develop ‘‘personal capacities enabling the organism to maintain and to flourish,’’ one of Wilcock’s major functions of occupation (Wilcock, 1993, p. 20). In April 1998, Mary Law, Sandy Steinwender, and Leanne Leclair critically reviewed 22 studies from health and social sciences literature using specific methodological review criteria. Although most of the research was done with individuals with disabilities, the findings indicated that regardless of measuring physiological or functional outcomes, the performance of everyday occupations is an important part of everyday life. Withdrawal or changes in occupation for a person have a significant impact on a person’s self perceived health and well-being, thereby concluding that occupation has an important influence on health and well being. The conclusion here is that occupations have tremendous power to be restorative and fulfilling. When you find the right match of occupation for your client, the person flourishes and grows. Furthermore, just as powerful as occupation is for our clients, we must use occupation to fulfill our need to be happy with life. We must do occupations that maintain and help us flourish. THE END PRODUCTS OF OCCUPATIONAL THERAPY In another paper, Jeffrey Crabtree (1998) discusses the nature of human beings, their ideal human state, and he argues about what should be the emphasis of occupational therapy. To summarize his paper, he proposes that humans are meaning makers and that this meaning is accomplished, not just through cognitive activities, but through their performance of occupations. Thus, he argues that occupational therapy should emphasize human performance and its role in

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meaning making. Furthermore, he suggests the meaning-making dimension of occupational therapy should be emphasized over the goals of independence and function. Through this, he feels occupational therapy should not only address all levels of functioning, but allow other therapeutic possibilities such as: developing deeper and more significant relationships with clients, finding therapeutic outcomes beyond performance, and also uncovering the potentiality of helping individuals who do not fit within the medical model of health care. That is, he states that occupational therapy is the best treatment for the inability to make and express meaning through occupation. The unique goal of occupational therapy is to help persons with performance deficits of any kind make and express meaning through occupation, or intentional, organized performance. In his paper he identifies what he sees as four by-products or ‘‘ends’’ of occupation. The by-products are exemplified in the following statements about scrapbooking with each of the excerpts showing that meaning making is really important for participants. First, Crabtree (1998) states that when doing an occupation that meets your innate needs, you have a sense of engagement, that is, you become absorbed by your effort. GP: In the months following the death of my husband, despite support of family and friends, I found I had lots of empty hours. My daughter, an occupational therapist, encouraged me to do a creative memories photo album. ‘‘My Heritage Album’’ gave me a renewed enthusiasm. I became ‘‘hooked’’ and spent many hours totally engrossed in the creativity and joy of putting together the lives of my parents whom I loved very much. Here was a new purpose for my life and it satisfies my need to be doing something creative. My book is uniquely mine, a one of a kind product, unlike any one else’s album. That first project is completed and I am very pleased with it now. Crabtree’s (1998) second by-product of occupation is the sense of actuality or engaging in a performance that is immediate and real and gives the sense of completion. BV: I find it enjoyable because it offers structure and focus, something often missing from my everyday life. When I sit down to do a page there are boundaries to what I must consider. The

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materials don’t require acts of assertiveness or aggression. They are passive in nature and await my action upon them. This allows me to maintain control, something important to me. I also enjoy it because it provides me the opportunity to paint the ‘‘big picture’’ of my life and the lives of my family. My intuitive and creative side is able to come out. Because of the inherent structure and the tools used, I can be assured that the end product will ‘‘look good’’ making me feel successful. Crabtree (1998) also identifies the sense of authorship or the sense that no matter how small, when we are productive, we have some power over our environment or our own body. RS: After the death of my 11 year old son, making a scrapbook album was a meaningful experience for me. It provided me with a review of his entire life putting the whole experience into perspective. And now, this album is a precious treasure for me, a tangible reminder of his life. I want my daughters to remember their brother, how much we all loved him, and his special part in our lives. Finally he presents a sense of identity. Occupation demonstrates that a person does exist within a family or community and why that person exists (Crabtree, 1998). JU: I am the only daughter in our family and my Mother and I had always been very close. We lived 5 miles apart for the past 25 years. During that time we talked, shopped and took trips together, alot. When my Mom passed away I had lots of memories running through my mind and until I did scrapbooking I couldn’t release the feelings. It is meaningful to have a beautiful scrapbook to look at over and over again. With scrapbooking I was able to get in touch with my memories and feeling of growing up. Journaling helped me work though the time spent with my Mom. When I finished with the scrapbook I gave it to my Dad for Father’s Day. Now he enjoys looking at it over and over again. DS: It is a pleasure to make a special page, but there is great fun in reviewing the page, too. When I look at this page, it reminds me of the day World War II was over. Although it was well over

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53 years ago the VICTORY was ours and I still get a chill up my spine remembering how joyous we all were that day! It seems like yesterday. CD: I do a lot of pictures of kids. I don’t get to see my nephews, Scott and Eric, very much so it makes me feel like I am part of their lives. . . . this page reminds me of my Dad. He would be proud, he loved to see his grandchildren eat. He is gone now, but looking at this page and creating this page made me feel like he was still with us. My niece, Amy, is going to high school now. This page brings back wonderful memories of Halloweens in the past. JL: For me, searching out photos from another era has been a labor of love. Looking at pictures from my husband’s childhood, and of mine, has been very comforting. Surely a visit with the past enriches us all. My step mother has Alzheimers’. I recently completed a page because I felt it was really important for me to remember the way she was before she is gone. DS: I really dislike fishing, however, my two grandsons would rather fish than eat. Putting their picture in an album and pouring over them, I can actually enjoy fishing. I can even put the worms on the hooks. Even though we are MANY miles apart, I feel so close to them, enjoying the day with them. MC: Scrapbooking, as opposed to simply putting photos in an album, allows me to keep all the memorabalia of a vacation or a family event together in one place. Journaling lets me write down those memories that are not easily captured in concrete mementoes so that I won’t forget them. Anecdotes, feelings and emotions are important to capture for remembering, both for myself and anyone who might look at the book later, and journaling along with photos and other mementoes allows that. Clearly, these comments illustrate the value and need for individuals to participate in occupations that help them ‘‘make meaning’’ of their lives.

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THE FLOW EXPERIENCE Mihaly Csikszentmihalyi (1990, 1997) is a professor of psychology and education at the University of Chicago who has been researching the states of optimal experience for over two decades. Optimal experiences are those experiences when people report feelings of concentration and deep enjoyment. He started his research with athletes and artists and soon began to realize that everyone had these experiences. He has introduced the concept of ‘‘flow’’ as a state of concentration so focused that it amounts to absolute absorption in the activity. I think his work, the innate need for occupation in humans, and the conceptualizations of occupation are closely linked. It is my belief that if we can find those occupations that can produce the ‘‘flow’’ experience for ourselves and our patients, we will be able to demonstrate the power of our profession. Csikszentmihalyi (1997) contends that in everyday life, it is rare for the different contents of experience to be in synchrony with each other. Rarely do we feel the serenity that comes when our heart, mind, and will are all in agreement with what we are doing. For example, I may be invited to go to dinner with friends and although I am enjoying their company and the food, I feel guilty because I should have gone to the gym to work out and I may be wasting money when I had food at home to eat. Everyday life is full of these scenarios, but often when you are doing your favorite activity, what we feel, what we wish, and what we are thinking are in harmony. Through his research, Csikszentmihalyi (1990) has found that although people are doing very different things during flow, their descriptions of the experience are remarkably similar. In fact, Csikszentmihalyi (1997) suggests that it is the full involvement of flow, rather than happiness, that makes for excellence in life. He explains that when in flow, we are not happy because to experience happiness we must focus on our inner state, and that would take away attention from the task at hand. For example, I get great joy from hugging and cuddling with my five year old son, but I am not trying to concentrate to attend to any task. On the other hand, when I scrapbook, I am concentrating on how the pictures should be placed, what color paper I should use, and what mood do I want to portray. I am not thinking about being happy, I am concentrating on the task and its outcome. With flow, only after the task is complete, do I look back on

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what has happened and become flooded with the positive feelings of the experience and in retrospect, be happy. What Csikszentmihalyi (1997) emphasizes is that the happiness that follows flow is of our own making and therefore it leads to increasing complexity and growth in our consciousness. It is the kind of happiness that has lasting effects. If we can understand this phenomenology of enjoyment, occupational therapists can better understand what makes enjoyable activities so gratifying and the information can be used to select activities that will improve the quality of life and produce flow for clients and therapists. Csikszentmihalyi (1990) believes the phenomenology of enjoyment has eight major components. First, the activity must be challenging and it must require skill. It must be goal-directed and be bounded by rules. It does not have to be a physical activity, though it can be, but it must be an activity that requires some psychic energy and could not be done without some level of skill. Occupational therapists know about this characteristic from our training. For flow to occur, there needs to be a fine balance between one’s ability to act and the available opportunities for action (Csikszentmihalyi, 1990). If the challenge is too high, a person gets frustrated, worried and/or anxious. If the challenge is too low and the skill high, one gets relaxed, then bored. If both the challenge and skill level are low, one gets apathetic. However, when high challenges are matched with high skills, then the deep involvement that sets the experience apart from ordinary life occurs (Csikszentmihalyi, 1990, 1997). What we are skilled to do as therapists is make sure the challenge is at the right level for patients. The point where the activity is most enjoyable is when the action is perceived by the individual to be equal to his or her capabilities. The second characteristic is the merging of action and awareness. When all of the person’s relevant skills are needed to cope with the challenge of the situation, that person’s attention is completely absorbed by the activity. Csikszentmihalyi (1990) says one of the most universal and distinctive features of the flow experience is that people become so involved with what they are doing, the activity becomes spontaneous and almost automatic that they stop being aware of themselves as separate from the actions they are doing. It is not effortless, it requires tremendous strength or mental concentration, but there is no reflection about why you are doing it or how you are doing it.

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The third and fourth characteristics are that there are clear goals and immediate feedback. The end goal is clearly established, for example, the completion of a scrapbook page. Moreover, there is immediate feedback in terms of how the person is doing on the task. For different activities, obviously the feedback varies, but as we all know, when we have that immediate feedback we can see that we are succeeding in our goal. Any feedback is useful and enjoyed when it is tied to a goal in which we have invested psychic energy. This knowledge of success in meeting our goal creates order in consciousness and strengthens the structure of the self (Csikszentmihalyi, 1990). Another characteristic is concentration of the task at hand. It is the sense of forgetting everything else except what you are doing. When you are concentrating on the task, you tend to forget your pains, troubles, or hunger because you are so focused on the attention at hand. It is not only temporal, but also only certain elements of the task are allowed into your consciousness with no room for irrelevant information (Csikszentmihalyi, 1990). Don’t we all have things we do knowing that we can forget our problems by doing that activity? Aligned with this characteristic is the loss of self-consciousness. When you are so engrossed in an activity, you don’t consider the past, future, or other irrelevant details. You also lose the sense of self consciousness because you are not focusing on your inner self. The loss of the sense of a self separate from the world around you sometimes is accompanied by a feeling of union with the environment, whether that be a mountain, a team, or scrapbook page. If we are well matched with the challenges of an activity, there is no opportunity to be threatened. Csikszentmihalyi (1990) found that the experience of this loss of self consciousness is necessary for building a strong selfconcept, so in fact, through these flow experiences, the individual will emerge with a stronger self concept, enriched by new skills and fresh achievements. The sixth characteristic is the paradox of control. In real life, we have to worry a lot about things that can happen to us upon which we have no control. With flow activities, there is a sense of control, or more specifically, a lack of worrying about losing control. What we enjoy is not the sense of being in control, but the sense of exercising control in difficult situations (Csikszentmihalyi, 1990). Finally, the last characteristic is the transformation of time. During flow activities, time no longer passes the way it ordinarily does. Hours

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seem to pass in minutes. Csikszentmihalyi (1990) states that although the loss of the sense of time is not one of the major elements of enjoyment, freedom from the tyranny of time adds to the exhilaration we feel during the state of complete involvement. The following excerpts illustrate the feeling of flow while scrapbooking.

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KJ: Due to the fact that I am a full-time student, working on my albums is a great stress reducer. It allows my creativity to flow as I choose colors and stickers to enhance my photographs. Scrapbooking is fun, creative and organizational. It produces a lasting record of the life and purposeful activities of my family. CD: I enjoy scrapbooking, it makes me happy. I am alone a lot, it fills up my time and makes the evening fly by. PD: I so enjoy doing my pages. When I work on my books, the time slips by so quickly. LB: When I get my stuff out to do scrapbooking, my family knows to leave me alone. This is my time. I start working on it and often forget to stop until it is late in the night. The characteristics of flow seem very similar and closely aligned to Crabtree’s description of the by-products of occupation. This idea of flow also meets well with Anne Wilcock’s sense that occupation is innate and related to well being in that it appears to be universally described and experienced. Finally, Doris Pierce’s description of the power of occupation as its appeal, intactness, and goal fit also can be related to these characteristics of an activity that is deeply enjoyed. In summary, I have summarized some theoretical concepts about occupation that clearly emphasize the need and power of occupation. I used scrapbooking as an illustration as the ultimate occupational therapy experience we can offer our patients because of its inherent qualities and components to be an engaging occupation that has the potential to exercise and develop personal capacities for an individual to flourish as described by Wilcock; has the occupational appeal, intactness, and goal fit as described by Pierce; can produce the by-products of occupation of engagement, actuality, authorship, and a sense of identity as described by Crabtree; and can produce flow experiences described by Csikszentmihalyi.

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REFERENCES Christiansen, C. H. & Baum, C. M. (1997). Occupational therapy: Enabling function and well-being (2nd edition). Thorofare, NJ: Slack, Inc. Clark, F., Azen, S., Zemke, R., Jackson, J., Carlson, M., Mandel, D., Hay, J., Josephson, K., Cherry, B., Hessel, C., Palmer, J., & Lipson, J.L. (1997). Occupational therapy for independent-living older adults, a randomized controlled study. Journal of the American Medical Association, 278, 1321-1326. Crabtree, J. L. (1998). The end of occupational therapy. American Journal of Occupational Therapy, 52, 205-214. Csikszentmihalyi, M. (1997). Finding flow: The psychology of engagement with everyday life. New York: Harper & Row Publishers. Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. New York: Harper & Row Publishers. Law, M., Steinwender, S. & Leclair, L. (1998). Occupation, health, and well-being. Canadian Journal of Occupational Therapy, 65, 81-91. Pierce, D. (1998). What is the source of occupation’s treatment power? American Journal of Occupational Therapy, 52, 490-491. Wilcock, A. (1993). A theory of the human need for occupation. Occupational Science: Australia, 1, 17-24. Wilcock, A. (1998). An occupational perspective of health. Thorofare, NJ: Slack, Incorporated. Wood, W. (1996, November). Environmental influences upon chimpanzee occupation and adaptation. Paper presented at annual North Carolina Occupational Therapy Conference, Raleigh, NC.

The power and flow of occupation illustrated through scrapbooking.

This paper discusses the concept of occupation by summarizing the theoretical work of Wilcock, the recent discussions of the power of occupation by Pi...
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