Leisure as an End,Not Just a Means,in Occupational Therapy Intervention

Definition and Meaning of Leisure

Leisure is a complex concept. According to the OTPF–3, leisure is “nonobligatory activity that is intrinsically motivated and engaged in during discretionary time, that is, time not committed to obligatory occupations such as work, self-care, or sleep” (Parham & Fazio, 1997, as cited in AOTA, 2014, p. S21). This definition encompasses three main elements, including time that people have the ability to spend however they choose, activity that is freely chosen and not an obligation, and subjective experiences (Kelly, 2012; Suto, 1998). This multidimensional concept illustrates that leisure is not simply a list of fun and relaxing activities but is, in fact, something that varies in form and time in the eyes of different people, or even the same person at different stages of his or her life. Moreover, each form of leisure should bear the central idea of self-determination and autonomy (Kelly, 2012).

Leisure, as one of the few occupations that persist throughout the life course, plays an important role in human lives (AOTA, 2014; Kelly, 2012). As suggested by the definition, to each person in his or her own way, participating in leisure can provide unique meaning that a person may not be able to attain from other occupations, including a sense of freedom (Craik & Pieris, 2006); physical and mental relaxation from obligations and routines (Roelofs, 1999); a channel of self-expression and exploration of one’s identity (Nadasen, 2008); and a platform for social engagement with family, friends, and society (Kelly, 2012).

Leisure: A Historical Perspective

In ancient Greece, leisure was accessible only to the ruling class and was used as a method to cultivate the capability to govern and entitle individuals to leadership roles. In ancient Rome, however, leisure was used more as a political instrument to occupy the free time of soldiers and prevent rebellion. During the Middle Ages and the 16th century, Christianity emphasized the importance of worship and work ethic over all else; thus, pagan leisure activities were banned (Kelly, 2012). Leisure resurged and became more accessible to the common people during the Industrial Revolution, and it greatly influenced the way people lived and worked. Workers’ pursuit of leisure became separate from their work (Kelly, 2012). After the American recreation movement and the growing awareness of the need for leisure, by the early 1940s organizations of leisure services were firmly established in society. As history illustrates, the meaning and perceived importance of leisure have changed as its roles have evolved throughout the ages, with leisure gradually being seen as having more and more importance as we approach the present day (McLean & Hurd, 2015).

At the time of occupational therapy’s founding, the value of leisure was quickly recognized by Adolf Meyer (Schwartz, 2003), one of the early leaders of the occupational therapy profession. Meyer expanded on the ideas of his contemporary, William Rush Dunton, Jr., concerning work as an occupation to also consider leisure one of the constructs of occupation (Meyer, 1922/1977; Schwartz, 2003). Meyer believed that a lack of balance between work and leisure was a reason for mental illness; he therefore saw a need to provide programs for patients to engage in pleasurable and creative occupations (Meyer, 1922/1977; Schwartz, 2003), such as handicrafts. This early recognition of the therapeutic value of leisure, however, waned after the profession of occupational therapy embraced biomedical approaches after World War II, when efforts were directed more toward job-related occupations in serving wounded soldiers (Schwartz, 2003). Until the 1990s, leisure generally remained undervalued in most occupational therapy practice (Bundy, 1993; Suto, 1998).

Why Leisure Should Be Included as a Goal of Intervention

We believe leisure should be a goal of occupational therapy intervention for three reasons. First, the profession of occupational therapy should advance and evolve in keeping with the changing views of U.S. society on the relationship of leisure and work. Although the influence of the traditional work ethic can still be perceived in North American society, the value attributed to leisure has increased steadily, and the value given to work has decreased across the generations (Twenge, 2010). Also, the younger generation puts more emphasis on work–life balance and self-development goals than does the older generation (Smola & Sutton, 2002; Twenge, 2010). Moreover, unlike in earlier times, leisure activities and amenities have been integrated into work environments in some leading companies, such as Google, to provide employees with a more balanced life. These developments signal that work is no longer seen as important above all else and that leisure is increasingly valued in U.S. society.

History has shown that the development and philosophy of a profession are inevitably influenced by the values of a society and the core values of the profession when it was founded (Schwartz, 2003). Likewise, occupational therapy practice should not only reflect the current values of society but also embrace the profession’s basic philosophy (Hinojosa, Kramer, Royeen, & Luebben, 2003), that is, valuing what people can gain by doing occupations and viewing leisure as one of the occupations. In other words, if we in the occupational therapy profession start to value leisure more, we will be more in tune with the changing values of U.S. society and the core value of our profession, which is key in distinguishing occupational therapy from other professions.

Second, leisure confers unique life meanings that cannot be replaced by other occupations, and it is also a necessity to achieve occupational balance. Studies have shown that clients gain more than just relaxation (Roelofs, 1999) and enjoyment (Pereira & Stagnitti, 2008) from leisure. By participating in leisure activities, clients rebuild confidence; gain higher levels of self-esteem (Patterson & Pegg, 2009); experience a sense of control (Craik & Pieris, 2006); and acquire better coping skills for stress, disability, and illness (Specht et al., 2002).

However, not all clients have the opportunity to explore what leisure means to them. Many clients encounter a wide range of barriers in leisure participation as a result of disease, injury, or aging (Berger, McAteer, Schreier, & Kaldenberg, 2013; Padilla, 2011). Moreover, clients’ leisure needs are not consistently identified by occupational therapists, and thus occupational therapy interventions tend to focus primarily on regaining independence in ADLs and IADLs (Wolf et al., 2015). Such an approach neglects that some clients may view leisure as more important than self-care activities (Rudman, Cook, & Polatajko, 1997), in part because self-care activities can be done by caregivers, yet the essence of leisure can be experienced only by clients themselves. The emphasis solely on ADLs and IADLs can also lead to a further imbalance in occupations, which is associated with decreased well-being and life satisfaction (Anaby, Backman, & Jarus, 2010). Therefore, occupational therapists should include leisure as a goal of intervention.

Third, participating in leisure is beneficial to one’s health and has a positive impact on several health-related functions and clinical outcomes. Descriptive studies and meta-analysis involving several adult populations, such as younger and older adults and people with intellectual and developmental disabilities, have shown that participating in leisure is associated with better quality of life (Duvdevany & Arar, 2004) and well-being (Kuykendall et al., 2015). In older adults, it is associated with better ADL and IADL function and fewer depressive symptoms (Janke, Payne, & Van Puymbroeck, 2008). Also, participating in leisure over time is associated with reduced risk of dementia (Akbaraly et al., 2009) and mortality (Paganini-Hill, Kawas, & Corrada, 2011).

Moreover, interventions to enhance leisure participation, such as traditional compensatory and remedial approaches, and leisure education programs (i.e., building knowledge, exploring interests, and enhancing self-value; Sivan & Stebbins, 2011), have been shown to be effective in helping clients with stroke and spinal cord injury gain a better quality of life (Daniel & Manigandan, 2005), increase well-being (Drummond & Walker, 1996), and reduce levels of depression (Desrosiers et al., 2007). Positive effects have also been found in older adults, indicating decreased life stress (Chang, 2014) and improved self-reported health (Chang, Yu, & Jeng, 2015). Substantial evidence has confirmed the benefits of leisure participation for clients’ health, making it clear that occupational therapy, as a health profession that addresses health through occupation, should make leisure a valued goal of intervention.

Challenges and Solutions

The biggest obstacle for providing leisure as a goal in occupational therapy practice is caused by a lack of Medicare coverage. As described in the Medicare Benefit Policy Manual (Centers for Medicare & Medicaid Services [CMS], 2014), activity, therapy, programs, or equipment that is recreational in nature or used for leisure purposes will not be reimbursed. Also, no CPT ^® codes (American Medical Association, 2016) exist for occupational therapy intervention to solve leisure participation problems. This situation implies that leisure is not deemed medically necessary in a traditional medical model and strongly affects how occupational therapists practice.

However, occupational therapists still have opportunities to address leisure to benefit clients. After the 2010 enactment of the Patient Protection and Affordable Care Act (ACA; Pub. L. 111-148), work began on the transition of the reimbursement system from a fee-for-service to a fee-for-value (FFV) model. The FFV model favors the occupational therapy profession in providing services such as leisure intervention that are geared toward maximizing clients’ quality of life (CMS, 2015). Although the results of the 2016 election cast uncertainty on the fate of existing ACA policies, it seems unlikely that the ACA will be repealed completely (Sparer, 2016). Health care quality has long been emphasized, so even if the ACA may be partly repealed, the FFV model will likely be retained (Whitman, 2016). Moreover, the new administration presents an opportunity for the profession to have a say in future legislation about health care reimbursement for leisure.

In addition, expanding alternative health care service models, such as the Program of All-Inclusive Care for the Elderly (PACE), can help occupational therapists provide leisure intervention. PACE is an innovative long-term care model to help frail older adults age in place by tailoring services such as prevention, primary care, and rehabilitation to their health care needs (Hirth, Baskins, & Dever-Bumba, 2009). PACE is funded by monthly capitation payments from Medicare and Medicaid, which allows professionals to provide more flexible and creative care services (Mui, 2001). PACE expanded into rural and suburban areas years ago, and the PACE Innovation Act of 2015 (Pub. L.114-85) broadened the inclusion criteria for older adults and includes other populations, such as people with disabilities (Bowers, 2015). The occupational therapy profession should take every advantage of these new positive changes in health care legislation to keep expanding its focus on leisure as a goal of intervention.

Another obstacle to making leisure a goal of intervention is the idea that doing so would seem to cause the functions of occupational therapists to overlap with those of recreational therapists. Although the two professions have similarities in terms of population served, practice settings, and treatment goals (American Therapeutic Recreation Association, 2016), occupational therapists have unique knowledge and insight that differ from those of recreational therapists.

Occupational therapists use a comprehensive approach to understand leisure as but one of many interrelated human occupations (AOTA, 2014). Thus, information obtained from other occupations can serve as a complement to understand clients’ leisure needs, interests, or performance and enables therapists to build a complete picture of a client’s life, ensuring that an occupational balance is achieved (Mccoll, 1994). It also allows therapists to make the best use of resources among different occupations (Olson, 2014), such as prescribing assistive devices that can be used for both leisure and other occupations. In addition, occupational therapists are well equipped with the knowledge and skills needed to analyze activities and environments, carry out principles of grading and adapting activities, and modify environments, which form the essence of helping clients reengage in activities (Olson, 2014).

Informed by the approach and the specialized skills, a potential collaboration between occupational therapy and recreational therapy could result in a beneficial synergy that optimizes clients’ leisure outcomes. For example, occupational therapists could apply their unique background to guide the initial evaluation and then collaborate with recreational therapists to establish treatment goals. In addition, when funding resources are limited in practice settings, a reduced recreation staff calls for occupational therapists to deliver more leisure services. Clearly, occupational therapy is not a duplicate of recreational therapy in leisure practice.

Another challenge to including leisure as a goal of treatment is that occupational therapists have long viewed leisure as less important than other occupations. To change this mindset, the occupational therapy profession can start by better emphasizing leisure in entry-level education to establish its importance from the outset (Krishnan, 2008). This emphasis could take the form of exploring leisure-related assessments and the application of assistive technologies to leisure activities and so on.

In addition, the possible ongoing transformation of payment and service delivery systems can change people’s mindsets by starting a virtuous cycle; that is, when current practice in leisure yields better outcomes for clients’ health and quality of life, third-party payers will be more likely to transform reimbursement systems to FFV and the government might further expand alternative programs such as PACE. Occupational therapists will have greater flexibility in planning treatment goals. These changes, in turn, combined with continuing education courses focused on enhancing leisure, may help therapists recognize that leisure is an important occupation that warrants intervention.

From there, this beneficial cycle could continue to gain force as more people recognize the importance of leisure. This positive cycle would also have an impact on the education system, prompting more research and courses on leisure topics. A repeated emphasis on leisure in each link of the larger system can thus change a value system (Hüther, 2013). As shown, each step plays an important part in the value-changing process, and although the goal of changing values may take quite some time to achieve, the occupational therapy profession needs to take action now to begin the work of setting this change in motion.

Conclusion

Leisure, as a meaning-laden occupation, provides great health benefits and has gained importance in U.S. society. The occupational therapy profession should expand its focus to include leisure as a goal of intervention to better match changing societal values and thereby help clients achieve occupational balance and better health. The solutions offered here are a start. Continuous advocacy is needed to bring leisure as an end goal of intervention to the attention of the occupational therapy profession.