Aspects involved in the occupational roles of the depressive episodeM. Angélica Montenegro , Laura Rueda, Claudia Ornstein ,
This paper studies the place from which occupation emerges and its positioned, analyzing it through collective reflection. It also explores traits such as everyday life, spatiality, temporality, and territoriality, and tries to correlate the life experience of the depressive subject and the difficulty they have to join the demands that are imposed by occupation. In each area, it gives account of the natural life experience of people and how depressive symptoms interfere and impact occupational performance, limiting its development and, subsequently, the self-esteem that is obtained through the execution of meaningful tasks.
It proposes a therapeutic approach from Occupational Therapy.
Keywords: occupation, depression, dimension of occupation, therapeutic approach.
Received October 2018, Accepted December 2018.
An occupation provides meaning and significance to one's existence (1). Throughout the course of one's life, one performs different occupations that somehow impact one's identity according to the sense of self-efficacy obtained from their achievement. The human being, as an occupational being, will be the agent and protagonist of its growth process and will also have impact in the socio-cultural context in which it is inserted. According to Townsend and Willock (2), an occupation must be enriching to the subject executing it. It also allows him or her to deploy all the potentiality that unarmed; it is put to the service of personal realization, as well as the microcosms to which it belongs (3).
From the perspective of Occupational Therapy, an occupation develops in certain areas, which will be addressed next.
Everyday life is always changing. Consequently, people are permanently challenged and appealed to by everyday life. They must respond to such challenges by using the highest number of adaptive strategies to obtain results that are satisfactory to their expectations and, many times, to that of others as well. These appeals are relentless, therefore is not possible to give up.
A daily activity represents a challenge, and forms of response may be unknown. Predicting the occurrence of that which is about to occur is improbable. It only happens and appears.
Everyday life in depressive episodes is frequently experienced as a feeling of heaviness. This experience, in a certain way, prevents the free exercise of occupational roles. There is a sense of heavy gravitational weight that alters deployment and limits movement, which leads to certain passivity. Occasionally, the interest to commit to a past, pleasant occupation persists. Today, anhedonia (4) does not allow this to happen. The appeal to resume everyday life is completely impaired, and its duration will depend on the severity of the depressive episode and the speed of remission of anergic symptoms.
The experience of space is typically perceived as unattainable. Nevertheless, there are spaces that are experienced with more consciousness of familiarity, where one is allowed to transit with more certainty and confidence, and where close relationships with people considered kin are established. Space is also "occupied" to give place to action, to leisure and pleasure strolls, to the exhausting subterranean demand of a miner or the revelry of a festive encounter. In each one of these situations, the body must adapt to the occupied space, if only in its physical form, because, as such, it occupies a place in the space (5).
The depressive subject experiences the spaces with a sense of narrowness; of imprisonment. Somehow, space becomes less habitable: the occupation is interrupted, one is only in the captivity of one's sadness and hopelessness. Without anything, then, the purpose of the occupation decays. The physical, social, and affective space is constrained., Friends are not visited, there is no playful participation or enjoyment or pleasure in other occupations.
To "occupy" consist of taking possession of any task and for that task to provide satisfaction and empowerment; it becomes dismantled, without vigour, disabled.
The experience of temporality appears to be subjective. Objective time elapses relentlessly towards the future, and, inasmuch as it is experienced with the purpose of designing a vital plan, it is not experienced with a permanent registry of it elapsing. The normal human being goes through time with a certain relaxation that is only interrupted by a threatening and/or exulting situation, where it seems that somehow, time is transformed by extending or abbreviating itself, whichever the case may be. The passing of time is permanent and sustained.
Any type of occupation performed will be executed in a determined space and time, in a here and now, more or less bounded and with more or less level of personal satisfaction.
In the depressive episode, the persistent decrease of the mood is critically influential in the experience of temporality, which then impacts the performance of occupational roles. In fact, one of the five symptoms that comprise criteria A of the major depressive episode according to the DMS5 is the significant decrease of interest or pleasure in all or almost all activities (6). Discouragement, lack of energy, and hopelessness do not allow the projection of the historical outline. If nothing is expected, nothing can be ventured in the future; there is vital disinterest, one falls into the nothingness. Time seems to stop, and that detention is oppressive. At times there may be remnants of future projections that are always visualized as somber and dismal and do nothing but validate the pain of the current state. According to Gebsattel, the temporal disturbance of the depressive subject is the pathetic disturbance of time, meaning of what is occurring, of what is elapsing (7) . Therefore, occupational roles are not even performed: there is certain detention, a parenthesis, which emotionally taxing to the person and their family members who do not understand the devastation in which the person, someone who in the past was vigorous, responsible and receptive in relationships, is now submerged. That same subject today is found fragmented and withered.
When the word occupation is alluded to or searched for, it is generally found in reference to the taking or possession of a territory. Thus, the "okupa" movement has privatized the word to designate a habitable place, often collective, which has been accessed through the transgression of established norms. Once the territory is taken through ethnic conquest, legal acquisition, and/or the illegitimate occupation of groups or social collectives, its existence is acknowledged, and a certain domain over it persists.
According to Giménez, the appropriation process is con-substantial to the territory, as it represents rooting, attachment, and belonging (8).
The human being manages the spaces they inhabit to develop their affections, their recreation, and, obviously, their occupation. Usually, this territory represents trust and familiarity. It is made accessible; it does not represent threats--it is occupied and that is all. According to Giménez, the essential level or territory is the home, a space of absolute closeness and intimacy. The next level is constituted by certain territories that extend the home: the town, the neighborhood, the city, whose function is to articulate a social life that bases education, security, routes and roads, and celebrations (9).
During the depressive episode, the patient tends to occupy less territory. What was experienced with the certainty of comfort yesterday, today is perceived as threatening at times and constraining at others. This has an impact on the occupational performance in the execution of daily life activities such as hygiene and feeding, both of which are performed indoors, as well as instrumental activities such as managing medication at corresponding schedules and dosages.
Consequently, the territory is reduced to minimal deployments in the domestic realm.
FROM THE PERSPECTIVE OF OCCUPATIONAL THERAPY
The permanent reflection of occupational therapy professionals leads to practical realizations in people's tasks, where the analysis of such occupation allows to boost the understanding of such realizations for therapeutic purposes. This analysis refers to the composition of occupations comprised of three aspects: form, function, and significance (10); the understanding that is closest and most regular, and which includes all people, is registered in the functionality of the everyday life or daily activities.
The priority of occupying oneself in fulfiling basic daily needs (maintenance, self-care, survival) produces in the human being an interesting chain reaction among psychobiological components, specially when it creates behaviors that are sensoperceptal or that explore the environment which links people to their sociocultural environment in a way that the end result is the determination and rhythm of occupations.
The adequacy of the execution of occupation will have an impact on personal identity, family and community, exercising a powerful influence in the process of social integration and inclusion. An example of this is phenomenon is clothing styles, personal adornments, and the sense and care of personal appearance. In summary, occupation is defined as human performance that responds to the vitals needs of an individual, which allows the fulfillment of social demands, differentiation, and self-expression (11).
The therapeutic value of activities performed daily lies in the fact that they are permeated in the lives of people: they provide an organized structure and determined tasks (12). This construction is a sign of social adequacy as well as of education, maintenance, and recuperation of basic rehabilitation programs. The therapeutic value of daily activities is noteworthy as it provides a way to manage psychological and behavioral symptoms (13) when they provide life structure, form habits, and regulate emotional relationships with others as well as with the environment.
The Occupational Therapist must consider the occupational activity as a restitution process that has significant value in the recuperation of stability (14). Evidence of the benefits of preserving an occupation is known even in advanced old ages of life. Nevertheless, perhaps the first therapeutic approach to the depressive subject must be about validating discouragement and lack of motivation, to empathize with lack of energy, and to understand their hopelessness. Only then a solid trust relationship can be articulated, which will allow a long-lasting therapeutic alliance.
From the area of EVERYDAY LIFE, it is fundamental to help provide again a daily structure that allows for the gradual assumption of tasks and obligations balanced with leisure, entertainment, and fun activities.
In terms of SPACIALITY, the therapeutic space will represent a receptive space of empathic understanding. If the intervention is provided from the first instance as part of a hospital regimen, the occupational therapist will use a designated space to contribute to the reconstruction of parts fragmented by the depressive episode. The therapeutic space "is not" reality; therefore, compliance demand can be regulated (15) by assigning tasks from less to more complex.
With respect to TEMPORALITY, silence, rhythms, pauses, and rests must be respected. Eventually, the achievement of an assigned task may gradually return self-esteem and a sense of self-efficacy. External reinforcements of the therapeutic figure, such as pairs will sufficiently promote motivation in such way as to maximize the use of time. It seems crucial to note the importance of psycho-education in terms of a balanced occupational routine; the election of activities must not be forced on subjects, but they must consent to it voluntarily on a daily basis.
In relation to TERRITORIALITY, the practice of performing an occupation always occurs in a territory in which relationships, routines, rhythms, norms, and knowledge are established, which nourish both the subject and the environment. It is the duty of the Occupational Therapist to facilitate exit from the captivity and/or seclusion represented by the depressive episode to the outside world. This can be achieved through therapeutic escorting to gradually exit intimate territories.
From the perspective of communication tools, it is recommended to avoid blockers such as persuasion and even less so, demand. Useful strategies are:
- I understand that...because...
- “I understand that you do not want to get up because I can see you have a long day ahead and full of demands.”
- “I understand (comprehend, I can see) your discouragement because this episode has been long, and it is tiring for you to talk to me" (come to therapy).
It is recommended that these concessions be expressed in the same emotional and affective tone of the patient. Likewise, it is not advisable to use "but" given that it is a blocker that implies criticism, respect the "times" of the patient as it can only mean they need space for themselves and invite participation without pressure.
Gradually, the process of recuperation will be worked out, fostering restitution of personal worth. It is important to highlight the network of social support as close relationships provide several functions such as emotional support, financial assistance, guidance, advice, and other help.
This way, personal interaction will be promoted - an environment in which the adaptive achievement of the occupation, meaning the action-oriented to a task that is just, balanced and satisfactory.
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