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Exploring occupational therapists’ views about Nussbaum’s central human functional capabilities : an… Mousavi, Seyedeh Tahmineh 2014

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	 ?  EXPLORING OCCUPATIONAL THERAPISTS? VIEWS ABOUT NUSSBAUM?S CENTRAL HUMAN FUNCTIONAL CAPABILITIES: AN EXPLORATORY SEQUENTIAL MIXED METHODS STUDY     by   Seyedeh Tahmineh Mousavi  B.Sc. (Occupational Therapy), Iran Medical Science University, 1995 M.A. (History and Philosophy in Religion), Concordia University, 2004    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY  in  THE FACULTY OF GRADUATE AND POSTDOCTROL STUDIES  (Rehabilitation Sciences)    THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)  February 2014    ?Seyedeh Tahmineh Mousavi, 2014       	 ? ii	 ?ABSTRACT BACKGROUND: The 21st century marks a shift in the perspective of care of people with disabilities with greater attention to individual human rights. An innovative approach related to human rights that provides a basis for conceptualizing and framing the rights of people with disabilities, is the Capability or Capabilities Approach. Developed by Sen and extended by Nussbaum, the approach advocates that fundamental human rights can be viewed as claims to certain basic capabilities. Nussbaum has proffered ten so-called Central Human Functional Capabilities (CHFCs).  OBJECTIVE: To explore the views of Canadian occupational therapists (OTs) related to the CHFCs and their understanding and perceived relevance, with respect to their professional practice.  METHODS: An exploratory sequential mixed methods design including an initial qualitative phase that informed a subsequent quantitative phase. Phase One consisted of semi-structured interviews with OTs (n=14) in British Columbia, Canada. The findings from Phase One generated 11 categories with 22 themes and 75 sub-themes. These findings informed the development of a questionnaire to survey Canadian OTs, nationally. A cross-sectional survey, registered with the Canadian Association of Occupational Therapists was conducted in Phase Two to determine the applicability of Phase One findings about the CHFCs to a broader group of OTs from across Canada. The survey was hosted at the website Fluid Surveys?. We sampled 780 OTs with a response of 109 (14%).  RESULTS: Respondents understood the CHFCs as reflecting occupational therapy values. They perceived the CHFCs as relevant and consistent with established models of and approaches to occupational therapy practice including professionally-valued constructs of human rights and social justice as well as health and client-centered care.  CONCLUSION: These findings unify and advance the conceptual bases for occupational therapy models and approaches by enabling OTs to better fulfill their professional mandate of addressing their clients? needs from an overarching human rights perspective. Importantly, these results align occupational therapy services with client-centered practice, and human rights initiatives of the United Nations and World Health Organization. Our findings could be used by other health professions and across cultures to establish whether the Capabilities Approach is applicable across professional practices and health services.  	 ? iii	 ?PREFACE This research was approved by the University of British Columbia, Behavioral Research Ethics Board (Reference number: H11-00570) on February 6, 2012. I conceived the project described in these chapters, designed the study and analyzed and interpreted the findings with the guidance of Drs. Elizabeth Dean, Susan Forwell, and Shafik Dharamsi. Specific chapters of this dissertation are in preparation for publication. All chapters have multiple authors.                	 ? iv	 ?TABLE OF CONTENTS  ABSTRACT  ........................................................................................................................ ii PREFACE  .......................................................................................................................... iii TABLE OF CONTENTS  ................................................................................................. iv LIST OF TABLES  ............................................................................................................ ix LIST OF ABBREVIATIONS  ............................................................................................ x ACKNOWLEDGEMENTS  ............................................................................................. xi DEDICATION  .................................................................................................................. xii 1           INTRODUCTION, LITERATURE REVIEW, AND RATIONALE FOR THE THESIS  ..... 1 1.1     Introduction  ............................................................................................................. 1 1.2     Literature Review  .................................................................................................... 5 1.2.1     Practical Rehabilitation Service Approaches  .................................................... 5 1.2.2     Capabilities Approach  ..................................................................................... 10 1.3     Rationale for the Thesis  ........................................................................................ 20 1.4     Thesis Chapters  ..................................................................................................... 21 2          METHODOLOGY  ...................................................................................................... 22 2.1     Study Design  ......................................................................................................... 22 2.1.1     Purpose of Statement  ...................................................................................... 22 2.1.2     Research Questions  ......................................................................................... 22 2.1.3     Mixed Methods Design  ................................................................................... 23 2.1.4     Exploratory Sequential Mixed Methods Design  ............................................. 24 2.2     Overview of the Research Phases  ......................................................................... 25 3          THE VIEWS OF OCCUPATIONAL THERAPISTS ABOUT THE CENTRAL HUMAN FUNCTIONAL CAPABILITIES WITH RESPECT TO THEIR PROFESSION AND PRACTICE: A QUALITATIVE STUDY  ........................................................................................................ 26 3.1     Study Design  ......................................................................................................... 26 3.1.1    Interpretive Descriptive  .................................................................................. 27 3.1.2    Reflexivity and Researcher Positionality  ........................................................ 28 	 ? v	 ?3.1.3     Selected Sampling  ........................................................................................... 29 3.1.4     Qualitative Phase Recruitment  ........................................................................ 30 3.1.5     Description of Participants  .............................................................................. 31 3.2     Data Collection  ..................................................................................................... 31 3.2.1     Semi-structured Interviews  ............................................................................. 31 3.2.2     Designing the Interview Questions  ................................................................. 32 3.2.3     Conducting the Interviews  .............................................................................. 32 3.3     Data Analysis ......................................................................................................... 33 3.3.1     Conducting Thematic Analysis  ....................................................................... 34 3.3.2     Trustworthiness  .............................................................................................. 42 3.4     Findings .................................................................................................................. 44 3.4.1     Life Capability  ................................................................................................ 49 3.4.2     Bodily Health Capability  ................................................................................. 56 3.4.3     Bodily Integrity  .............................................................................................. 62 3.4.4     Senses, Imagination, and Thought Capability  ............................................... 68 3.4.5     Emotions  ........................................................................................................ 74 3.4.6     Practical Reason  ............................................................................................. 81 3.4.7     Affiliation  ....................................................................................................... 86 3.4.8     Other Species  ................................................................................................. 94 3.4.9     Play  .............................................................................................................. 101 3.4.10     Control over One?s Environment  ............................................................... 107 3.4.11     General Views of Central Human Functional Capabilities  ........................ 114 3.5     Limitations and Delimitations  ............................................................................. 122 3.6     Summary  ............................................................................................................. 123 3.7     Table  ................................................................................................................... 124 4         THE VIEWS OF OCCUPATIONAL THERAPISTS ABOUT THE CENTRAL HUMAN FUNCTIONAL CAPABILITIES WITH RESPECT TO THEIR PROFESSION AND PRACTICE: ONLINE SURVEY  .............................................................................................................. 125 4.1     Study Design  ....................................................................................................... 125 4.1.1     Research Questions  ...................................................................................... 125 4.1.2     Sampling  ...................................................................................................... 126 	 ? vi	 ?4.2     Survey Development  ........................................................................................... 126 4.2.1    Validity  ......................................................................................................... 126 4.2.2     Survey Design  .............................................................................................. 127 4.3     Survey Procedure  ................................................................................................ 127 4.4     Data Analysis  ...................................................................................................... 129 4.5     Survey Results  .................................................................................................... 129 4.5.1    Demographic Information  ............................................................................. 129 4.5.2    Occupational Therapists? Views of Central Human Functional Capabilities  .................................................................................................................................... 130 4.6     Limitations and Delimitations  ............................................................................. 141 4.6     Summary  ............................................................................................................. 142 4.7     Tables ................................................................................................................... 144 5           DISCUSSION, IMPLICATIONS, AND CONCLUSION  ............................................... 166 5.1     Participant Description  ........................................................................................ 166 5.2     Discussion of Findings in Relation to the Capabilities Approach Literature  ..... 167 5.2.1     Occupational Therapists? Views of Life Capability  .................................... 167 5.2.2     Occupational Therapists? Views of Bodily Health Capability  .................... 170 5.2.3     Occupational Therapists? Views of Bodily Integrity Capability  ................. 172 5.2.4     Occupational Therapists? Views of Senses, Imagination, and Thought Capability  .................................................................................................................. 173 5.2.5     Occupational Therapists? Views of Emotion Capability  ............................. 174 5.2.6     Occupational Therapists? Views of Practical Reason Capability  ................ 177 5.2.7     Occupational Therapists? Views of Affiliation Capability  .......................... 179 5.2.8     Occupational Therapists? Views of Other Species Capability  ..................... 181 5.2.9     Occupational Therapists? Views of Play Capability  .................................... 182 5.2.10   Occupational Therapists? Views of Control over Ones Environment Capability  .................................................................................................................. 184 5.2.11   Occupational Therapists? General Views of the Central Human Functional Capabilities  ............................................................................................................... 187 5.3    Discussion of Findings in Relation to the Occupational Therapy Literature  ....... 189 5.3.1     Central Human Functional Capabilities as a Client-centered Approach  ..... 190 	 ? vii	 ?5.3.2     Central Human Functional Capabilities as a Human Rights Model  ............ 193 5.3.3     Central Human Functional Capabilities as a Framework for Health and Well-being  .......................................................................................................................... 196 5.3.4     Central Human Functional Capabilities as a Social Justice Approach and Advocacy Perspective  ............................................................................................... 200 5.4     Discussion of Findings in Relation to the Occupational Science Literature  ...... 203 5.5     Study Strengths and Limitations  ......................................................................... 209 5.6     Implications  ......................................................................................................... 211 5.6.1     Implications for Theory and Practice  ........................................................... 211 5.6.2     Implication for Policy Makers  ..................................................................... 212 5.6.3     Implication for Further Research  ................................................................. 213 5.6     Further Insights  ................................................................................................... 214 5.7     Concluding Thoughts  .......................................................................................... 214 5.8     Table .................................................................................................................... 216 References ......................................................................................................................... 217 APPENDICES  ..................................................................................................................... 239 Appendix A: Description of the Occupational Therapy Profession  ................................. 239 Appendix B: Interview Guide  ........................................................................................... 240 Appendix C: Consent Form  .............................................................................................. 241 Appendix D: Analytic Memo  ............................................................................................ 244 Appendix E: The Thematic Map for Emotions Capability  ............................................... 246 Appendix F: Example of How Themes within Subsamples Were Identified  ................... 247 Appendix G: Online Survey  .............................................................................................. 248 Appendix H: Cover Email  ................................................................................................ 260 Appendix I:  Participants? Written Quotes about Life Capability  .................................... 261 Appendix J:  Participants? Written Quotes about Bodily Health Capability  .................... 262 Appendix K: Participants? Written Quotes about Bodily Integrity Capability  ................. 263 Appendix L: Participants? Written Quotes of Sense, Imagination, and Thought Capability  ............................................................................................................................................ 264 Appendix M: Participants? Written Quotes about Emotion Capability  ............................ 265 	 ? viii	 ?Appendix N: Participants? Written Quotes about Practical Reason Capability  ................ 266 Appendix O: Participants? Written Quotes about Affiliation Capability  .......................... 267 Appendix P: Participants? Written Quotes about Other Species Capability  ..................... 268 Appendix Q: Participants? Written Quotes about Play Capability  ................................... 269 Appendix R: Participants? Written Quotes of Control over One?s Environment Capability  ............................................................................................................................................ 270 Appendix S: Participants? Written Quotes about the Central Human Functional Capabilities  ....................................................................................................................... 271     	 ? ix	 ? LIST OF TABLES    Table 3.1 Phase One Participants? Description  ................................................................. 124 Table 4.1 Survey Response Rate  ...................................................................................... 144 Table 4.2 Personal Demographic Information  .................................................................. 145 Table 4.3 Location Demographic Information  ................................................................. 146 Table 4.4 Practice Demographic Information  ................................................................... 147 Table 4.5 Occupational Therapists? Views of Life Capability  ......................................... 148 Table 4.6 Occupational Therapists? Views of Bodily Health Capability  ......................... 149 Table 4.7 Occupational Therapists? Views of Bodily Integrity Capability  ...................... 150 Table 4.8 Occupational Therapists? Views of Sense, Imagination, and Thought Capability  ............................................................................................................................................ 151 Table 4.9 Occupational Therapists? Views of Emotions Capability  ................................. 152 Table 4.10 Occupational Therapists? Views of Practical Reason Capability  ................... 153 Table 4.11 Occupational Therapists? Views of Affiliation Capability  ............................. 154 Table 4.12 Occupational Therapists? Views of Other Species Capability  ........................ 155 Table 4.13 Occupational Therapists? Views of Play Capability  ....................................... 156 Table 4.14 Occupational Therapists? Views of Control over One?s Environment  ........... 157 Table 4.15 Occupational Therapists? General Views of the Central Human Functional Capabilities  ....................................................................................................................... 158 Table 4.16 Comparison of Themes between Phase One and Phase Two  ......................... 160 Table 5.1 Central Human Functional Capabilities: Determinants, and Implication in Relation to Occupation ...................................................................................................... 216   	 ? x	 ? LIST OF ABBREVIATIONS  CAOT     Canadian Association of Occupational Therapists   CHFCs    Central Human Functional Capabilities CIHI        Canadian Institute for Health information  OT           Occupational therapist (except where the abbreviation OT(s) was/were used in                     quotations by participants to mean either occupational therapy or occupational                   therapist(s)) QoL         Quality of life   	 ? xi	 ?ACKNOWLEDGEMENTS       I would like to thank a number of people for their love and support. I wish to express my deep gratitude to all participants who shared their time, thoughts, and valuable experiences with me.       I am thankful to my supervisory committee for guiding me through this process. I owe a special thank you to my principal advisor, Dr. Elizabeth Dean, whom I regard as a great mentor and friend. Thank you for your guidance and your continuous support over the years. Thank you to Dr. Susan Forwell for acting as my co-supervisor. Your experience, intellectual feedback and thoughtful comments were extremely valuable. I would like to thank Dr. Shafik Dharamsi, as member of my thesis committee, for their ongoing support, keen insights, and helpful advice; you have enriched the learning process through your questioning and engagement in the qualitative discussions. Thank you all for your willingness to join me on this journey.      I owe my sincere gratitude to my colleagues at UBC, Dr. Regina Casey, Dr. Mineko Wada, Dr. Shalini Lal, Dr. Hana Al-Bannay, and Dr. Setareh Ghahari, who shared their thoughts and experience, and provided me with valuable feedback. My deepest thanks go to my husband, Hossein Houshmand, who first gave me the idea of the ?Capabilities Approach? and the motivation for this project, and provided support in numerous ways. Without you, none of this would have been possible. I would like to thank my parents, brothers, and sisters, with all my heart, for their love and never ending support. Finally, I would like to thank my children, Ali and Ibrahim, for the joy and happiness they bring into my life.    	 ? xii	 ?DEDICATION   To my mom, dad, and Hossein  for all their love and support    	 ? 1	 ?1     INTRODUCTION, LITERATURE REVIEW, AND RATIONALE FOR THE THESIS  1.1      Introduction      Disability has been described as ?the most urgent problem of social justice? (Nussbaum, 2006, p. 1). The link between disability and social exclusion is strong. People with disabilities are more likely to experience social and economic deprivation than able-bodied people. Children with disabilities are much less likely to be literate and more vulnerable to being malnourished and dying prematurely. People with disabilities are less likely to be employed; women with disabilities are vulnerable to physical violence and sexual abuse (Quinn et al., 2002, Turmusani, 2003; UK Department for International Development (DFID) Report, 2000; Barnes, 1991; Beresford, 1996). The extension of human rights to people with disabilities on the basis of equality with people who are able-bodied is a compelling perspective that provides a rational means of improving the lives of people with disabilities. This extension of human rights to meeting the needs of people with disabilities from the perspective of health care practice, specifically, rehabilitation services, is novel.      A variety of rehabilitation services has been implemented globally to respond to the needs of over 600 million people with disabilities in the world today. According to the literature, the four established models for rehabilitation service delivery include the biomedical model, community-based rehabilitation, independent living, and client-centered rehabilitation (McColl et al., 1997).    Rehabilitation service delivery from the biomedical model tends to view disability as a problem at the level of the individual, and defines disability in terms of impairments. Impairments are associated with a variety of medical needs for people with disabilities, and specialized expertise is needed to recognize and respond to these needs (Bickenbach, 1993). The biomedical model in providing rehabilitation services depends upon ?trained professionals and well-equipped facilities? (McColl et al., 1997, p. 511). This model has been criticized however on the grounds that many dimensions of disability are absent (Oliver, 1990, 1999; Marks, 1997; Williams, 2001; Shakespeare, 2001, 2006; McLean & Williamson, 2007).       Community-based rehabilitation has emerged in developing countries as an effective and efficient method of providing rehabilitation services to people with disabilities globally over the last twenty-five years. Community-based rehabilitation is a model of community development designed to empower people with disabilities within their communities (Peat, 1998; Mitchell, 	 ? 2	 ?1999; Kendall et al., 2000). In community-based rehabilitation, intervention has shifted from institutions to homes and communities, and is carried out by families and community programs. Interventions associated with community-based rehabilitation include education, vocational training, social rehabilitation, and prevention (Peat, 1998, p. 27). Community-based rehabilitation has been considered as a strategy ?for equalization of opportunities and social integration of all people with disabilities? (International Labour Organization, United Nations, Educational Scientific and Cultural Organization, United Nations Children?s Funds, World Health Organization, 2004, p. 2). Community-based rehabilitation is implemented through ?the combined efforts of people with disabilities themselves, their families and communities, and the appropriate health, education, vocational and social services" (International Labour Organization, United Nations, Educational Scientific and Cultural Organization, World Health Organization, 2002, p. 1).      Independent living and client-centered rehabilitation reflect new attitudes toward rehabilitation service delivery. One of the philosophical assumptions in these models of rehabilitation services is that each person is of considerable and unconditional worth, each having the capacity to determine his or her destiny (McColl et al., 1997). In the independent living model, people with disabilities are described as being handicapped by society?s failure to provide appropriate services to facilitate their full participation in society. Therefore, restrictions imposed by society, such as social attitudes and barriers, create the disability (Williams, 2001, p. 128). The independent living model views people with disabilities as equal members in society who ?are demanding the right to take the same risks and seek the same rewards? (Brisenden, 1986, p. 177). This model does not view disabilities as deficits, but rather as conditions of life. The independent living model advocates that ?individuals are disabled by inaccessible buildings, lack of access to education, unemployment, and hostile attitudes? (McColl et al., 1997, p. 516). Further, the independent living model views people with disabilities as ?rational, informed consumers of the service? (p. 516). For the most part, they are able to control the resources that affect their lives and are able to make informed choices about their needs. The independent living model aims to ensure that people with disabilities have access to housing, health care, transportation, employment, education, and mobility so they can participate in life fully (McColl et al., 1997).   	 ? 3	 ?     In client-centered rehabilitation, ?the clients know what they want from therapy and what they need? (Law, 1998, p. 92). In other words, they are the experts on their service needs, and can make choices and have control over all available service delivery (McColl et al., 1997). Rehabilitation therapists are viewed as facilitators who create an environment to assist change, enhance self-esteem, and promote independence and empowerment of people with disabilities (Law, 1998; McColl et al., 1997).       In Canada, the occupational therapy profession is an established rehabilitation profession that is committed to client-centered services (Canadian Association of Occupational Therapists [CAOT], 1991, 1997; Law, 1998). The profession focuses on maximizing clients? capacity for complete physical, social and emotional functioning in all domains of their lives, which is referred to as their capacity to engage in their life occupations (more broadly defined than gainful employment). The profession of occupational therapy and its established competencies are described in Appendix A. Client-centered practice within the context of client-centered services has been advanced as a guide for occupational therapists (OTs) since the 1980s (Law, 1998). Despite the emphasis on client-centered practice, some barriers have been identified at the client, therapist and organizational levels (Law et al., 1995; Sumsion & Smyth, 2000). Implementing strategies to determine barriers to client-centered practice has been advised by various scholars (Sumsion, 1999; Sumsion & Smyth, 2000; Wilkins et al., 2001; Restall & Ripat, 2003). At the level of the therapist, education to enhance knowledge and understandings about the meaning of client-centered philosophy has been advocated. It has been suggested however that the skills of such health practitioners are often inadequate to practice fully in a client-centered manner (Wilkins et al., 2001).        Client-centered practice has been criticized at a number of levels. One criticism has been based on the ambiguity of its principles and the challenges regarding the ethical notion of autonomy. The core value of client-centered practice is patient?s autonomy (Law, Baptiste, & Mills, 1995; Law, 1998). Although patients' rights and autonomy can provide the foundation for ethical decision making in rehabilitation practice (Kerkhoff et al., 1997; Brockett & Bauer, 1998), it has been challenged in terms of coming ?into conflict in situations of actual practice? (Kruse, 2006, p. 372). Zeidman (1998) questions the neutrality view in client-centered practice: ?Whether or not neutrality is a laudable goal, it is not possible to achieve. In fact, when we utilize the services of professionals, we expect and demand the benefits of their training, 	 ? 4	 ?experience, wisdom and advice? (p. 908).     Some investigators argue that health professionals have to not only consider the autonomy principle, but also the beneficence, nonmaleficence and justice principles in order to have an active role in ethical decision-making, rather than a passive role (Atwal & Caldwell, 2003). Scott (1998) in ?Professional Ethics: a Guide for Rehabilitation Professionals? believed although these principles needed in caring for patients and could serve as a practical guide for health care practice, the implementation of these guiding principles appears challenging because there are ?significant actual and potential conflicts of interests? (p. 21). One case in point where such conflict would exist, is confronting an individual verbalizing suicidal thoughts, and the role and responsibilities of health professionals.           Although community-based rehabilitation, independent living and client-centered models are distinct with respect to how they frame the provision of rehabilitation services, these models are similar in that they view people with disabilities as those with rights rather than impairments. Broadly speaking, in the 21st century, people and increasingly those receiving health services are becoming aware of their rights and demanding these be respected. Similar to other health service providers, OTs may better fulfill their professional mandate by having a solid understanding of their clients? human rights and needs in order to provide appropriate services for their clients in a rational and reasoned manner. One approach related to human rights that may provide a meaningful basis for conceptualizing the rights of people with disabilities is the Capability or Capabilities Approach1, otherwise known as the ?Human Development Approach? (Nussbaum, 2007, p. 21). This approach, developed by Sen2 and extended by Nussbaum3 has been recognized as an important theory for analyzing ?women?s human rights, the rights of people who are poor and more recently, the rights of people with disabilities? (p. 21). The Capabilities Approach has been included in the 	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?	 ?1 Sen typically uses the term Capability Approach, but Nussbaum uses the term Capabilities Approach.  2 Amartya Sen (1933- ), an Indian economist and philosopher, who was winner of the 1998 Nobel Prize in Economics. He is Lamont University Professor and Professor of Economics and Philosophy at Harvard University.   3 Martha Nussbaum (1947- ), an American philosopher, with a particular interest in ancient philosophy, law and ethics. During the 1980s Nussbaum began collaboration with economist Amartya Sen on issues of development and ethics. With Sen, she promoted the "capability approach" to development.  She is currently Ernst Freund Distinguished Service Professor of Law and Ethics at the University of Chicago.    	 ? 5	 ?annual Human Development Reports of the United Nations Development Program and has been reported by over 500 national human development reports since 1990 (Robeyns, 2006; Nussbaum, 2007). Aligning the value of human development and its constructs such as those articulated by Nussbaum could provide a meaningful and useful approach in health care, in particular, rehabilitation.   1.2     Literature Review  1.2.1     Practical Rehabilitation Service Approaches      This section reviews three principal approaches to the provision of rehabilitation services for people with disabilities, namely, the biomedical, social, and socio-political (otherwise known as human rights) approaches. In the early twentieth century, rehabilitation services for people with disabilities were dominated by the biomedical approach. In the late twentieth century, the social approach to rehabilitation services dominated. In recent years, with the contemporary disability rights movements inspired by the Universal Declaration of Human Rights, the human rights approach to rehabilitation services has emerged.   Biomedical Approach      During the nineteenth century, people with disabilities were often ostracized in society and housed in institutions including shelters, hospitals and workhouses. Such practices continued well into the twentieth century (Braddock & Parish, 2001). Over the past century, the biomedical definition of disability emerged. According to the World Health Organization (2001), disability within the biomedical approach is defined as a problem at the level of the individual that is  directly caused by a disease or some other health condition ?which requires medical care provided in the form of individual treatment by professionals? (McLean & Williamson, 2007, p. 12).        The essence of disability in the biomedical approach is that people with disabilities are abnormal or have something wrong with them (Bickenbach, 1993; McColl & Bickenbach, 1998). In this approach, disability is understood as sickness, and people with disabilities tend to be considered as invalids (Hughes, 2002, p. 58). People are regarded as disabled on the basis of 	 ? 6	 ?being unable to function as ?normal? people (Marks, 1997, p. 86; McLean & Williamson, 2007, p. 12). The normal-abnormal dichotomy is the basis of the biomedical approach which is problematic in the context of disability. Accordingly, this dichotomy is not unbiased but is associated with normality being related to ?virtuousness?, and abnormality with guilt and ?shame? (McLean & Williamson, 2007). Therefore, when impairment is negatively construed, people with disabilities are subjected to negative social responses (Shuttleworth & Kasnitz, 2006). In this approach, disability is viewed as ?a defect inherent in the individual? and people with disabilities are regarded as ?defective? rather than physically different (Bickenbach, 1993, p. 87). Since disability is associated with illness or impairment, people with impairments may be viewed as needing correction (McColl & Bickenbach, 1998). Finally, the biomedical approach depends on ?trained professionals and well-equipped facilities? (McLean & Williamson, 2007; McColl et al., 1997, p. 511). Early on, the biomedical approach to rehabilitation services referred to the International Classification of Impairments, Disabilities and Handicaps (ICIDH). The ICIDH developed by the World Health Organization as an international instrument for the purpose of classifying problems or functional incapacity (World Health Organization, 1980). The ICIDH distinguished between the terms ?disability,? ?handicap,? and ?impairment?. It defined impairment as an anatomical, mental, or psychological loss, or some other abnormality. A disability was any restriction or lack of ability to perform an activity in the manner or within the range considered normal. A handicap was a disadvantage resulting from impairment or disability. Consequently, the ICIDH gave substantial authority to rehabilitation professionals and disempowered people with disabilities by professionalizing disability.      Several advantages and disadvantages underlie the biomedical approach to the provision of rehabilitation services. The advantage of this approach is that it is reasonable for rehabilitation professionals to identify the essential goals for their patients. In other words, this approach can be considered as the basis for ?diagnosing disability, influencing treatments, and guiding access to disability benefits? (Herr et al., 2005, p. 291). The disadvantage is that this approach fails to reflect a comprehensive view of disability. Scholars and disability advocates have argued that disability is more than impairment. In their perspectives, people with disabilities experience greater disability as a result of negative attitudes and social and environmental barriers than from functional losses. Consequently, this approach has not only been criticized on the grounds that it imparts considerable power to medical professionals, 	 ? 7	 ?disempowers people with disabilities, and depends on experts, but also because many dimensions of disability, such as social, economic, and cultural, are absent (Liachowitz, 1988; Oliver, 1990, 1999; Longmore, 1995; Williams, 2001).  Social Approach      Over the latter part of the last century, the social definition of disability emerged in industrial countries. The construct of disability within the social approach is largely associated with social oppression and barriers (Oliver, 1990). Disability is not strictly associated with impaired body parts, but rather with addressing an oppressive social environment. If disability is associated with social oppression, then people with disabilities can be viewed as ?the collective victims of an uncaring, discriminatory society? (Williams, 2001, p. 128). In this view, society and its institutions through legislation, and social attitudes and barriers are thought to create disability. Therefore, society?s failure to provide appropriate services potentially may exclude certain people, hence, disable them.        From the perspective of the role of the social environment in creating disability, rehabilitation services have a primary role in addressing social and environment challenges and removing barriers. The social approach to rehabilitation services is inherent in the independent living and community-based rehabilitation models, which have emerged from critiques of rehabilitation services based on the biomedical approach (Batavia & McKnew, 1991; Lysack & Kaufert, 1994). Despite their common beginnings, these models have distinct historical contexts and, in turn, distinct underlying social and political conditions.        The independent living model emerged in response to a need to remove social and environmental barriers to living independently, for working-age people with disabilities in the United States in the early 1970s (Batavia & McKnew, 1991; Lysack & Kaufert, 1994). The independent living model aimed to ensure people with disabilities had access to housing, health care, transportation, employment, and education, and could be mobility. These aims were achieved through self-help and peer support, research and service development, and referral and advocacy (McColl et al., 1997).      Community-based rehabilitation was introduced by the World Health Organization at the Alma-Alta conference in 1978 and arose in developing countries in response to the lack of financial resources and experts (Lysack & Kaufert, 1994). One of the assumptions of community-based rehabilitation was that improving the quality of life in a limited way for all 	 ? 8	 ?people with disabilities is superior to greatly improving the quality of life for a few people. Therefore, community-based rehabilitation attempts to make services accessible to more people with disabilities and their families in the most cost-effective and culturally appropriate ways (Miles, 1996; McColl et al., 1997; Peat, 1998; Mitchell, 1999; Kendall et al., 2000; Turmusani et al., 2002).       Compared to the biomedical approach, the social approach may better describe the experiences of people with disabilities, and help elucidate deficiencies of the biomedical model in relation to people with disabilities.       Several disadvantages underlie the social approach to the provision of rehabilitation services. First, a common criticism is that it neglects the role of impairment. The social approach distinguishes between the impairments that people have and the oppression, which they experience (Shakespeare & Watson, 2001). The distinction between impairment and disability is central to the social approach (Shakespeare, 2006). Impairment itself is relevant to many people with disabilities. Impairment can cause pain and difficulties that are not solely attributable to disabling factors in society. Second, in some cases, even when environments are accessible and there is no unfair discrimination on the basis of disability, many people with disabilities would still be disadvantaged (p. 66). Third, the social approach cannot respond to the complete range of ?special needs? of people with disabilities. Needs vary among people with disabilities. Some people need more than others in their societies given they have different capabilities and limitations. Fourth, fully accessible and barrier-free facilities are a central goal of the social approach, but there are challenges to creating a fully accessible society. Therefore, ?a barrier-free? society may appear to some as a utopian ideal.                   Socio-political Approach: Human Rights Approach      The paradigm shift in disability policy from the biomedical to the human rights approach of disability is reflected in the United Nations Convention on the Rights of Persons with Disabilities. ?The Convention on the Rights of Persons with Disabilities is the response of the international community to the long history of discrimination, exclusion and dehumanization of persons with disabilities? (United Nations, 2007, p. III). The United Nation?s ?Convention on the Rights of Persons with Disabilities? advocated that people with disabilities are people with rights (p. III). This convention was seminal in elucidating 	 ? 9	 ?contemporary views of disability through shifting the perspective from a biomedical to a socio-political one (Herr et al. 2005, p. 62).       The construct of disability from a socio-political approach is viewed as a complex interaction of biological, psychological, cultural and socio-political factors (Bickenbach, 1993, 2003). Although the social approach broadens our understanding and appreciation of disability, capturing a broad picture of this construct does not appear to be a matter of simply adopting a single approach. The socio-political approach is broader and more inclusive than the biomedical approach. It provides a means of examining various dimensions of disability in conjunction with the biomedical approach.       Assumptions underlying the socio-political approach are reflected in the World Health Organization?s International Classification of Functioning, Disability and Health (ICF) which is distinct from and an extension of its earlier version, the ICIDH. In the ICF, disability serves as an umbrella term for impairments, activity limitations and participation restrictions (ICF, 2001, p. 3). The ?ICF attempts to achieve a synthesis, in order to provide a coherent view of different perspectives of health from a biological, individual and social perspective? (p. 20). The ICF depicts the process of functioning and disability across domains (body functions and structures, activity and participation) and the inclusion of ?contextual factors? (personal and environment) expands the construct of disability.       At the global level, the profession of occupational therapy has adopted the ICF of the World Health Organization and its definition of health. The ICF is becoming a generally accepted framework in medicine as well as the rehabilitation sciences (Stucki, 2005). As stated, the ICF consists of three key components, namely, body functions and structures, activity, and participation. Some aspects of the ICF are thought to need further development and research to better elucidate the determinants of functioning and health (To?ra & Dahl, 2002; Imrie, 2004). As well, the ICF has been criticized by the disability research and disability rights communities on the grounds that several dimensions of individual rights and of life satisfaction are absent (Herr et al. 2005; Imrie, 2004). The terminology reflected in the ICF is limited to health terminology. For example, because of their races, sex, religions and other socioeconomic characteristics, people may be restricted in their execution of a task in the environments in which they live. Although the ICF is predicated on the World Health Organization?s definition of health (i.e., health is a complete state of physical, 	 ? 10	 ?social and emotional well-being, including being able to participate fully in one?s community and life), some advocates for people with disabilities fail to recognize this central fact. Thus, race, sex, religion and other socioeconomic characteristics are not viewed by some as health related restrictions of participation as classified in the ICF. In fact, some disability rights critics have rejected the ICF as being no more than a ?repudiated medical model? in that it does not seem to them to be a practical means of understanding the complexity of disability (Herr et al. 2005, p. 61). Thus, despite its general acceptability by the rehabilitation professions, the ICF is viewed by some others as not completely reflecting a human rights perspective.        In the socio-political approach, the three elements of the concept of disablement, i.e., impairment, disability, and handicap, are integrated to formulate disability as a rights issue (Bekhenbach, 1993, p. 232). According to this perspective, disability is a problem of equality. But what does equality mean? Bekhenbach described equality as having three dimensions: equality of respect, equality of opportunity, and equality of capability. Equality of respect was conveyed as ?a respect in which everyone is relevantly equal, a respect which is unaffected by any manifestation of human difference? (Bekhenbach, 1993, p. 243).  Equality of opportunity was derived from John Rawls?s discussion on principles of justice; the priority of basic equal liberties and fair opportunity for all citizens (Rawls, 1972). According to Rawls, a just society must protect equal basic liberties and fair equality of opportunity for all citizens (Rawls, 2001).       Sen argued that equality of opportunity can be better understood in terms of ?equality of what? (Sen, 1980). According to Sen,?equality of what,? means equality of capabilities. The idea of ?capability? means ?the opportunity to achieve valuable combinations of human functionings, i.e., what a person is able to do or be? (Sen, 1992, 1999, 2004, 2005; Nussbaum, 2000, 2006).       1.2.2     Capabilities Approach      The concept of human rights has been understood in various ways. One way that appears consistent with contemporary philosophy of occupational therapy is the Capabilities Approach. The Capabilities Approach can embrace the language of rights and the main conclusions of the international human rights movements, as well as the content of many international human rights documents (Nussbaum, 2011, p. 67). The idea of capability is central to understanding human rights (Nussbaum, 2000; Sen, 2005). According to the Capabilities Approach, human rights can 	 ? 11	 ?be seen as claims to certain basic capabilities or as entitlements to capabilities (Sen 1999, 2005; Nussbaum, 2000, 2006).       Sen?s priority in developing the Capability Approach was to provide a framework for the conceptualization of human development and for the analysis and assessment of poverty. Sen viewed the Capability Approach as having two core concepts: functionings and freedom. Functionings is the achievement of the individual, what he or she achieves through being or doing. Functionings is ?beings and doings? such as being nourished, being confident, or taking part in group decisions. Functionings includes all types of functioning, from basic ones to complex ones.  Freedom is the second core concept of the Capability Approach. In Sen?s view, freedom is ?a person's ability to get systematically what he would choose? (Alkire, 2002, pp. 5-6). Thus, capability, for Sen, is a kind of freedom to achieve alternative functioning combinations.      Sen initially conceptualized the Capability Approach in the context of poverty. According to Sen, poverty can be conceptualized in terms of ?capability deprivation?. In his perspective, income is not the only means of determining one?s capabilities (Sen, 1999, pp. 87-88). In assessing poverty, Sen considers that the relationship between income and capability is strongly affected by parametric variations such as the person?s age, sex, social roles, location (proneness to flooding or drought), and epidemiological environment (based on disease in a region); and by other variables over which a person has limited control. Therefore, according to Sen, not only personal characteristics such as disability or illness reduce one?s ability to earn an income, but they also make it harder to convert income into capability because a person who is more disabled or seriously ill may need more income for aid and treatment to achieve a level of functioning comparable to a person without such disability or illness (Sen, 1999, p. 74). Finally, in terms of capabilities, deprivation results from the interaction among the resources available to a person, personal characteristics (e.g., impairment, age, and sex) and the environment. Thus, poverty can be viewed as a person?s failure to achieve basic capabilities or the failure to choose what he or she values.      Similar to poverty, disability can be logically viewed in terms of the failure of a person with a disability to achieve basic capabilities (Welch Saleeby, 2002; Mitra, 2006; Terzi, 2005). Although deprivation can result from the nature of an impairment, it may not be the only cause. In light of the Capability Approach, the relationship between impairment and capability may be 	 ? 12	 ?more consequential than impairment alone. In addition, this relationship may be affected by the age of the person, his or her sex, geographical location, and culture. In summary, disability can be defined in terms of the failure of a person with a disability to achieve basic capabilities, or the failure to choose what he or she values.  Capabilities Approach in Practice      The United Nations Development Program has published the Human Development Report annually since 1990; the content of this report is partly based on the Capability Approach (UNDP, 1990?2008; Robeyns, 2006; Alkire, 2002). In the Human Development Reports, human development is defined as ?a process of enlarging people's choices?, which is achieved ?by expanding human capabilities and functionings? (UNDP, 2000, p. 17). Today, over ?500 national-level human development reports? use the Capabilities Approach as a basis for discussing ?regional, national and local development strategies? (Robeyns, 2006).        In addition to the Human Development Reports which put the Capability Approach into practice, several recent studies have assessed this approach empirically. Robeyns (2006a) addressed the current applications of the Capability Approach, specifically, general assessments of the human development of a country (Dr?ze & Sen, 2002; Ranis, Stewart, & Ramirez, 2000); identification of the poor in developing countries (Laderchi, 1997; Klasen, 2000, Qizilbash, 2002; Asali, Reddy, & Visari, 2005); poverty and well-being assessments in developing countries (Balestrino, 1996; Phipps, 2002; Chiappero-Martinetti, 2000); the assessment of gender inequalities (Sen, 1985;  Robeyns, 2003; Chiappero-Martinetti, 2003); theoretical and empirical analyses of policies (Schokkaert & Otegem, 1990; Lewis & Giullari, 2005; Dean et al., 2005; Terzi, 2005); critiques on social norms, practices and discourses (Olson, 2002 ; Robeyns, 2005c); and an analysis of the deprivation of people with disabilities (Zaidi& Burchardt, 2005; Kuklys, 2005).      There have been few studies of the Capabilities Approach based on qualitative methods (Arends-Kuenning & Sajeda, 2001; Alkire, 2002; Anand et al., 2005). Zimmermann (2006) argues that the Capabilities Approach has largely been studied within quantitative methods. But the importance of examining Capabilities Approach qualitatively has largely been ignored. Zimmermann argues that researchers need to seriously consider the use of qualitative methods in studies of the Capabilities Approach to obtain a rich and detailed understanding of constructs such as freedom and opportunities which are core concepts of the Capability Approach. 	 ? 13	 ?  Capabilities Approach and Disability      In recent years, there has been increasing literature reporting the usefulness of the Capability (Capabilities) Approach for understanding, analyzing, and assessing disability. In 2002, Baylies reviewed human rights discourses related to disability and argued that the Capabilities Approach may provide a better framework ?for identifying the responsibilities of governments and external agencies in genuinely equalizing opportunities? (p. 725).      Terzi (2005) argued that the Capability Approach is ?an ethical, normative framework based upon justice and equality? (p. 197), which provides an essential view for reconceptualizing disability and special needs. Terzi (2006) believes that the Capability Approach is an appropriate framework for ?assessing the relevance of impairment and disability in designing just and inclusive institutional and social arrangements? (p. 203). She believes that the capability perspective on disability provides appropriate directions for inclusive educational policies to respect human diversity and to consider the special needs of children with disabilities. Terzi (2007) provides a conceptual framework based on the Capability Approach for a just distribution of opportunities and effective access to educational functionings for children with disability and special educational needs. Following the increasing literature on conceptualizing equity in education within a social justice framework, Polat (2011) discusses the theoretical relationships between inclusion in education and social justice. Polat draws on Nussbaum?s Capability Approach which brings disability into the social justice debate to develop an index of inclusion in Tanzania. Robeyns (2006) believes that the central aim of educational policy must be to expand people's capabilities.      Mitra (2006) believes that the Capability Approach helps to understand disability at the conceptual level, namely, potential and actual disability. Accordingly, disability may result from an individual's personal characteristics, resources, and environment. Further, Mitra believes that the Capability Approach can be considered a useful framework for analyzing the employment and the standard of living of people with disabilities.       Sherlock and Barrientos (2002) argued that Nussbaum's Capabilities Approach can be considered a useful tool for understanding the condition of older people in developing countries. Gilroy (2006) suggested that the Capabilities Approach could be a valuable tool for providing a 	 ? 14	 ?framework for evaluating the environments of older people and the level of support that they provide.      Some researchers have been interested in the applicability or compatibility of the Capability Approach within the ICF or social model. Welch Saleeby (2007) believes that together the Capability Approach and the ICF help to understand disability. This approach, according to her, helps practitioners to evaluate what people with disabilities are actually able to do in their lives. Morris (2009) believes ?the capability approach provides an alternative framework to the ICF for examining inequalities in well-being and social arrangements? (p. 92). Morris believes that including a capability perspective for measuring participation may be more helpful than ?measuring only ?capacity? and ?performance? as proposed by the ICF? (p. 92). According to Morris, the goal of services should be to equalize children?s capability sets by removing barriers to enable participation and giving children a degree of choice and freedom, therefore, a key outcome in evaluation services is increasing children?s capabilities, rather than performance. Reindal (2009) claims that a modified version of the social model is more compatible with the Capability Approach than the ICF.        Trani, Bakhshi, Noor, and Mashkoor (2009) discussed disability policy in Afghanistan and that it has had rather limited impact. Trani et al. suggested that Sen's Capability Approach can be considered as a relevant framework for designing disability policy and implementation. Orton (2011) explored whether the Capabilities Approach offers a potential framework for new thinking in relation to policy in the United Kingdom. After reviewing this policy on employment, work and welfare, Orton concluded that ?the capabilities approach is best thought of not as offering a detailed road map for policy, but as providing a critically different conceptualization of the purpose and principles of public policy? (p. 352).      To conclude, in a review of the literature, the Capabilities Approach is generally considered a tool for social justice in the context of disability. Despite the growing literature on the Capabilities Approach, its application has been largely overlooked within the context of the rehabilitation professions, including occupational therapy, and their practices.  Central Human Functional Capabilities        Sen?s Capability Approach was deliberately incomplete (Alkire, 2002; Sen, 2004). His main concern was showing how the Capability Approach can be shared among scholars, even those 	 ? 15	 ?with opposing philosophical ideas. A common conceptual base enables scholars from various backgrounds to work on common issues (Alkire, 2002; Robeyns, 2005a).      But the questions of what are basic capabilities, and how can they be identified, operationalized, and put into practice, have remained at the core of the Capabilities Approach (Alkire, 2002; Gasper & Staveren, 2003; Robeyns, 2005b, 2006; Deneulin, 2008).      Nussbaum attempted to address these questions. She detailed the Central Human Functional Capabilities (CHFCs) with the intention of providing a basis for ?constitutional principles that should be respected and implemented by the governments of all nations, as a bare minimum of what respect for human dignity requires?. Nussbaum?s description of CHFCs was an effort ?to summarize the empirical findings of a broad cross-cultural inquiry? (Nussbaum, 2000, p. 5). She advocated that the list that resulted should be considered as ?a list of very urgent items that should be secured to people? (Nussbaum, 1997-1998). Nussbaum?s CHFCs include (Nussbaum, 2000, pp. 78-80):   1. Life. Being able to live to the end of a human life of normal length; not dying prematurely, or before one?s life is so reduced as to be not worth living. 2. Bodily Health. Being able to have good health, including reproductive health; to be adequately nourished; to have adequate shelter. 3. Bodily Integrity. Being able to move freely from place to place; having one?s bodily boundaries treated as sovereign, i.e. being able to be secure against assault, including sexual assault, child sexual abuse, and domestic violence; having opportunities for sexual satisfaction and for choice in matters of reproduction. 4. Senses, Imagination, and Thought. Being able to use the senses, to imagine, think, and reason ? and to do these things in a ?truly human? way, a way informed and cultivated by an adequate education, including, but by no means limited to, literacy and basic mathematical and scientific training. Being able to use imagination and thought in connection with experiencing and producing self-expressive works and events of one?s own choice, religious, literary, musical, and so forth. Being able to use one?s mind in ways protected by guarantees of freedom of expression with respect to both political and artistic speech, and freedom of religious exercise. Being able to search for the ultimate meaning of life in one?s own way. Being able to have pleasurable experiences, and to avoid non-necessary pain. 	 ? 16	 ?5. Emotions. Being able to have attachments to things and people outside ourselves; to love those who love and care for us, to grieve at their absence; in general, to love, to grieve, to experience longing, gratitude, and justified anger. Not having one?s emotional development blighted by overwhelming fear and anxiety, or by traumatic events of abuse or neglect. (Supporting this capability means supporting forms of human association that can be shown to be crucial in their development.) 6. Practical Reason. Being able to form a conception of the good and to engage in critical reflection about the planning of one?s life. (This entails protection for the liberty of conscience.) 7. Affiliation. A. Being able to live with and toward others, to recognize and show concern for other human beings, to engage in various forms of social interaction; to be able to imagine the situation of another and to have compassion for that situation: to have the capability for both justice and friendship. (Protecting this capability means protecting institutions that constitute and nourish such forms of affiliation, and also protecting the freedom of assembly and political speech.) B. Having the social bases of self-respect and non-humiliation; being able to be treated as a dignified being whose worth is equal to that of others. This entails, at a minimum, protections against discrimination on the basis of race, sex, sexual orientation, religion, caste, ethnicity, or national origin. In work, being able to work as a human being, exercising practical reason and entering into meaningful relationships of mutual recognition with other workers. 8. Other Species. Being able to live with concern for and in relation to animals, plants, and the world of nature. 9. Play. Being able to laugh, to play, to enjoy recreational activities 10. Control over One?s Environment. A. Political. Being able to participate effectively in political choices that govern one?s life; having the right of political participation, protections of free speech and association. B. Material. Being able to hold property (both land and movable goods), not just formally but in terms of real opportunity; and having property rights on an equal basis with others; having the right to seek employment on an equal basis with others; having the freedom from unwarranted search and seizure. 	 ? 17	 ?Critical Review of the Capabilities Approach       Although there is not any literature to specifically criticize Nussbaum?s Central Human Functional Capabilities, the Capabilities Approach itself has confronted some objections and critiques. This section examines various critiques of this approach. First, we review some of John Rawls? advocates and also Ronald Dworkin?s critics of the Capabilities Approach. Second, we examine some of the opponents to this approach with respect to its universal applicability and cultural considerations. Third, we review criticisms related to the cosmopolitan approach.        Strict critical ideas are from adherents of Rawls? theory of justice, for instance, Thomas Pogge (2002a) argues that although the Capability Approach has ?done much to advance the discussion of social justice ??, it cannot be justified as a comprehensive theory of justice (p. 71). He maintains that a theory of social justice must clarify its principles; as Rawls developed ?justices as fairness? based on the two principles of justice: the priority of equality and fair opportunity for all citizens (Rawls, 1971). In the same vein, Joshua Cohen (1998) has criticized one of the main claims of the Capability Approach, that ?the facts of diversity complicate our understanding of equality? (p. 288). He argued that Rawls?s ?primary-goods comparisons will suffice? in that case (p. 288). Rawls described primary goods as ?what persons need in their status as free and equal citizens, and as normal and fully cooperating members of society over a complete life? (Rawls, 1999, p. 54). Rawls?s primary goods are ?things which a rational man wants; whatever else he wants? (Rawls, 1971, p. 92).       In response to these Rawlsian critics, Robynes (2009) argues that these criticisms are overstated difference between the Capabilities Approach and Rawls?s justice as fairness. In this way, she continues, Rawls argues that interpersonal comparisons for social justice is based on social primary goods, the main claim of the Capability Approach is that in making interpersonal comparisons based on the dimension of capabilities (Robeyns, 2009). She asserted that ?rather than pitting both theories against each other as rivals, it is possible to understand the capability approach and justice as fairness as complementary and potentially converging theories? (p. 398).       Another critic is Ronald Dowrkin, who argues that the Capability Approach is unclear and ?the false goal of equal welfare or well-being? (2000, p. 303). He claims that Sen?s view of capability is vague as it either collapses into equality of welfare, or into equality of resources (p. 286).       Responding to Dworkin?s critique, Sen argues that the distinction between capability and 	 ? 18	 ?achievement shows equality of capability is not the same as equality of welfare. He also argues that the equality of resources is not the same as the equality of capability:  Since resources are ?merely useful and for the sake of something else? (as Aristotle put it), and since the case for equality of resources rests ultimately on that ?something else?, why not put equality of resources in its place as a way of getting to equality of the capability to achieve- if the congruence between the two does actually hold? (Sen, 2009, p. 265).       Other critics, however, argue that the Capabilities Approach is indifferent to cultural diversity. For example, Gasper (1997) argues that the Capabilities Approach needs to pay more attention to ?culture? and ?the individual?. Also, Skerker (2000) believed that universal applicability of Nussbaum?s Capabilities Approach has some limitations, particularly with respect to religion (p. 409).        Nussbaum, however, asserted that the Capabilities Approach is ?fully universal?, because it is based on ?the freestanding moral core of a political conception, without accepting any particular metaphysical view of the world, any particular comprehensive ethical or religious view, or even any particular view of the person or of human nature? (Nussbaum, 2000, p. 76). Also rejecting the critique concerning inappropriateness of a conception of person in the Capabilities Approach, Nussbaum states that capabilities should be considered as ?important for each and every citizen, in each and every nation, and each is to be treated as an end.? (p. 6)      Presenting the Capabilities Approach as ?a form of universalism that is sensitive to pluralism and cultural difference?, Nussbaum provides a strong critical response to the objection based on cultural arguments (Nussbaum, 2000, p. 8). According to Nussbaum, the Capabilities Approach does not ignore cultural differences; it is rather attempting to avoid cultural relativism. The idea of relativism, as Nussbaum states, is clearly in conflict with the modern world. She argues that ?Why should we follow the local ideas, rather than the best ideas we can find? ... Most local traditions take themselves to be absolutely, not relatively, true?. So in asking us to follow the local, relativism asks us not to follow relativism? (p. 49). Thus she maintains, ?the cultural argument fails; nor can it be rescued by an appeal to moral relativism? (p. 49). Nussbaum believes that we need local knowledge in order to understand the problems people face. But this is completely different with the claim of paternalism to treat people with insufficient or unequal respect. Nussbaum writes, People are the best judges of what is good for them, and if we prevent people from acting 	 ? 19	 ?on their own choices, we treat them like children?. the variety of ways citizens actually choose to lead their lives in a pluralistic society, and therefore to prefer a form of universalism that is compatible with freedom and choice of the most significant sorts (Nussbaum, 2000, p. 51).       She argues that we should reject paternalism ?because there is something else that we like, namely each person?s liberty of choice in fundamental matters? (Nussbaum, 2000, p. 53).        Some critics such as Anthony Burns (2013) emphasized the ambiguous relationship between Nussbaum?s Capabilities Approach and the cosmopolitan tradition. According to cosmopolitan thinkers, there are various versions of cosmopolitanism. Pogge (2002 b) distinguishes between two versions of cosmopolitanism: legal (strong), and moral (weak). He writes, Legal cosmopolitanism is committed to a concrete political ideal of a global order under which all persons have equivalent legal rights and duties - are fellow citizens of a universal republic. Moral cosmopolitanism holds that all persons stand in certain moral relations to one another. We are required to respect one another?s status as ultimate units of moral concern - a requirement that imposes limits on our conduct and, in particular, on our efforts to construct institutional schemes. This view is more abstract, and in this sense weaker than, legal cosmopolitanism (p. 169).        Nussbaum (2011) believes ?Because the Capabilities Approach is a form of political liberalism, it is not a comprehensive doctrine of any sort. It is therefore mistaken, and a serious misreading of my political views, to call it a form of cosmopolitanism? (p. 92). Despite Nussbaum?s claim, Burns argues that Nussbaum can be related with a weak form of cosmopolitanism. While it is hard to support legal (strong) cosmopolitans, moral (weak) cosmopolitans are defensible. One can argue that the weak version of cosmopolitanism ?can be accepted by almost anybody ? excepting a few racists and other bigots? (Miller, 2002, p. 84). However, although the Capabilities Approach is not based on any comprehensive doctrines including cosmopolitanism, as Nussbaum says, it can be endorsed by many comprehensive doctrines: ?Cosmopolitans can probably accept most of what I recommend, but one does not have to be a cosmopolitan to accept the idea that all citizens should have a minimum threshold amount of the ten capabilities? (Nussbaum, 2011, p. 93).      Although there are some important arguments among these critics, it seems that the Capabilities Approach is able to answer a range of questions. By making a distinction between capabilities, functionings, and freedom of choice, it shows its boundary with Rawsian? theory of justice and Dowrkin?s equality of welfare and equality of resources. Also, it shows that this 	 ? 20	 ?approach has no conflict with cultural differences but it is against cultural relativism. Furthermore, it shows although it is not based on any comprehensive doctrines, many cultural and religious traditions or moral cosmopolitans can endorse it.  1.3     Rationale for the Thesis       Disability has become a human rights issue (UN, 1993, 2007). People with disabilities in much of the world lack the support to ensure their basic human rights are respected, and their fundamental capabilities are maximized. They are more likely to experience failure in their capabilities, as articulated by Nussbaum, including living a normal life expectancy, being healthy, being able to move freely from place to place, being able to experience self-expressive and creative activities, having attachments to people and things, being able to plan for one?s life, being able to show concern for other human beings and engage in various forms of social life, being able to live with concern for and in relation to the world of nature, being able to laugh, play, to enjoy recreational activities, being to participate effectively in political choices that govern their lives; having the right to political participation, and having the right to seek employment on an equal basis with others (Nussbaum, 2006). People with disabilities, ?like other human beings, have needs in the areas covered by all the capabilities? (p. 169).       Rehabilitation programs ?should be based on the individual needs of people with disabilities and on the principles of full participation and equality? (United Nations, 1993). Rehabilitation professions such as occupational therapy have a particular commitment to functional independence and participation in life in an environment that is both enabling and respectful of an individual?s right to live, work and play without imposed restriction. For the purposes of this research, we argued that the contemporary values of occupational therapy practice are consistent with maximizing people?s functional capabilities embedded in the Capabilities Approach, hence, consistent with promoting the rights of people with disabilities. Therefore, we queried whether Nussbaum?s ten CHFCs have a role in enhancing OTs? knowledge about a client?s basic needs and rights, such that they could be used systematically to inform and guide a client?s management to maximize his or her functional capabilities. We planned to elucidate the perspectives of Canadian OTs related to their understandings of the ten CHFCs put forth by Nussbaum, and their perceived 	 ? 21	 ?relevance to professional practice. This exploration and examination of the Capabilities Approach in an applied health context could help align health care specifically occupational therapy services with human rights initiatives of the United Nations and the World Health Organization, based on adherence to universally accepted principles. This type of exploration has the potential to be extended to other health care professions and across cultures.  1.4     Thesis Chapters      To explore the views of Canadian OTs about their understandings and perceived relevance of Nussbaum?s ten CHFCs to the profession and their practices, the study consisted of two phases. Phase One consisted of semi-structured interviews and Phase Two consisted of a national online survey. The overall dissertation is organized into five chapters. Chapter 1 presented the introduction to the study, reviewed the literature on common rehabilitation service approaches and the Capabilities Approach, and the general aims of the work. Chapter 2 describes the study?s methodology and presents the exploratory sequential mixed methods design as the best-fit design, and overviews its two phases. With respect to Phase One, Chapter 3 describes the qualitative methodology selected for collecting and analyzing the data, and describes the findings. With respect to Phase Two, Chapter 4 describes the online survey for collecting and analyzing the quantitative data, and presents the survey results. Chapter 5 discusses the mixed qualitative and quantitative findings, and the main findings overall, their implications, and the strengths and limitations of the study overall.    	 ? 22	 ?2     METHODOLOGY   2.1     Study Design       This chapter describes the methodological and epistemological perspectives that frame the study, specifically, the methods guiding the study and the rationale for the use of mixed methods and a pragmatist approach to the research.   2.1.1     Purpose of Statement       The purpose of the exploratory sequential mixed methods design of this study was to explore and understand the views of occupational therapists (OTs) about their understandings and perceived relevance of the Central Human Functional Capabilities (CHFCs) with respect to their professional practices. Phase One of the study consisted of a qualitative exploration of the views of OTs about the CHFCs based on interviews. Findings generated from the qualitative study informed the development of a questionnaire survey that was used to collect data from a larger population of Canadian OTs. Phase Two of this study consisted of a quantitative description of their views and thoughts regarding the qualitative findings generated in Phase One. Data from both phases were mixed for the final analysis designed to provide a more complete description of OTs? views regarding the relevance of the ten CHFCs to OT practice.      Based on the purpose of the research and the research questions, the researcher chose a pragmatist approach to the inquiry using mixed methods to gather data. The following section describes the mixed methods design and justifies the philosophical underpinnings of a pragmatist approach for this research.  2.1.2    Research Questions      The design described above was selected to address the following research questions: 1. What are OTs? understandings of the ten CHFCs?  2. How may these capabilities be relevant to the contemporary practice of OTs?      These questions were addressed in both the qualitative and quantitative phases of this thesis.    	 ? 23	 ?2.1.3     Mixed Methods Design      Mixed methods research is ?an approach to knowledge (theory and practice) that attempts to consider multiple viewpoints, perspectives, positions, and standpoints? (Johnson et al., 2007, p. 113). Mixed methods designs have become increasingly popular among rehabilitation researchers this past decade (Creswell, 2003; Plano Clark, & Creswell, 2008).      Mixed methods designs described as ?the collection or analysis of both quantitative and qualitative data in a single study in which the data are collected concurrently or sequentially, are given a priority, and involve the integration of the data at one or more stages in the process of research? (Creswell et al., 2003, p. 212). These designs take advantage of both qualitative and quantitative methods to enhance the credibility of the research findings through integration of data from two data collection methods (Patton, 2002; Ivankova et al., 2006). The reason for combining qualitative and quantitative methods begins with the recognition that different methods have different strengths (Morgan, 1998).       Morgan (1998) cited that some researchers have criticized mixed methods designs on the ground that quantitative and qualitative approaches stem from various paradigms and assumptions about the nature of knowledge. From the critics? point of views, mixed methods researchers have not deeply considered issues and concerns of each paradigm (Morgan, 1998). They asserted that quantitative approaches stem from positivism tradition that seeks objectivity, and that qualitative approaches stem from the interpretative paradigm that recognizes the existence of multiple realities and meanings (Morgan, 1998).       Researchers have argued that the use of mixed methods becomes a technical task of choosing appropriate methods by trying to combine the strengths of both approaches within one framework, rather than trying to combine conflicting paradigms. They assert that mixed methods designs enable researchers to maximize the ability to bring various strengths together in the same study (Morgan, 1998; Johnson &Turner, 2003; Johnson & Onwuegbuzie, 2004).       Mixed method researchers do not advocate one approach over another, they view qualitative and quantitative approaches as being compatible rather than opposed. For them, all approaches are valuable (Teddlie & Tashakkori, 2003). An advantage of mixed methods designs is that these designs enable ?the researcher to simultaneously answer confirmatory and exploratory questions, and therefore verify and generate theory in the same study? (p. 15). Therefore, both qualitative and quantitative methods appear to be valid means of generating and verifying theory. 	 ? 24	 ? 2.1.4     Exploratory Sequential Mixed Methods      An exploratory sequential mixed methods design was selected as best fitting the purpose of this study. The design consisted of an initial qualitative data collection and analysis followed by a quantitative data collection and analysis (Creswell & Plano Clark, 2007, 2008). According to Creswell and Plano Clack (2010), the four major types of mixed methods designs are the triangulation design (where two methods are used to obtain triangulated results in the same study (p. 77); the embedded design (where a second source of data is used to enhance the study); the explanatory design (where quantitative methods are used to explain the results), and the exploratory design (where qualitative methods are used to explore a phenomenon in depth) (p. 59).       An exploratory mixed methods design is considered when ?measure or instruments are not available, the variable are unknown, or there is no guiding framework or theory? (Creswell & Plano Clark, 2007, p. 75). Researchers employ this design when they need to ?generalize results to different groups, to test aspects of an emergent theory or classification or to explore a phenomenon in depth and then measure its prevalence? (p. 75).      According to Morgan (1998), it is important to determine ?a priority decision? and ?a sequence decision? when using mixed methods design. The priority decision establishes the principal method for collecting data. Priority can be given to one method over the other, or both methods can play equal roles in a study. Many factors influence the priority decision, e.g., the purpose of the study, the research questions, the researcher?s background, and resources (Plano Clark, & Creswell, 2008; Creswell, 2009). Priority in this study was given to the qualitative phase because the topic was new and little is known (Morgan, 1998). Thus, the results from the qualitative phase (Phase One) informed the quantitative phase (Phase Two).      The sequence decision concerns ?the order in which the qualitative and quantitative data are used? (Morgan, 1998, p. 366). The sequence decision is based on timing considerations (Creswell & Plano Clark, 2007). Timing refers to when one source of data is collected and analyzed before the collection and analysis of the other source of data (Creswell, 2009; Creswell and Plano, 2008). In an exploratory sequential design, the qualitative data are collected and analyzed first, follow by the quantitative data. The rationale for this design was that the quantitative data and their subsequent analysis provide a general understanding of the area of 	 ? 25	 ?interest. Its advantages include opportunities for the explanation of the qualitative results. This design can be especially useful for exploring or developing new idea (Hanson, et al., 2005) as was proposed for this study.       The initial qualitative phase allowed determination of OTs? understandings and views about the ten CHFCs and in what way these capabilities are described as relevant to occupational therapy practice. The qualitative data of Phase One were used to develop the survey questionnaire for Phase Two. The quantitative data of Phase Two were used to further explain the data overall. All data were then examined together in a process of data integration, in order to comprehensively address the research questions.   2.2     Overview of the Research Phases       The main purpose of this study was to explore and describe the views of Canadian OTs with respect to their understandings and perceived relevance of Nussbaum?s CHFCs to their professional practices. An exploratory sequential mixed methods study was conducted in two phases. Phase One focused on how the Nussbaum?s CHFCs may be relevant to contemporary occupational therapy practices. Semi-structured interviews were conducted with 14 OTs in British Columbia, Canada, who had indicated their willingness to participate in order to explore their views related to the ten CHFCs, and provided insight into how each of the capabilities might be operationalized within the context of the practice of occupational therapy. Findings generated from Phase One (the qualitative study) informed the development of a survey instrument that was used to collect data from a larger population of OTs. A cross-sectional survey of a population of OTs practicing in Canada was conducted in Phase Two to confirm and extend the categories that emerged from Phase One. Data from both phases were then mixed in the final analysis to provide a more complete description of the OTs? views about the ten CHFCs in relation to occupational therapy practice.   	 ? 26	 ?3     THE VIEWS OF OCCUPATIONAL THERAPISTS ABOUT THE CENTRAL HUMAN FUNCTIONAL CAPABILITIES WITH RESPECT TO THEIR PROFESSION AND PRACTICE: A QUALITATIVE STUDY       This chapter describes the qualitative methodology for Phase One of the study. It describes the strategies used to collect and analyze the data, and describes the qualitative findings.   3.1     Study Design      Qualitative methods are said to be useful when describing a point of view, when the variable will not be identified easily, when the topic needs to be explored and explained with detailed descriptions, and when the topic is new or little is known (Morse, 1992; Creswell, 1998, 2003). Qualitative researchers are committed to incorporating many truths and multiple realities, rather than one truth and one reality. They are committed to elucidating ranging perspectives and reporting their observations in a ?rich literary style? (Streubert & Carpenter, 2011, p. 22). In addition, if a research idea deals with ?imprecise concepts? or intends to study issues in depth and in detail, this then leads better to qualitative rather than quantitative methods (Flick, 2002, Patton, 1990).       As the notion of ?the relevance of Central Human Functional Capabilities (CHFCs) to occupational therapy practice? is new to the profession of occupational therapy and little is known, Phase One was designed to be qualitative to allow the topic to be explored and explained with detailed descriptions.       The qualitative phase of this study did not precisely match the five commonly reported qualitative traditions; namely, ethnography, case studies, phenomenology, narrative research, and grounded theory (Creswell, 2003). The ethnographic design was not a component of this study because cultural issues and observation were not its focus. Nor could it consider a phenomenology design, as this inquiry did not seek to understand and describe the phenomenon of experiences. The study was neither consistent with being classified as a case study nor narrative research, because it did not intend to report stories; nor did it constitute grounded theory as it did not intend to develop a new theory.      As this study was not guided by established qualitative traditions, a generic qualitative approach was used. Caelli, Ray, and Mill (2003) noted that many terms used in qualitative research literature do not match an explicit qualitative approach; such as ?interpretive 	 ? 27	 ?description? defined by Thorne et al. (1997) or ?basic or fundamental qualitative description? described by Sandelowski (2000), they are generic qualitative approaches. Caelli et al. (2003) defined generic qualitative studies as ?those that present some or all of the characteristics of qualitative endeavor but rather than focusing the study through the lens of a known methodology they seek to do one of two things: either they combine several methodologies or approaches, or claim no particular methodological viewpoint at all? (pp. 3-4).       Given the overall purpose of this study was to explore the views of occupational therapists (OTs) about the CHFCs, the Phase One was approached from the interpretive description, which focuses on the understandings and perceptions of the participants (Thorne, 2008).   3.1.1     Interpretive Description      ?Interpretive description? as a methodological approach employed in this phase enabled us to address the research questions in a way that was not addressed by the five commonly reported qualitative traditions. Interpretive description methodology developed by Thorne, Kirkham, and MacDonald-Emes (1997) refers to ?noncategorical qualitative research approaches that are derived from an understanding of nursing?s philosophical and theoretical foundations? (pp. 169-170). Although interpretive description was developed in nursing science, it has recently been employed within the health professions as well (Hunt, 2009).       Interpretative description methodology recognizes the influences of the theoretical basis for the study, and the knowledge and practice of the discipline (Thorne, 2008). As described in Chapter 1, the theoretical framework for this study was derived from the Capabilities Approach literature, characteristics of rehabilitation services, and the importance of client-centered practice in Canada. Interpretive description uses the theoretical structure of the research as a frame for the data collection and analysis. Therefore, in this study, Nussbaum?s ten CHFCs were used as a frame for data collection and analysis. The researcher?s experience as an OT and her academic background in philosophy provided a unique lens through which to explore and interpret the data.       This methodological approach enabled the researcher to examine the views of OTs by identifying the shared realities of their experiences; and, to integrate the themes that emerged with the collective knowledge underpinning occupational therapy.  	 ? 28	 ?     One characteristic of interpretive description is the use of the researcher?s theoretical background and experience as a framework for the data collection and analysis. Thus, this study was informed by several sources: (a) the researcher?s examination of the literature of the Capabilities Approach; (b) several research projects that she had conducted during her graduate studies that examined social justice in health care, and (c) her experiences as an OT.    3.1.2     Reflexivity and Researcher Positionality   Researchers who conduct qualitative research must address the reflexivity and their theoretical positioning. Reflexivity refers to the process of how researchers have influenced the research (Dowling, 2008). In other words, it means ?sensitivity to the ways in which the researcher and the research process have shaped the collected data, including the role of prior assumptions and experience, which can influence even the most avowedly inductive inquiries? (Mays & Pop, 2000, p. 51). As there is no personal neutrality in conducting a research (Asselin, 2003), researchers need to be aware of their ?motives, presuppositions, and personal history that leads him or her toward, and subsequently shapes, a particular inquiry? (Caelli, et al., 2003, p. 9).      Therefore, the researcher in the present study adopted reflexivity by writing a journal to assist in her understanding of her prior assumptions and attitudes (Dowling, 2008). Writing about her background and identifying my assumptions in carrying out this research, shaped her reflections about the work and understanding and interpretation of the results.       Her perspective during this research has been greatly affected by her previous experience as an occupational therapist (OT), and graduate studies in philosophy at Concordia University.       From 1995 to 2000, she was working as an OT with the Iran Welfare Organization. During that time, the biomedical model was the predominant model in rehabilitation services, and health professionals treated people with disabilities as people with illness and impairment. She  observed that the biomedical framework could not fully address the concerns of her clients. The majority of her clients were suffering from poverty and lack of access to basic needs more than their disabilities.       The complexities of problems that people with disabilities in developing countries such as her country (Iran) experience, led her to extend her knowledge outside occupational therapy practice. Her aim was to explore the relationship between poverty and disability. She learned that poverty and disability have been identified as part of a ?vicious circle? in the international 	 ? 29	 ?development literature; disability increases the risk of poverty and circumstances of poverty raise the risk of disability.       During her master's program, she was fascinated with the idea of justice. Her understanding of justice has been influenced by John Rawls?s idea of ?justice as fairness?. Rawls defined ?justice as fairness? as the priority of equality and fair opportunity for all citizens. Her mind was preoccupied with how to extend justice to people with disabilities so they have equal opportunities to achieve their goals.      During her doctoral program, she planned to explore further these issues of interest to her. She became familiar with an important theory, related to world poverty, the so-called Capability Approach. It provided her with a sound basis for thinking about the multidimensional nature of poverty and disability. She learnt that poverty could be understood as deprivation of basic human rights; and, human rights can be seen as claims to the CHFCs.       She thought about the applicability of the CHFCs to occupational therapy practice. Thus, she became interested in exploring the views of her colleagues with respect to their perceived relevance of the CHFCs to professional practice. She interviewed OTs related to this topic. Throughout her research interviews, she was challenged to reflect on her own notions and assumptions of the CHFCs. So early in her research, she believed it was important to write about her understanding of the CHFCs to clarify her personal assumptions.       She assumed that occupational therapy program plays a crucial role in reducing poverty and promoting basic rights by expanding the basic capabilities of people with disabilities. Also, she assumed that Nussbaum?s CHFCs framework have implications for health practitioners. Given the creative nature of occupational therapy practice, she assumed OTs could identify strategies for expanding, improving, and creating the functional capabilities of people with disabilities. Finally, she  believed the outcome of this research would enable OTs to better reflect on issues related to human rights and their role in promoting equal opportunities across people with varying needs. Her assumptions were written down during the initial interviews and they influenced her during her research as a whole.  3.1.3     Selected Sampling       Purposive sampling was employed for Phase One, the qualitative study, in accordance with an interpretative paradigm. The sample of OTs selected for participation consisted of those who 	 ? 30	 ?were thought to be able to best assist in enhancing the understanding of the meaning, relevance and applicability of the CHFCs to occupational therapy practice. Selecting a purposeful group of participants helped to maximize the chance of acquiring a range of perspectives based on the participants? diverse experiences, educationally and professionally (Patton, 2002; Minichiello et al., 2004). Specifically, participants were selected to represent a range of interests and positions in relation to the profession of occupational therapy. The researcher sought to gather the most varied and insightful information possible from the participants to reflect potential diversity of opinion about the relevance and applicability of the CHFCs to occupational therapy practice.      There are no strict criteria for sample size determination in qualitative methods. Sample size is often justified when no new information seems to emerge (the saturation point). Morse (2000) stated that reaching saturation ?depends on a number of factors, including the quality of data, the scope of the study, the nature of the topic, the amount of useful information obtained from each participant, the number of interviews per participant, the use of shadowed data, and the qualitative method and study design used? (p. 3).       Initially, the researcher?s supervisory committee agreed that a sample of 8 to12 interviewees would capture an appropriate sample size to obtain various perspectives. Because the topic of this study was new, reaching a clear saturation point took longer. The researcher continued interviewing participants until data saturation has been achieved (n=14). Estimating the number of participants in Phase One of this study depended on the scope of the research questions, the clarity of questions, the difficulty of the topic, and study design. As well, writing field notes and reviewing audio files assisted with decisions related to further sampling and attaining saturation.   3.1.4     Qualitative Phase Recruitment      As a recruitment method, the researcher used a purposive and a maximum variation sample. The researcher sought to gather the most varied information possible from the participants to reflect the possible diversity of opinions. Purposive sampling included contacting professors at the University of British Columbia (UBC) Department of Occupational Science and Occupational Therapy to assist with identifying potential participants. As well, the UBC Occupational Science and Occupational Therapy Academic Fieldwork Coordinator provided information to access OT practice coordinators at the GF Strong Rehabilitation Center, Mount Saint Joseph Hospital, Saint Paul?s Hospital, Vancouver Community Health Services, and 	 ? 31	 ?Vancouver General Hospital Acute Care Services, all of which were within the Greater Vancouver metropolitan area.      The researcher established the following criteria for participants for Phase One: They were working in BC and were able to communicate in English. In order to have a sample group as representative as possible in the field, some participants worked in clients? homes and in community settings, while others worked in hospitals, institutional, schools, and private clinic settings.   3.1.5     Description of Participants       The description of the 14 participants appears in Table 3.1. The researcher attempted, unsuccessfully, to recruit men as participants to the study, so all participants were women.  Eleven OTs were educated in Canada. Although each participant had experienced working in multiple settings, six had worked in hospitals, and five had worked mainly in clients? homes or community settings, two had worked in hospitals and communities, and two were working at the university.        In this study, the researcher initially decided to recruit OTs from a range of settings and professional roles including practice, educators, faculty members, and administrators in British Columbia. At the same time, consideration was given to participants? age, duration of experience, and practice settings. The ages of participants ranged from 27 to 64 years. Participants graduated from occupational therapy training between 1967 and 2010. They had worked as OTs between 2 and 34 years and in a range of settings.   3.2      Data Collection  3.2.1     Semi-structured Interviews      Consistent with interpretive description, interviews have become the primary source of data in many fields of qualitative inquiry to produce meaningful answers to research questions (Thorne, 2008, p. 78, p. 86). The primary source of data collection in Phase One was through one-on-one, face-to-face, open-ended, semi-structured interviews.       Comparable to administering structured interviews, in the semi-structured interviews, the researcher asked the same questions, in the same order for all participants (Morse, 1992, pp. 	 ? 32	 ?361-362). One advantage of using semi-structured interviews is comparability of the data, because they were obtained through consistent use of an interview guide (Morse, 1992; Flick, 2002). Flick (2002) points out that if collecting concrete statements about an issue is the aim of the data collection, semi-structured interviews are the most efficient means of doing so. As the purpose of Phase One was to explore the OTs? views about the ten CHFCs with respect to their understandings and perceived relevance of these capabilities to their professional practice, the semi-structured interview method was understood to be the most appropriate method. This method enabled the researcher to use the interview guide to ask each participant the same questions, and generated additional questions during the interview when needed to clarify the participants? meanings and views.   3.2.2      Designing the Interview Questions       Pilot interviews with two OTs were conducted to generate feedback about the interview guide, which is generally considered to be a list of questions or a series of issues that the researcher brings to an interview (Johnson & Turner, 2003, p. 305). Pilot interviews provided feedback about the clarity and logical ordering of the interview questions, the duration of the interview, as well as allowing the researcher to evaluate her interviewing technique. Finally, an interview guide was finalized based on the issues raised through the pilot interviews. Interview questions were designed to address the initial research questions: 1) What are OTs? understandings of the ten CHFCs, and 2) How may these capabilities be relevant to the contemporary practices of OTs (Appendix B). The interview questions were therefore designed based on 11 parts (10 CHFCs, and one general views about the 10 CHFCs). Each part has two categories based on the two research questions (OTs? understandings, and the relevance).  3.2.3   Conducting the Interviews      Following the pilot study, the researcher interviewed 14 OTs who indicated they were willing to participate in the study. At the initial meeting, the consent form (Appendix C) was reviewed with each participant, and then she was requested to sign the form. Prior to each interview, the participants were informed about the study and its requirements, and informed that they were free to discontinue the interview or refuse to answer any question. On meeting with each 	 ? 33	 ?participant, the researcher provided further instruction to them. Permission to record the interview was obtained. Informed consent was reviewed, assuring participants that their participation was voluntary and their responses would be confidential. They were informed that the interview would be tape-recorded and transcribed and that some of the information they provide might be quoted anonymously in the study results. The participants were interviewed once, in a quite environment of their choice (for example, at their workplace, at their homes, or at my office). The informed consent, demographic questions, and a copy of the interview guide were sent to participants a week prior to the interview date to allow time for reflection on the topic.       The interviews were audio recorded and transcribed verbatim from the digital recordings. Interviews were conducted between February 10, 2012 and March 20, 2012. Each interviewee participated in an interview that lasted 40 to 60 minutes. The researcher maintained memos while conducting the interviews and while listening and reading the transcripts. Interview recordings were transcribed by a professional transcription service with an agreement of confidentiality and removal of information identifying the participants. In addition, the researcher listened to all interview recordings and re-read the transcripts several times to ensure accuracy.    3.3     Data Analysis      Data analysis began as the data were collected and this served as a basis for further data collection (Streubert & Carpenter, 2011; Minichiello et al., 2004; Creswell, 2003).       Analysis of the data began with reflecting on the researcher?s assumptions related to CHFCs and their relevance to occupational therapy practice. Based on interpretive description, the preliminary phase of data analysis is a time that the researcher reacts to the initial pieces of data that seem interesting and labeled them as ?meaning units? (Thorne, 2008, p. 143). For example, the researcher reflected on a part of the transcript that seemed meaningful to her:  ??it sort of reflects some approaches that we have already been introduced to, either as students, or I guess as students, and may be even just sort of  societal, just some level of common knowledge, I guess.? (Participant 1, p. 1)       In interpretive description, ?the hard work of data analysis relies on the intellectual practices associated with seeing possible relationships among pieces of data you are gathering and then 	 ? 34	 ?considering the manner in which these relationships play out (or don?t) across the growing and evolving wider data set? (Thorne, 2008, p. 138). So, the researcher asked herself: why do I interpret this part as a meaningful unit? What does it mean for me? Does it provide meaning for my research questions? Such questions allowed the researcher to reflect on the ?meaning unit?, and to break it down into a shortened meaning unit and start coding (Thorne, 2008).      In interpretive description, one of the types of coding that is widely recommended is open coding (Thorne, 2008, p. 145). Therefore, the transcriptions of the initial interviews were reviewed and open-coding undertaken prior to subsequent interviews with participants. Thematic analysis was used to segment and categorize the data. The following section describes the process used for thematic analysis.  3.3.1     Conducting Thematic Analysis       Thematic analysis involves the identification of prominent or frequent themes in the literature to summarize the findings of interviews under thematic headings. Thematic analysis allows clear identification of prominent themes as well as organized and structured ways of dealing with the themes (Dixon-Woods et al., 2005; Boyatzis, 1998; Braun a& Clarke, 2006).       This analysis procedure in Phase One enabled the researcher to:  ? systematically reduce and manage, organize and summarize  data; and interpret them based on deductive thematic analysis (related to the ten capabilities), ? quantify emerging themes for Phase Two of her study which aimed to extend and confirm the thematic categories to a larger population, and ? transform the qualitative data into quantitative data (Boyatzis, 1998).       The process for analysis of the data consisted of: 1) familiarization, 2) reducing the raw information, 3) generating initial codes (first cycle coding), 4) reviewing themes, 5) identifying themes within subsamples, 6) comparing themes, 7) creating themes, 8) ensuring the credibility, and 9) producing the report.                 There are two approaches to thematic analysis, inductive and deductive. This research used both processes. First, the deductive approach was applied t to examine the data, and then the nine-step process was used to inductively develop themes based on the guidelines of Braun & Clarke (2006) and Boyatzis (1998).  	 ? 35	 ?     As there is no one way to conduct thematic analysis, there is no one set of guidelines. Braun and Clarke (2006) provide a six-step process for analysis that includes: familiarizing yourself with your data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; and producing the report. Boyatzis (1998) uses five steps to inductively develop themes: reducing the raw information, identifying themes within subsamples, comparing themes across subsamples, creating themes, and determining the reliability of themes.      Although the nine-step process was followed as systematically as possible, analysis is not a linear process of simply moving from one step to the next. The process of thematic analysis required moving back and forth within the data to establish a comprehensive set of themes (Braun & Clark, 2006).  Familiarization      Becoming familiar with the data involves ?repeated reading? of the data, and reading the data in an active way, searching for meanings, patterns and so on. The researcher read the data set in its entirety before beginning the coding.  Reducing the Raw Information      To codify is to arrange the data in a systematic order (Saldana, 2009). The raw information was reduced to a manageable size (Boyatzis, 1998). This involves preliminary identification of a priori themes, in this case, the ten CHFCs guided the coding of the data. To summarize, the researcher reduced the data based on 11 parts (10 capabilities and 1 general view). Each part consisted of 2 categories based on the two main research questions (OTs? understanding and perceived relevance). Generating Initial Codes       Coding is the process of generating ideas and concepts from raw data. In interpretive description, ?the idea of attaching ?code? to a piece of interview transcript or file derives from assumptions that one knows what the element entails, what other kinds of things might be similar and what it ought to be distinguished from?(Thorne, 2008, p. 144).      The coding process refers to the steps taken to identify, arrange, and systematize the ideas, concepts, and categories uncovered in the data. Coding consists of identifying potentially interesting events, features, phrases, behaviors, or stages of a process and distinguishing them with labels (Benaquisto, 2008).  	 ? 36	 ?     During the coding process, memo writing was used and was an essential part of the analysis (Appendix D provided an example of analytic memo writing). It was used to elaborate and reflect on ideas that emerged from the data during the coding process. The researcher integrated memo writing throughout data collection and processing.      In thematic analysis, the unit of analysis is inclined to be ?more than a word or phrase? (Boyatzis, 1998). It is not easy to derive a simple answer to the question of what amount of a data set should be consider as a theme (Braun & Clarke, 2006). Researcher judgment is necessary to determine what a theme is (Sipe & Ghiso, 2004; Braun & Clarke, 2006). In this step, the researcher chose the parts of the data set that best addressed the interview questions, in terms of establishing themes. Then, she queried whether each theme shed light on new discoveries, insights, and connections about the participants? thoughts (Saldana, 2009).       The researcher coded the data manually to feel ?close? to the data (Creswell, 2012, p. 240). Labels were written in the margins of transcripts, and memos were written as ideas emerged. The researcher used more than one method for first-level coding which included (Saldana, pp. 50-51):  Attribute Coding: used for essential information about the demographic characteristic of the participants, for example, age and gender.  In Vivo: referred to a word or short phrase from the actual language. This technique ?helps us to preserve participants? meanings of their views and actions in the coding itself? (Charmaz, 2006, p. 55).  Process Coding: used for ongoing action/interaction, response to situations, or problems). For example, when the phrase ?it is important to listen to clients? emerged, it was coded as ?Listening to clients?.  Emotion Coding: used to label the participants? emotions and experiences. For examples: ??I don?t know? was coded as ?Uncertainty?.  Values Coding: used to reflect participant?s value, attitude, and beliefs, for example, ?Affiliation capability is key to living?. Evaluation Coding: used to understand whether the participants made a positive (+) or negative (-) comment or recommendation (REC) tag was noted. For example, ??that not only it?s relevant, it may be helpful? reflects a positive view (+), while ??I don?t think it?s relevant to 	 ? 37	 ?daily practices in OT? reflects a negative view (-). When a participant provided a recommendation, for example, ?there should be a guide for action? the (REC) tag was noted.          In the initial coding stage, as many potential themes as possible were coded as it was difficult to predict what might be interesting later. Key phrases or words that captured the main ideas of the participants? responses to a specific question were highlighted, and any statements that the researcher felt were strongly communicated.        At the end of this phase, the codes were analyzed to consider how they would fit into an overarching theme. ?A theme is a phrase or sentence that identifies what a unit of data is about and what it means? (Saldana, 2009, p. 139). Reviewing Themes       This stage consisted of the code refinement. In this stage, themes were categorized based on main topics, themes, sub-themes, useless, and ?miscellaneous? themes (Braun and Clarke, 2006). The researcher labeled some themes such as ?OTs? understandings of Life Capability?, or ?Relevance of Life Capability to occupational therapy practice? as the main themes. Or,  ?Affiliation Capability is about social relations?, ?Control over One?s Environment Capability is about making decisions? as sub-themes. Some themes did not seem to be useful in addressing the research questions, such as: ?People with disabilities usually have a lot of grieving?, so the researcher categorized these as being less meaningful themes. Some themes did fit into main themes or sub-themes, such as ?people with mental health issues are treated differently?, ?many people with mental health issues live at the poverty line?, and ?Bodily Integrity Capability is related to occupational therapy practice in developing countries?, so these were temporarily labeled as ?miscellaneous? themes with the potential of informing an essential theme or being a  new theme.       According to Braun and Clarke (2006), ?the outcome of this refinement process can be seen in the thematic map? (p. 91) in relation to the entire data set. The researcher went back and forth within the data set to further refine the categories until a thematic map emerged. A thematic map helped to translate categories into themes.      As Braun and Clarke suggested, it is impossible to provide clear guidelines on when to discontinue data collection. Therefore, the researcher discontinued when she noted refinements were no longer adding anything substantial. At the end of this stage, she had an idea about the themes that emerged, namely, a set of themes and sub-themes that were relevant to the study 	 ? 38	 ?research questions. A total of eleven thematic maps were generated through this analysis. As an example, a representative thematic map for the Emotions Capability is shown in Appendix E. Identifying Themes within Subsamples      The two samples of OTs (those who work in the area of mental health and those who work in pediatrics) were selected to identify themes within these practice areas (Appendix F provides an example of how themes within subsamples can be identified).            Initially, the comparison of the transcripts was done with color coding to show differences and similarities between the two samples (Appendix F). Participants from the two samples noted that CHFCs: 1) reflect occupational therapy models or approaches such as client-centered approach or the Canadian Occupational Performance model (shown in grey), 2) are applicable in occupational therapy practice (shown in yellow), 3) are interesting (shown in dark blue), 4) are about basic human rights and needs (shown in blue), 5) are important to OTs work with mental health (shown in purple), and 6) are about improving an individual?s function which reflects the goal of occupational therapy practice (shown in green). No differences were found between the two subsamples. Comparing Themes across Samples      First, the themes that emerged from two samples of OTs were compared and contrasted. Then, each transcript was re-read by the researcher to ensure the themes applied across the data set. She would make notes in the margins for later reflection about a theme?s relevance.  Creating Themes      The themes that showed a distinction between the two samples of OTs, were rewritten for maximum clarity. The researcher asked herself such questions as: ? Can I read each of the transcripts and clearly see that a given theme is present or absent?  ? Is the theme presented with the fewest concepts possible?  ? Have I reduced the number of themes as much as possible without losing their meanings?      If there was no clear differentiation between the themes, it was dropped from further analysis. This process clearly defined what the themes were and what the themes were not as noted by Braun and Clarke (2006).    	 ? 39	 ?Ensuring Credibility      As part of the transcription process the integrity of the data was preserved by listening to the transcriptions several times as previously described, and using an additional transcription service to double check the transcripts to ensure accuracy.       Vrious strategies have been suggested to ensure the credibility of qualitative research findings. Creswell (1998) recommends that at least two of following eight procedures be incorporated: 1. Prolonged engagement and persistent observation in the field; 2. Triangulation, which makes use of multiple and different sources, methods, investigators and theories to verify study findings; 3. Peer review or debriefing, in which a peer asks the investigator hard questions about methods and interpretations to enhance the credibility; 4. Negative case analysis, in which the researcher refines the working hypothesis as the inquiry advances in light of disconfirming evidence; 5. Clarifying researcher bias, in which the researcher clarifies past experiences and biases so that readers understand the researcher?s position and any assumptions; 6. Member checks, in which the researcher has participants verify findings and interpretations;  7. Rich, thick description, which allows readers to determine whether the finding can be transferred to other settings; and 8. External audits which allow an external consultant to examine the process and findings of the study.      For the purpose of the present research, four of these strategies were thought to be most relevant to the data set, namely, thick description, clarifying researcher bias, peer review, and triangulation.      Thick Description is a method for enhancing the quality of research by quoting the participants? exact words. This method was employed to allow the reader to determine the accuracy of interpretation.      Clarifying Researcher Bias is indicated because the researcher is the key instrument of the data collection, and her biases may threaten the credibility of data (Patton 2002; Creswell, 2003). Although there is no personal neutrality in conducting a research, it is important ?to assume he or she knows nothing about the phenomenon under study and start gathering data from a fresh 	 ? 40	 ?perspective with his or her ?eyes open? (Asselin, 2003, p. 100).      Steps were taken to identify the personal biases of the researcher, in her role as the primary investigator. A few methods were applied in this study to minimize the risk of researcher bias in the data analysis. First, her biases and assumptions were identified and documented. Second, memo writing provided an opportunity to reveal her biases and assumptions.       According to Krefting (1991), writing a field journal is a way that researchers can be aware of their biases and assumptions. The field journal ?reflects the researcher's thoughts, feelings, ideas, and hypotheses? (p. 218). Through this stage, the researcher decided to write her assumptions and any thoughts that might impact on the research process. Her reflections revealed that she had some assumptions about the relevance of the CHFCs to occupational therapy practice. These assumptions included: 1) CHFCs can enhance client-centered occupational therapy practice, 2) CHFCs would be well-defined concepts for OTs, 3) CHFCs was a new approach for OTs, and 4) OTs struggled to explain how the CHFCs could be relevant to occupational therapy practice. Some assumptions were challenged during the interviews, thus encouraged her to remain open to the experiences and perspectives of the participants.      Based on her assumptions, the researcher attempted to minimize her biases. For example, during the interviews, she learned that although the Capabilities Approach was a new approach for OTs, they did not perceive the CHFCs as new concepts in the context of occupational therapy.       Ahern (1999) described the importance of identifying anything new or surprising in the data collection or analysis. Some of the unexpected data that the researcher identified included: the range of definitions of the CHFCs provided by the study participants, and the diversity of their professional settings and practice areas. Finally, the researcher attempted to minimize her biases in order to explore the experiences of the participants in an authentic manner and enhance the credibility of this research.       Peer Review although Creswell (1998) suggested that using a peer-review strategy helps the researcher to ensure the credibility of qualitative research findings, some scholars believe peer-review can be subject to biases. Mahoney (1977) criticizes the assumption that peer-review can be considered as ?an adequate and objective process? (p. 174). He asserted ?confirmatory bias is the tendency to emphasize and believe experiences which support one's views and to ignore or discredit those which do not? (p. 161).  	 ? 41	 ?     Thus, peer-review can prejudice not only because there are distinct areas of science and schools of thought, but also because of the irrational component of the nature of science. Kuhn (1962) shows how extra-scientific factors such as social, political, and religious factors influence the outcome of scientific debates.       Accordingly, some reviewers might be influenced by their adherence to a certain opinion and opposite view to others, and reject other views based on irrational elements. Consequently, in the current research, it was difficult to choose unbiased reviewers. Therefore, a member of the supervisory committee agreed to review the researcher?s decision-making process regarding the selection of relevant themes from the quotes. The researcher created records detailing the various stages of analysis and the rationale for her decisions with respect to coding and creation of themes. The member of the supervisory committee also wrote summaries of the meetings with the researcher and the decision making process.      Triangulation Denzin (1978) identified four types of triangulation: data triangulation, investigator triangulation, theory triangulation, and methodological triangulation (Plano Clark & Creswell, 2008, p. 21). Data triangulation and investigator triangulation were used to collect data in this study. Patton (2002) provided examples of data triangulation such as ?comparing what people say in public with what they say in private?, and ?comparing the perspective of people from different points of view? (p. 559). In this study, triangulating data from various sources (OTs who work in the area of mental health and OTs who work in pediatrics) and the different points of view (occupational therapy practitioners, educators, faculty members, and administrators) helped the researcher present the results from multiple perspectives. Investigator triangulation involved comparing the line-by-line coding of responses with a member of the supervisory committee. The areas of agreement and disagreement were identified and examined across themes.  Producing the Report       The findings of Phase One provided an enriched understanding of the relevance of the CHFCs to occupational therapy practice. The findings of this qualitative phase included 11 parts and 22 categories consisting of 75 themes when written into a cogent report of findings. This is detailed in the 3.4 section.   	 ? 42	 ?3.3.2      Trustworthiness       There are varying views about how rigor can be achieved in qualitative research. Some qualitative researchers, such as Altheide and Johnson (1998) and Leininger (1994), claimed that reliability and validity are relevant to quantitative research and entirely inappropriate terms in qualitative inquiry (Morse et al., 2002). According to such researchers, reliability and validity stem from positivist paradigm that seeks objectivity, while qualitative approaches stem from a post-positivist paradigm that acknowledges the existence of multiple realities and meanings (Morgan, 1998; Winter, 2000).       Other qualitative researchers assumed new criteria for ensuring rigor and determining reliability and validity in qualitative research (Morse, 2002). They suggested using terms such as 'trustworthiness', 'worthy', 'relevant', 'plausible', 'confirmable', 'credible' or 'representative', believing that these are more appropriate terms in qualitative research (Winter, 2000).       Lincoln and Guba (1985), for example, replaced reliability and validity with ?trustworthiness?. According to them, trustworthiness consists of four aspects: ?credibility (parallel to internal validity), transferability (parallel to external validity), dependability (parallel to reliability), conformability (parallel to objectivity)? (Markula & Silk, 2011, p. 205). We explain these aspects within specific methodological strategies for determining rigor in Phase One of our study.       To increase credibility, the researchers can ask themselves ?How can one establish confidence in the ?truth? of the findings of a particular inquiry? ( Lincoln & Guba 1985, p. 290). As discussed earlier, credibility in Phase One is enhanced with the use of strategies such as thick description, clarifying researcher bias, and triangulation (see Ensuring Credibility section).      To increase transferability of the findings of a qualitative study, it is useful the researchers ask themselves the question of ?How can one determine the extent to which the findings of a particular inquiry have applicability in other contexts or with other subjects (respondents)? ( Lincoln & Guba 1985, p. 290). Researchers can apply some strategies; such as thick description and purposeful sampling, to enhance transferability of the data (Jensen, 2008). The researcher in the present study provides the reader with a full description of the 14 participants (see Participation Description section and Table 3.1.) and by quoting the participants? exact words. Also, purposive sampling was employed to enhance the understanding of the meaning, relevance and applicability of the CHFCs to occupational therapy practice to the participants, and to 	 ? 43	 ?maximize the chance of acquiring a range of perspectives based on the participants? diverse experiences, educationally and professionally (Patton, 2002; Minichiello et al., 2004). Participants were selected because they most represent the research design to enhance the potential that readers can assess the degree of transferability to their given context.       Qualitative researchers are concerned with the dependability of their work rather than replicating it. Lincoln and Guba (1985) cited that in qualitative research, the researcher has to ask the question of ?How can one determine whether the findings of an inquiry would be repeated if the inquiry were replicated with the same (or similar) subjects (respondents) in the same (or similar) context?? (p. 290). Bozinovski (1995) noted ?any techniques which bolster credibility (e.g., triangulation) will also improve dependability? (p. 131). In our study, the researcher used triangulation to enhance the creditability and dependability of the data (see Ensuring Credibility section).       Dependability also means that the research cannot be absolutely assumed a priori (Jensen, 2008). The researcher can enhance dependability of a qualitative inquiry by describing the changes in context and circumstances, and providing rationale for doing the changes. The researcher needs to ?track all of the notes that differ from the design in the proposal? (Jensen, 2008). Dependability in this phase also was enhanced by changes to the recruitment procedure (the researcher first used a maximum variation sample to gather the most varied information possible from the participants to reflect the possible diversity of opinions. The researcher attempted, unsuccessfully, to recruit men as participants to the study, so she used purposive sample). Initially, the researcher?s supervisory committee agreed that a sample of 8 to12 interviewees would capture an appropriate sample size to obtain various perspectives. Because the topic of this study was new, reaching a clear saturation point took longer, so the researcher continued interviewing participants until data saturation has been achieved (n=14). Also, in the proposal, we used a thematic analysis method based on a five-stage process described by Ritchie and Spencer (1994) (i.e., familiarization, identifying a thematic framework, indexing, charting, and mapping and interpreting) for analyzing the data in Phase One. For more accurate analysis, the researcher decided later to use the nine-step process by combining the guidelines of Braun and Clarke (2006) and Boyatzis (1998) for conducting thematic analysis. The researcher?s supervisory committee reviewed all modifications, and the rationales for changes to ensure the dependability of this phase of the study.  	 ? 44	 ?     Conformability is concerned with ?How can one establish the degree to which the findings of an inquiry are determined by the subjects (respondents) and the conditions of the inquiry and not by the biases, motivations, interests, or perspectives of inquirer?? (Lincoln and Guba 1985, p. 290). According to Bozinovski (1995), ?triangulation and keeping a reflexive journal also increase the likelihood of conformability (p. 132). To ensure conformability in this phase, steps were taken to understand the CHFCs from the perspective of the research participants by providing quotes from the interview transcripts, using triangulation, and identifying the personal biases of the researcher and minimizing them (see section 3.3.1 Conducting Thematic Analysis).  3.4     Findings      This section is organized into eleven parts. The first ten parts describe OTs? views as related to each of the ten capabilities, namely, Life; Bodily Health; Bodily Integrity; Sense, Imagination, and Thought; Emotions; Practical Reason; Affiliation; Other Species; Play; and Control over One?s Environment. The eleventh part describes the OTs? views of Nussbaum?s ten CHFCs, overall. The findings are described in relation to the two research questions for each capability. Within each capability, the themes that emerged are described in detail. These are as follows:  1) Life Capability  Question I) What are OTs? understandings of Life Capability?  Themes: ? basic human rights  ? quality of life  ? longevity  Question II) How may Life Capability be relevant to occupational therapy practice? Themes: ? quality of life  ? working with people with mental health issues  ? working with seniors ? acute care, palliative care, and end of life care  	 ? 45	 ?2) Bodily Health Capability  Question I) What are OTs? understandings of Bodily Health Capability? Themes: ? basic human right ? health promotion ? interconnected with the Life Capability  Question II) How may Bodily Health Capability be relevant to occupational therapy practice? Themes: ? promoting health and preventing diseases  ? feeding and/or eating  ? addressing physical health for those with mental illness  ? advocating for adequate shelter and basic nutrition  ? uncertainty about managing reproductive health   3) Bodily Integrity Capability  Question I) What are OTs? understandings of Bodily Integrity Capability? Theme: ? basic human rights  Question II) How may Bodily Integrity Capability be relevant to occupational therapy practice? Themes: ? client-centered approach  ? an advocacy perspective  ? providing (emotional) trauma-informed care  ? addressing mobility issues   ? referring clients to resources  4) Sense, Imagination, and Thought Capability Question I) What are OTs? understandings of Sense, Imagination, and Thought Capability? Theme: ? expressing oneself in various ways Question II) How may Sense, Imagination, and Thought Capability be relevant to occupational therapy practice? 	 ? 46	 ?Themes: ? self-expression  ? people with mental health issues ? children with disabilities  5) Emotions Capability  Question I) What are OTs? understandings of Emotions Capability? Themes: ? basic needs and rights Question II) How may Emotions Capability be relevant to occupational therapy practice? Themes: ? people with mental health issues ? children with disabilities ? all those seen by OTs ? finding support systems ? helping people manage their emotions ? teaching anxiety management skills 6) Practical Reason Capability  Question I) What are OTs? understandings of Practical Reason Capability? Theme: ? making personal decisions Question II) How may Practical Reason Capability be relevant to occupational therapy practice? Themes: ? a client-centered perspective ? providing educational and supportive strategies  7) Affiliation Capability Question I) What are OTs? understandings of Affiliation Capability? Themes: ? basic needs and rights ? social relations  Question II) How may Affiliation Capability be relevant to occupational therapy practice? 	 ? 47	 ?Themes: ? helping clients to identify their interests  ? developing friendships, social network, and social skills  ? advocating for their clients  ? working with clients with mental illness  8) Other Species Capability  Question I) What are OTs? understandings of Other Species Capability? Theme: ? the environment  Question II) How may Other Species Capability be relevant to occupational therapy practice? Themes: ? relationship with animals and nature affects health ? a spirituality perspective ? a client-centered perspective ? an environmental perspective ? is not the main focus of occupational therapy practice 9) Play Capability Question I) What are OTs? understandings of Play Capability? Themes: ? human happiness  ? preserves quality of life  ? achieves a work/life balance  Question II) How may Play Capability be relevant to occupational therapy practice? Themes: ? a primary therapeutic approach in pediatric practice ? a therapeutic approach when working with persons with mental health issues  ? its importance for everyone  10) Control over Ones? Environment Capability Question I) What are OTs? understandings of Control over Ones? Environment Capability? Themes: 	 ? 48	 ?? decision-making  ? a basic human right  ? political opinions  Question II) How may Control over Ones? Environment Capability be relevant to occupational therapy practice? Themes: ? developing decision-making ? helping clients gain and retain employment ? advocating for their clients 11) General Views Question I) What are OTs? general understandings of the ten CHFCs? Themes: ? a new approach  ? a range of occupational therapy practices  ? more theoretical than practical ? more related to mental health practice  ? The construct of function is common to the CHFCs as well as OT models ? They overlap  Question II) How may CHFCs be relevant to occupational therapy practice? Themes: ? the Canadian Model of Occupational Performance ? the Human Occupational Model ? the Person Environment Occupation Model ? a client-centered approach ? a recovery approach ? a human rights model ? Maslow?s hierarchy of needs ? a social justice model ? an advocacy approach   	 ? 49	 ?3.4.1     Life Capability This part aims to explain the views of OTs of the Life Capability related to the two research questions: Question I) What are OTs? understandings of Life Capability?       The participants were asked about their understandings of the Life Capability based on Nussbaum?s definition and three themes emerged: Basic human right; Quality of life; and Longevity of life. The following describes the quotes that support these themes. i) A basic human right      One of the perspectives from which the majority of participants addressed Life Capability was to see it as ?basic human rights?. Here basic human rights include both rights and needs, meaning everyone has the right to life as a basic human right and to have basic needs met.       Right to life as a basic right was described as the right to live to the end of a normal human life, right to be free from dying early, deadly violence, suffering, and famine. A number of participants indicated that Life Capability is relevant to OT practice. They described it as a basic human right.  I think that?s sort of a basic principle. (Participant 1, p. 1)  I think that it?s a general human right, and so to me, it?s a right?(Participant 5, p. 2)      Life Capability was also described as a basic need that is consistent with survival and having access to basic things; such as, foods, shelter, and health. Life Capability was said to be necessary for achieving healthy well-being. ?the basic things that are required for health, access to housing and water and medical care, and food. (Participant 13, p. 1)  ii) Quality of life      The second perspective from which some participants addressed Life Capability was to see it as ?quality of life?.  ?it?s also I think the quality of life. (Participant 2, p. 3)  ?[it] is certainly about, well it is quality of life. (Participant 5, p. 2) ..it is a basic quality of life that everybody should be able to achieve. (Participant 7, p. 1)      There were multiple meanings of quality of life from the point of view of the participants. Participant 3 described it as, ?it should be more about the quality of life as opposed to the length of life. (p. 2). 	 ? 50	 ?While participant 12 described quality of life as, ?I think there?s much more of an understanding and approach to looking at the life and the quality of life and if it?s worth living or not ...(p. 2)  The term ?Life worth living? was ambiguous for some participants. Participant 8 critiqued it from the perspective of bioethics.  The other thing that frightened me was the term ?life is so reduced as to be not worth living?. It doesn?t say according to the person of whose life is being discussed. Who decides when a life is worth living or not? Who decides if that person must stay alive because their life is worth living or doesn?t need to stay alive because it isn?t worth living? (p. 2)       The phrase ?life worth living? also was critiqued from the perspective of the tension between universalism and cultural doctrine. Participant 7 referred to the differences between western and eastern cultures that largely influence the western understanding of ?life worth living?. ?I always critique things from a universal perspective of how relevant is this to everybody, because presumably it?s a western developed theory and so how relevant is it to people who live in non-western contexts or to indigenous people. (Participant 7, p. 1)  iii) Longevity of life       The third perspective from which some participants addressed Life Capability was to see it as longevity. Some participants noted that Life Capability is about both quality of life and longevity. They asserted that the lifespan of people with disabilities may be shortened. For example, participant 2 noted that, We know that people living with mental health issues are not living a long life. They are living a shorter life ? they?re dying a lot more early than typical population. Life is reduced, so therefore, it?s the longevity of life but it?s also I think the quality of life. (p. 2)  Participant 5 also mentioned suicide as an example of dying prematurely in people in mental health issues. In mental health, dying prematurely might be related to suicide. (p. 2) Some pediatric OTs also asserted that Life Capability is about ?a normal life expectancy?. Participant 4 expressed that, Obviously, we want to be able to live a normal life and, you know, feel that is worth-living, but I am working in pediatrics with children with a huge variety of either diagnoses or disabilities, or, there?s a lot of cases where those kids would not be living at, sort of quote:  ?a normal life? or, that there is a good chance that they going to be dying 	 ? 51	 ?prematurely, and yet I would still hope that they?re having a life that is worth-living, and that there is lots of great things for them in their life, despite the fact that their lifespan may be shortened. (p. 3)     In addition to disability itself that reduces life expectancy, some participants indicated that some socioeconomic factors affected life span. ?there are a lot of people in our society, in Canada for example, whose life expectancy is less, based on their social economic status, living conditions, ethnicity maybe, gender, right?...yeah so, and those people, are they able to live to the end of their life of normal length, not dying prematurely? (Participant 7, p. 2)  Question II) How may Life Capability be relevant to occupational therapy practice?       The results described the four themes on the relevance of Life Capability to occupational therapy practice. These were: Quality of life; Working with people with mental health issues; Working with seniors; Acute care; and Palliative care and end of life care. The following describes the quotes that support these themes. i) Quality of life       Almost all participants agreed that increasing and improving clients? quality of life is a priority of occupational therapy practice. They asserted that the Life Capability could be relevant to occupational therapy from quality of life perspective. [Life Capability is relevant to occupational therapy] only if you look at it from the quality of life perspective. (Participant 3, p. 3)  Some participants asserted that OTs? focus is on promoting the quality of life of their clients rather than the longevity. ? OTs would go further to not just to live a human life of normal length, but OTs, I think understand that it?s to promote people?s quality of life. It?s not just to encourage people to live length of lifespan, in fact we more focus on quality more than quantity. If somebody in fact has disability or progressive illness and cancer or whatever, something that you know they?re going to deteriorate very soon and there?s not much that we can do, then the OT is not going to be focusing on the normal focus, not trying to have them live a certain number of years but actually whatever number of years that they have, try to promote their quality of life. (Participant 1, p. 1)  Some participants who work in acute care also agreed that OTs attempt to maximize the quality of people?s lives even if they are dying.  OT?s about the quality of life, not the length of life, now those two go together, but I work on a ward where people are dying and it becomes, it strips it down to the basics of what?s important to the person, and its quality not length. (Participant 8, p. 2) 	 ? 52	 ?One participant noted OTs maintain the clients? quality of life by providing a supportive environment as described in the following: I think so because the whole idea is what we want to do is maximize the quality of people?s lives and that we do that through prevention, through restoration, but I also think that we work in palliation and that we are concerned with the quality even when someone is at the end of life, and it doesn?t matter where on the age range that is, that we have a view about what?s comfortable for that person and we work with that person to try and decide that so that time at any stage of the spectrum of life is maximizing that person?s goals that they set for themselves, and we facilitate that. (Participant 10, p. 3)  Participant 9 explained that occupational therapy programs and public health have overlapping goals with respect to increasing the clients? quality of life. I think OT and public health have a lot of links in terms of being able to, we?re trying to educate clients, or doctors or whoever to, about increasing health through all stages, so diabetes prevention or whatever it might be, trying to encourage people to eat well, live healthy, etc., to try increase their quality of life. (p. 2)  Some participants stated that OTs increase the quality of life through promoting health and preventing injury. Participant 13 noted that OTs have roles in the area of chronic disease management, and implementing self-management programs.  Well first of all we have a role in, I think in primary health care, so making sure that people are living actively and well, if they are well and maintaining their health, and then if they are in the whole area of chronic disease management, we have a role as well.  Again, helping people live well with a chronic disease and be involved in self- management programs and have access to the information that they need to live well, so yeah, I saw it really compatible with OT [occupational therapy]. (p. 3)  Some participants expressed that OTs try to maintain their life as high quality as possible by giving the clients tools and strategies to participate. Participant 3 mentioned that OTs help their clients use assistive technology, such as wheelchairs, to improve social participation and exercise control over their environment.  Well, most of our kids may technically not be able to participate in some things because of their disabilities, but they still may want to. Especially, you know, when the younger children are often influenced by their peers, or it?s such an important time for social interaction and so, we want to, whether it?s putting the equipment in place or compensative strategies or something helping them to still be able to participate in all those things and I think that is a part of quality of life. (p. 3)   	 ? 53	 ?Quality of life is about improving a life worth living from a few participants? point of views.  Some participants stated that OTs have important roles in helping people ?adjust to a major trauma? and cope with their disabilities.  ?so we?re mostly seeing people after the ill-effects after the disease or an accident, but certainly from this ?so it?s not reduced to be not worth living?, that?s a huge role that we play, helping people adjust to a major trauma or a major loss of independence. (Participant 13, pp. 2-3)   ii) Working with people with mental health issues           Some participants who described Life Capability as longevity asserted that it is relevant to OTs who work with mental health illness as it impacts on their work, and their clients? health and wellness issues.  So people I know who live with mental health issues, literature indicates that people die 25 years earlier as a result of having mental health issues, so definitely that [Life] Capability has huge impact for the kind of work that we do and it has impact in particular around health and wellness issues. (Participant 2, pp.1-2)  As cited before, some participants noted that people with mental health illnesses? lifespan may be shortened, and they are dying earlier compared to typical population. Suicide was mentioned as an example for dying prematurely in people with mental health illnesses. Occupational therapists develop interventions to help people have a longer life through exploring their world and their perceptions related to Life. But I guess also if you?re working in mental health, so looking at some individuals who are suicidal and working with them, exploring what their perceptions are, and what their rationale is. Why do they see that as a real option and then being able to help them look at other options? (Participant 6, p. 1)  In mental health practice, a number of participants noted, OTs help clients enjoy a longer life through meaningful engagement in occupation and providing various perspectives about what constitutes meaningful engagement. But, as an occupational therapist, working with them on establishing what is going to be the most meaningful occupations for them to be pursuing, given their time. And strategies for maybe having a different perspective around how they?re dealing with that. So if it?s someone who?s depressed, perhaps, and lacking motivation to do anything, because of the imminent, they have a medical condition and they think life has ended as they know it, and helping them to explore...well really, there?s other things they could be doing, and what would be meaningful for them ? like to explore that with them. Perhaps to have the different perspective. And maybe to be more meaningful for them?(Participant 6, p. 2) 	 ? 54	 ? Some participants mentioned that OTs support clients to have a longer life by helping them overcome various barriers. For example, reducing side effects of medications, and helping clients to be employable and have housing. I think it?s to develop interventions that help people have a longer life, so to take away some of the barriers, because people who are on medication, we know that they may have increased heart troubles, they may gain weight, so part of it is to take away if we can, as some of the impacts of that medication to some somehow reduce the negative determinant such as poverty, so to help people have an income, for people who live on substance abuse, to ensure people to get things like housing. (Participant 2, p. 3)  iii) Working with seniors       Some participants asserted that Life Capability is relevant to OTs who work with elderly when using appropriate accessibility and fall prevention strategies to promote the elders? Life Capability. For example, Absolutely, I think that aging and dementia and being able to care for our elderly and our seniors with dignity and compassion is very much part of our role as an OT [Occupational therapist]?[we] looking at being able to offer appropriate accessibility. (Participant 4, p. 1)  I think probably just being able to support life, generally through provision of say like fall prevention strategies in the home to prevent people from falling which increases chances of early death or things like that, so there?s different things we do in the environment for example that might help?(Participant 9, p. 2) Some participants noted that the philosophy of residential care is to preserve life worth living. Occupational therapists prevent further medical problems in residential care and attempt to balance prevention and freedom. Participant 12 described how OTs can improve the residents? abilities in the following, ..[It] would be a philosophy in residential care ? to look whether one?s life is worth living and not having people die prematurely from, for example: bladder infections that are easily curable, and pressure sores that could be prevented, so there?s a lot of this approach to preventing some of the other untoward consequences of illness and immobility. (p. 2)   Participant 12 stated that although OTs can develop many interventions to increase their clients Life Capability, there are barriers. For example: ?but it?s so very difficult, just because the workload is high everywhere. (p. 2)   	 ? 55	 ?iv) Acute care, palliative care, and end of life care      Some participants who addressed Life Capability as longevity perceived that maintaining life and enhancing the Life Capability is more related to occupational therapy practice in acute care, palliative care, and end of life care settings.  Well, the goal is basically to have a normal life expectancy, so doing whatever you can to facilitate that, I would think. Maybe if you were in a more acute care model; that would be probably maybe a higher priority. Where you?d actually kind of work on specific strategies for that? if you were working on palliative care team, or working on a HIV/AIDs program, ?you would actually be going through some very specific strategies that would maintain life, and longevity. (Participant 6, p. 2)  Participant 10 mentioned that OTs? main focus is to increase people's quality of life through reducing their pains and stresses in palliative care.  ?I also think that we work in palliation and that we are concerned with the quality even when someone is at the end of life, and it doesn?t matter where on the age range that is, that we have a view about what?s comfortable for that person and we work with that person to try and decide that so that time at any stage of the spectrum of life is maximizing that person?s goals that they set for themselves, and we facilitate that. (p. 3)  Also, participant 6 stated OTs? increase people's quality of life through exploring what actually would be meaningful for the clients and helping them to achieve their goals in palliative care.  So someone who has HIV or someone who?s in a palliative care situation, they have cancer, their life is probably going to be shortened. But, as an occupational therapist, working with them on establishing what is going o be the most meaningful occupations for them to be pursuing, given their time. (pp. 2-3)  One participant highlighted the ways that OTs are involved in the end of life care by helping individuals to be comfortable and supporting end of life care. I think that one in particular is quite relevant to palliative care. We?re looking at sort of helping individuals be able to be comfortable, especially in the end component of human life and looking at how we can do to help, whether it?s health promotion as well, to look at increasing the amount of life that people have, by preventing diabetes and things like that, as well as the palliative care aspect in supporting life in the end. (Participant 9, p. 2)   3.4.2     Bodily Health Capability      This part describes the themes that emerged from the analysis of the interviews in answering the two questions:  Question I) What are occupational therapists? understandings of Bodily Health Capability?  	 ? 56	 ?     Three themes emerged: Basic human right; Health promotion; and Interconnection with the Life Capability. The following describes the quotes that support these themes. i) Basic human right      According to participants, the Bodily Health Capability refers to the right to be physically healthy, to have shelter and sufficient food, and is essential and worth achieving in OTs? interventions.  My general understanding it?s sort of, it?s the basics, you know, it mentions: shelter, and I think working in pediatrics, you see this a lot, that you want before we can even attempt to look at what the OT goals are, we need to know that our kids have a safe place to live, that they have food, loving caregivers. The basic needs, exactly? (Participant 3, p. 3)  That?s absolutely an OT value.  If people?s basic health needs are not being matched with food and shelter, for sure? (Participant 4, p. 2)  ?it [Bodily Health Capability] is a basic human right and function? (Participant 5, p. 2) People with disabilities are more likely to experience failure in being healthy and being able to meet their basic needs. Suggesting Participant 2 stated: ?So many of our clients are not in good health.? (p. 2)   ii) Health promotion      One of the perspectives from which some participants addressed the Bodily Health Capability was to see it as health promotion, wellness and lifestyle management as in: Bodily Health, I think probably just similar to Life or with health promotion. (Participant 9, p. 2)   Well, good health, I think this reminds me a wellness, good health being adequately nourished like that?they remind me how OT concern with people kind of lifestyle and life style management. (Participant 1, p. 2) Some Participants described Bodily Health Capability as the physical conception of health that includes nutrition, exercise, and sleep. To me it seemed to be a very physical concept of bodily health, body as is in physical?(Participant 7, p. 3)   So having good health is again? Certainly I know, within mental health, we talked a lot about nutrition, exercise, and sleep as just the basics of good health. (Participant 5, p. 2)  iii) Interconnected with Life Capability 	 ? 57	 ?     Some participants indicated that Bodily Health Capability was to overlap with the Life Capability as both are about basic rights and needs as well as related to health promotion. ?it relates to the life capability. (Participant 2, p. 3) For Bodily Health, I think probably just similar to Life or with health promotion. (Participant 9, p. 2) That kind of fits in with Life. I guess I kind of rolled them both in. (Participant 13, p. 2)  Question II) How may Bodily Health Capability be relevant to occupational therapy practice?       The results described the five themes that emerged from the analysis of the OTs? perspectives on the relevance of Bodily Health Capability to occupational therapy practice. These were: Promoting health and preventing diseases; Feeding and/or eating; Addressing physical health for those with mental illness; Advocating for adequate shelter and basic nutrition; and Addressing reproductive health. The following describes the quotes that support these themes. i) Promoting health and preventing diseases       Some participants mentioned that the Bodily Health Capability is more relevant to occupational therapy from an international perspective. They indicated that enhancing the Bodily Health Capability is related to OTs and other health professionals who work in poor areas. For example: I was in Africa and I was working with mothers who knew nothing about being able to offer clean drinking water to their babies, boiling water, rehydration.  They had no concept of how to meet basic very, very basic health care needs for their young children under a year of age, so I found myself in a role of being able to advocate for health and prevention availableness through making appropriate suggestions.  I don?t think its unique to OT I think anybody in any health care profession, nursing or physician would be doing the same but, I have done that as an OT in the past. (Participant 4, p. 4)   Some participants asserted OTs have significant roles in health promotion, diseases prevention, weight management, and obesity prevention areas. Participant 12 mentioned OTs? roles in healthy living programs in the community including managing chronic disease, and promoting exercise and smoking cessation.  ?Being able to have good health?, this is an area that I think there is a huge role for OT but very few OT?s have jobs in that area. So, for example, we have a healthy living program here in the community and it?s around, a lot around managing chronic disease, 	 ? 58	 ?and it?s around, you know, managing your respiratory problems, and it?s also around the determinants of health so eating right, exercise, stopping smoking, that kind of thing, and I feel very strongly that OT?s have a huge role in this. (p. 3)  One participant highlighted OTs try to ensure that their clients have appropriate nourishment through education programs.  ? being adequately nourished, [OTs] doing swallowing assessments, doing, educating families and whatnot, on the importance of eating and living well, which helps with management with a whole bunch of chronic diseases. (Participant 9, p. 2)  Participant 12 indicated that OTs are involved in lifestyle management. So I believe, OTs to my knowledge, being a real facilitator, not in prescribing what they should eat but how they?re going to eat what they?re supposed to or what they want to and how they?re going to integrate that into a healthy lifestyle. So I think that there?s a huge role?(p. 3)   Participant 10 mentioned that OTs not only help clients have a healthy lifestyle but also promote the health of families. ?in the nursery which is a highly abnormal environment for a neonate.  The baby?s not supposed to be here yet.  OTs are involved in creating an environment that supports normal development and that also supports family interaction and promotes health for the family but also the baby, so we are part of that team that tries to, I?m not going to use the word normalize, because it?s never going to be a normal environment, but tries to have an environment that is supportive of a healthy life, as much as possible. (p. 3)  Participant 13 declared that OTs provide the necessary skills for their clients to engage in self-care, leisure, and productivity to effect healthy lifestyles.  ?I mean we do have a role in that as well and being able to have good health, I mean that?s a part of our self-care, teachings and chronic disease management or general education once somebody has an illness, at this site, my three sites...I would see it, I mean if someone is living with a chronic disease, for example making sure that managing their life style, so balancing productivity, self-care, and leisure. (pp. 2-3)   ii) Feeding and/or eating       Participant 4 asserted that OTs work with children who are not reaching their developmental milestones adequately and have problems maintaining bodily health.   Children with autism tend to have feeding challenges. They tend to have difficulties with metabolizing nutrients ? that children with autism have difficulties maintaining good bodily health. They tend to be very sick which is tied in to nutrition and food allergies and how the brain is processing, what?s happening with diet. (p. 2)  	 ? 59	 ?Participant 6 stated that OTs have major roles in addressing feeding issues to help maintain their clients? bodily health irrespective of the reason for failing to thrive. ?there are other therapists that address what their [clients] feeding issues are, and trying to figure out ways that keep them gaining weight or of an adequate weight so that they?re not...more ill. So, I think, OTs definitely have a very strong position on that, especially around feeding issues. On a feeding team. So that would be bodily health on a very basic level. (pp. 3-4)   Participant 12 claimed that having an interdisciplinary approach enables OTs to practice in various areas including working with clients who have feeding problems.  There?s some specific roles that the OTs have and some of that currently, so for example to be ?adequately nourished?, the OTs do work with speech language pathologists and nutritionists to see that the person is able to eat and swallow safely. The feeding, so that?s a big one. ?so we have to have an interdisciplinary approach which is really consistent with the way we try to practice in any way in my settings, the community setting. (p. 3)    Participant 9 also pointed out that OTs have a more consultative role to help clients with feeding difficulties. She noted that OTs try to ensure appropriate feeding for their clients through healthy eating recommendations. It is in terms of like, say for example, to be adequately nourished, in terms of swallowing, so ensuring that people are able to eat a diet that?s appropriate to their needs, and ensuring that, take for example, they have appropriate nourishment to help them from developing pressure ulcers or helping with healing, that would be through eating a better diet or what not. (p. 3)   iii) Addressing physical health for those with mental illness       Many participants perceived that OTs address Bodily Health Capability in mental health practice. Certainly I know, within mental health, we talked a lot about nutrition, exercise, and sleep as just the basics of good health. And so, I think that there?s a connect between this and OT?(Participant 5, p. 3)  A few participants mentioned that maintaining good bodily health of people with mental health issues is one of OTs main concern in mental health occupational therapy practice. Wellness, so people are eating, sleeping, These are very important eating, sleeping and getting good exercise. My patients [people with mental health issues] will always talk about things like that?as things that they want to do, need to do, they desire doing.  They want to be in good physical health. And I think that programs who are focus on mental health are increasingly addressing these issues as well. Helping people to maintain good bodily health and it maybe particularly important because there are side effects of medications like people who have mental health issues, taking medications and 	 ? 60	 ?those medications may cause people to gain weight and things like that?so it is a priority concern for the patients themselves and as a result I think it becomes concern also for the therapists for working with them. (Participant 1, p. 2)   One participant noted that people with disabilities, specifically people with mental health issues, are much less likely to have good physical health.  So, people generally may have more poor health as result of living with mental health issues. (Participant 2, p. 3)  iv) Advocating for adequate shelter and basic nutrition      According to some participants, OTs advocate for basic resources to help clients take care of themselves more independently. Occupational therapists advocate for promoting the health of their clients including adequate shelter and adequate nutrition. ?we spend a lot of time around adequate shelter, mental health and physical dysfunction, around adequately nourished, I mean we do have a role in that as well and being able to have good health. (Participant 13, p. 2)   Participant 5 noted that OTs have advocacy roles in addressing shelter issues for people with disabilities. Yeah, adequate shelter. Yes, OTs are involved, in mental health, with keeping people in housing and so in practice, I can see that this is an important construct. You know, that they would be adequately housed?.[OTs] help to assess people with mental health issues to the appropriate level of housing that they may require. What kind of care needs they might need, whether they need assistants or you know the different kinds of housing ? there?s supported or independent living. There?s totally independent living, but financially supported. So they would assist in that process of helping to find people housing. (p. 3)   Participant 2 mentioned that the supported housing program enables people with mental illness to establish independent housing in the community.  Some people who work in housing and provide functional assessments to ascertain the kind of support people would need. Some OTs advocate for housing first model which is a best practice within mental health and to ensure that people have access to housing because we know that?s one of the determinants that makes a profound difference to people?s life, both in longevity and quality of life and one of my roles is being health coordinator for our system so that means developing services and supports around wellness issues for people with mental health issues. ?So the OTs may not be delivering the service but as an OT, I?m helping to develop those services for people within our systems. (p. 4)   	 ? 61	 ?Participant 7 noted that access to safe shelter has a direct impact on pediatric nourishment and development.  So one example is, I go into a school that?s on a First Nations reserve and there?s a little boy there who unfortunately was apprehended away from his mother and placed with his grandparents, and since he has been with his grandparents, he has been getting more sleep, more food and coming to school on a regular basis and those basics we?re seeing a huge impact on his developmental progress. He?s talking more, he?s more attentive and he?s definitely learning more easily then he was before. (p. 4)  Participant 12 indicated that OTs work to ensure ready access to adequate shelter for those in need. In order ?to have adequate shelter?, yes, in our community setting, we do have. We have case managers who work a lot with clients who have OTs of needs around their personal care and their living arrangements?OT would be working with the person wherever they live and try to enable them to do the best they can with that. (p. 3)  v) Uncertainty about managing reproductive health       Although the majority of participants mentioned OTs? roles in addressing feeding challenges and advocating for shelter, some were unsure about their roles in addressing reproductive health, as noted by Participant 12:  I am not aware of OTs who are involved with reproductive health. (p. 4) Some suggested that OTs do not address reproductive health issues in their practices.  ?but reproductive health, I thought, you know what? We just don?t address that in OT practice and I question whether we are the best people to be addressing it. (Participant 5, p. 2)  In contrast, some stated that OTs work with sexual health teams. Participant 6 indicated OTs have a role in reproductive health when working with adults and teenagers.  Yeah, and then reproductive health, again not an area I?m familiar with, but I do know there are therapists that work on sexual health teams, or sexual health resources. Especially for, not just adults, you know teen, or kids that I work with; they have a lot of questions, their bodies look different, they may be perceived as being very different. And they may or may not be of the understanding of other people around sexual health, and sexual development... So making the necessary connections for the family and for the health professionals to understand this family?s particular situation. (p. 4)  Participant 13 also noted that reproductive health is relevant to occupational therapy practice as OTs are committed in principle to advancing the health and lives of their clients across occupational domains.  	 ? 62	 ?I mean if someone is living with a chronic disease, for example making sure that managing their life style, so balancing productivity, self-care, and leisure. There are lots of OT?s who work in sexual health, so managing a nice healthy sex life following an injury or illness. (p. 3)  3.4.3     Bodily Integrity Capability      This part aims to explain the OTs? views on the Bodily Integrity Capability with respect to the two research questions: Question I) What are occupational Therapists? understandings of Bodily Integrity Capability?   Analysis revealed an overarching theme of Basic human rights. The following describes the quotes that support this theme. i) Basic human rights       Almost all participants acknowledged that the Bodily Integrity Capability in many ways is consistent with people?s rights as citizens and includes both moving freely from place to place, and protecting one?s body against violations, abuses, and harms. Some participants emphasized this opinion: I see it as a human right. I mean that is, something that everybody has a right to not have, you know, sexual or physical abuse against their body. So, in terms of this, I saw it as a basic human right?(Participant 5, p. 4) Some people with disabilities are more vulnerable and less able to protect their bodies against physical violence and sexual abuse.  A few participants who work with children with disabilities described that these clients are at risk of violation of body integrity.   ?many of the kids that I?m working with have physical disabilities and are probably quite vulnerable in a lot of ways. (Participant 3, p. 5)  Some participants who work with clients with mental illness suggested that these clients have distinct needs. Participant 2 stated that in contrast to common views that people who live with mental health issues are violent, they are several times more prone to violence against them. She mentioned that many women and children with mental health issues have histories of sexual assault, child abuse, and domestic violence in their backgrounds. She perceived that people with mental illness have less capability of maintaining bodily integrity and cannot move freely from place to place, and thus lose their rights as citizens. Moving freely from place to place around, I think it?s citizenship. So, citizenship is a huge issues for people who live with mental health issues because stigma and discrimination, people may not feel welcome or may not participate in things like 	 ? 63	 ?libraries, community centers. So they may feel like they?re not able to move about as freely as they would like. Also, when people are not well.  They may be certified to hospitals, so that?s a time when they really don?t have freedom to make choices, so they are medicated against their will, they are isolated against their will in hospitals, so that?s a time when lose their rights as a citizen. (p. 4)  Participant 7 noted that Bodily Integrity Capability is an important issue to consider when working with certain people. She mentioned that a traumatic life is definitely part of the aboriginal people?s background as they lost their freedom to live in their place and to freely move from place to place. So the context that I work in with Aboriginal people is that there is intergenerational trauma from colonization especially in the residential school system and so there are high rates of family trauma involving children, and women in particular and so when I look at this, it reminds me that many of us would take for granted that we live in a place that?s free of these things but there are many people in Canada and also internationally where these are enormous issues for them. (p. 3)  For some participants, the Bodily Integrity Capability is a form of the principle of non-maleficence that everyone should be protected from unnecessary treatment. But many persons with disabilities, specifically people with mental health issues, may be less capable of making decisions for themselves such as avoiding unnecessary tests and treatments. In my environment, babies are provided with treatment that is necessary but one could actually say is violent in relation to OTs? practices.  It involves painful procedures; it involves sticking tubes in various places; that?s not assault, it is part of care to save a baby?s life, so it?s provided in the greater good of the life support, nevertheless, all of that has, and there is a consent provided by the family to do that kind of medical intervention but the baby itself doesn?t have a sovereign right, in effect they?re spoken for by the parent and the family,?so they don?t really have a choice if the parent consents to treatment?(Participant 10, p. 4)  Participant 9 referred to informed consent as a process to respect bodily boundaries and to ensure client safety. ?this talks a lot about sort of bodily boundaries, and we often don?t know a person?s history or whether or not they?ve had abuse in the past or what not, and so I think that?s why it?s always really important for us to try carefully and always ask consent or permission to like enter someone?s house or being able to sort of touch someone or if we need to do some range movement exercise or what not, so trying to respect those boundaries, and if they say no, being able to respect that. (p.3)   	 ? 64	 ?Question II) How may Bodily Integrity Capability be relevant to occupational therapy practice?      The participants were asked how Bodily Integrity Capability is relevant to your practice and to the profession as a whole? Five themes emerged including: a client-centered approach; A social justice perspective; An advocacy perspective; Providing (emotional) trauma-informed care; Addressing mobility issues; and referring clients to resources. The following describes the quotes that support these themes. i) A client-centered approach     Some participants mentioned that OTs respect the Bodily Integrity of clients. Participant 9  described it as relevant to occupational therapy practice consistent with a client-centered approach.  I think that Bodily Integrity is extremely important and particularly in from our client-centered approach?(p. 3) Participant 1 asserted that Bodily integrity is important to occupational therapy practice not only as a part of occupational therapy evaluation and interventions of body functions, but as a process to establish what clients are able and want to do.  We are concerned about the body, the bodily capacities?, I mean we take a one step further I would say, we?re looking at not just what the capacities are, but how those capacities are supporting or limiting a person?s ability to do the things they want to do or need to do. (p. 2) ii) A social justice and an advocacy perspective       Some participants asserted that the Bodily Integrity Capability is related to occupational therapy practice from a social justice and equality approach to health.              So again from a social justice perspective, the language-ing is very pertinent when working with Aboriginal communities. (Participant 7, p. 4)  For some participants, social justice here means advocate equal opportunities for people with disabilities. For them, OTs not only educate people to advocate for themselves in terms of empowerment, but OTs do a lot of advocacy for their clients to retain or acquire jobs, or to improve relationships in their community.   So I think that some of this [Bodily Integrity Capability] is a little bit more in the advocacy area. (Participant 1, p. 2)  	 ? 65	 ?A few participants mentioned that there is a link between empowerment and advocacy. According to them, OTs empower their clients to advocate for their rights including those related to bodily integrity. This one speaks to me as a bit of empowerment; so how are we working to advocate and empower our clients, to know that they have the right to be respected and to be treated regardless of their disability, to be treated like an active member of society, so that one I do, I like that one in my practice. (Participant 14, p. 3)  Participant 14 provided an example of The Canadian Model of Client-Centered Enablement [CMCE] as a practical model for empowering people with disabilities to advocate for themselves.  CMCE has all those ten different blocks that we work with and I?m very, very, very much on the advocacy piece because I feel like sometimes people, when we?re working with people with mental illness or with some sort of cognitive deficit, it might not necessarily be the cognition that?s the barrier or it?s the confidence in the organization, so we?re just advocating for them to fulfill their dreams and setup some of their goals, so I think this piece really resonates with me so they know that to advocate?(p. 3)  To influence public policy and make request for change, Participant 8 noted that OTs advocate for reasonable accommodation and accessibility for people with disabilities. Advocacy in terms of accessibility, to a point, yes. And when I say to a point I don?t think Mt Everest should have an elevator put in, that?s obviously an extreme example, but do I feel that Chemainus Chief should have a paved path through the top at taxpayer?s expense so wheelchair people can go up? No, not necessarily. Do I think that City Hall, every office at City Hall should be accessible to the people who need to go in whether in a wheelchair, crutches or walking?  Yes, so we do have a role for reasonable access?(p. 4)  iii) Providing (emotional) trauma-informed care      Some participants stated that OTs provide trauma-informed care to help people with mental health issues who have experienced violence and sexual assaults.  [Occupational therapists] provide trauma informed care for people feel disenfranchise, disempowered, and fearful of a system that have power to incarcerate them. (Participant 2, p. 4)   Participant 7 also noted that OTs can provide trauma-informed care to help traumatized people such as aboriginal children who have the experience of ?intergenerational trauma from colonization?. 	 ? 66	 ?So the context that I work in with Aboriginal people is that there is intergenerational trauma from colonization especially in the residential school system and so there are high rates of family trauma involving children, and women in particular?(p. 3)  Participant 10 asserted that OTs provide trauma-informed care to help their clients rebuild a sense of personal safety through implementation of strategies to minimize emotional distress.  ? and we may be involved in mental health where practice, where people have experienced domestic violence, sexual abuse, child abuse, things like that, and so we would be in place to mitigate some of the negative aspects of that. (p. 3)  iv) Addressing mobility issues       Almost all participants described Bodily Integrity Capability in terms of the right to move freely from place to place. They agreed that OTs address mobility issues that enable this right to be taken advantage of.  ?in terms of being able to move freely from place to place, I think that?s a definite one that OTs work on. (Participant 1, p. 2)  Well, certainly with mobility, OTs are involved with being able to provide information and equipment and resources for people to be able to move about as freely as they possibly can, if they got physical limitations. And with mental health, certainly if people have anxiety or problems socializing and they can?t move about freely because of that, OTs might address that, by a group or by some of their treatments. (Participant 5, p. 3)  A number of participants indicated that OTs enhance the Bodily Integrity Capability of their clients through increasing mobility and function, and enable their clients to interact with their environments and move freely by providing them the necessary tools and skills. Well, I think we help these children through variety of different walking aids, wheelchairs, devices to be able to move freely from place to place. (Participant 4, p. 3)  Well certainly being able to move freely from one place to another, a big part of what I do is working with people who are not able to move themselves easily from one place to another. So either walking, limited walking or no walking. And what are the options, right? So a big part of what I do, I see is falling under bodily integrity. And then giving them the tools and the skills so that they, hopefully, can prevent or deal with situations that?s listed here ?against assault? or whatever. (Participant 6, pp. 3-4)   Participant 10 cited that OTs increase mobility by providing a way to move their babies to do various activities and interact with their families albeit they are living in critical conditions or chronic diseases, or they have parents with disabilities.  The role of OT would be to provide a way to move the baby into different positions for different types of activities? It might be that you have a parent who has a physical 	 ? 67	 ?disability and the occupational therapist might be involved in making sure that the access to the baby is managed given the parents limitations.  We?ve had parents who?ve had Multiple Sclerosis or who are paraplegic and OT?s have been involved in helping figure out how Moms are going to manage that. (p. 4)  v) Referring clients to resources         Some participants mentioned that OTs provide supportive service to assist their clients and refer them to available resources if needed.   [If someone being assaulted] and not having a way of being able to express that, right? So that?s not typically something that we actively pursue, but at the same time, because those resources are there, it?s certainly something that we can facilitate and let people know that they?re there, and where to go if they need that kind of support. And then also, having someone who?s able to communicate in any way is allowing them to be able to express what they?re thinking, what they?re feeling, what their concerns are. So yeah, definitely, in a lot of ways, I think the work that I do addresses that. (Participant 6, p. 5)  I think being able to say for example refer on, to counselling services if needed, and connect people up with social workers or whatnot, and if we notice any risk of self abuse or neglect or what not being able to report those ?I?ve seen quite a few clients in domestic violence situations and so being able to talk with them through it, ? and being able to liaise with the family support practitioner and counseling services, and getting them connected there and to try to support them in the home and give them information about resources. (Participant 9, p. 4)  Participant 12 indicated that those who are incapable of protecting themselves from abuse, and find themselves in situations of assault and violence, OTs have to refer them to legal system or report abuse to the police. But for those who are capable, OTs do have an educational role: We have adult guardianship regulations in this province that are similar across the country, so as an OT or as an employee in this organization, if I suspect that any of those things are happening, I have an obligation to report it and to come back and to work with the team to see if there?s anything we can do to lessen those risks, mostly that?s with adult?s who are incapable themselves of asking for help. For people who are capable or considered capable, then we may have an education role, but with adults who are incapable or maybe deemed incapable then, for sure we?ve got a role. (p. 5)  Participant 12 also mentioned that OTs not only provide supportive services to reduce risks to clients, but consider they are part of the team responsible for assessing an individual?s capability. Occupational therapists work in teams who assess capability and are involved in making decision about whether or not their clients are capable of deciding where to live or with whom. Therefore, OTs have a responsibility to detect or prevent abuse and violence by informing authorities or establishing a support system for their clients. 	 ? 68	 ?Well right now, that?s really interesting because the, up until now there?s just been a few, like the doctor and a few other people in the legislation but they?ve changed the legislation around adult guardianship that there?s a number of individual professionals and OT?s are included in that, that could make a capability assessment?(p. 4)  3.4.4     Sense, Imagination, and Thought Capability      This part describes the analysis of the semi-structured interviews with respect to the two questions regarding OTs? views about the Senses, Imagination, and Thought Capability with respect to their understandings and perceived relevance of this capability to their professional practice.  Question I) What are occupational therapists? understandings of Senses, Imagination, and Thought Capability?       In response to this question, the researcher?s analysis revealed one theme: Expressing oneself in various ways. The following describes the quotes that support this theme. i) Expressing yourself in different ways       According to some participants, Sense, Imagination and Thought Capability means having the freedom to be able to express yourself in various ways.  ?so I just see it as a person?s ability to use their resources as well as they can in order to express themselves. (Participant 13, p. 3)  Participant 10 noted that freedom of expression involving all types of expression, including freedom to determine one?s meaning of life: What it seems to me is that you should be able to see, think, imagine, create, independent, independently in a variety forms of expression. These may be as it says here religious, literary, musical, political or artistic, freedom of religion, being able to determine how your own life evolves and what the meaning of that life is. (p. 4)  Or, as participant 11 stated, a person?s ability to express his or her political thoughts: ?it has to do with freedom to express yourself in different ways, to be educated, to be creative, to use your mind, to be able to express your political views. (p. 2)   Participant 7 described this capability as justice with respect to expressing one?s thoughts. In social justice circumstances, people have freedom of opinion, expression, religion, and political thought. I think this relates to issues around social justice, and ?freedom of expression, to participate, and to express their thoughts and in some ways. (pp. 4-5)  	 ? 69	 ?Question II) How may Senses, Imagination, and Thought Capability be relevant to occupational therapy practice?        Three themes emerged related to the OTs? perspectives on the relevance of Sense, Imagination, and Thought Capability to occupational therapy practice. These were: Self-expression; People with mental health issues; and Children with disabilities. The following describes the quotes that support these themes. i) Self-expression        Participant 13 declared self- expression as a key component for occupational therapy practice to facilitate engagement in meaningful occupation. I think it?s [self-expression] a cornerstone for our practice, if we want to get people engaged, if we want to get people interested in participating?This is key. (p. 3)  Almost all participants agreed that this capability is an essential part in occupational therapy practice, and it is important for all to be able to express themselves. I really like it first of all. I like the way that it?s framed and it?s an area of self-expression. It?s an area that OTs have worked on also for quite a while. I used to do self-expressive groups with my client and I think, I agree that this is important, for a lot of people this is very important, being able to express themselves, and having the freedom to express themselves and this is relevant for OT. (Participant 1, p. 3)  Similar to the part of Nussbaum?s definition of Sense, imagination, and thought as ?Being able to have pleasurable experiences, and to avoid non-necessary pain.? Some participants acknowledged that experiencing pleasure activities and avoiding pain is relevant to occupational therapy practice. They stated OTs help people build their abilities to express themselves freely and explore what they want to do. Well, again, it?s just allowing the individual to do the activities that they want to be able to do, and what?s important to them. So you?re looking at the ultimate meaning of life in one?s own way. You?re allowing them to share with you what is important to them and then you?re, with them, working towards helping them achieve those goals. But you?re doing it in a way that allows...if they do have limitations in those areas of sensory or cognitive mental capacity, you?re allowing them to be able to function at the level that they have. And you?re trying to help them make the most of it, right? (Participant 6, p. 5)   Participant 9 mentioned that OTs have an important role in enhancing the Sense, Imagination, and Thought Capability through learning processes and copying strategies, and resuming some of their previous activities where applicable.  	 ? 70	 ?I think that?s actually quite a huge area of OT in terms of, being able to use your own mind say for example and your own senses to be able to do something, so, we often see people where that?s impaired whether it?s like after a brain injury or after a stroke, so being able to help them to process and reason, problem solve and being able to sequence things and having greater insight into situations or whatnot, so I think that is a big role for OT. (p. 4)  A few participants indicated that OTs support their clients in coping with new situations and their disabilities through engaging in self-expression activities. For example, Participant 9 noted that OTs may help clients use artistic expression as an indirect means of communicating and expressing their imagination and thoughts. ?being able to use the alternate meaning of life in one?s own ways, so helping people process through like, whether it is their sorting out, their learning how to deal with their new disability and so they use like an artistic expression of that to try cope with that or whatnot and using their own  through imagination meaningful to them, or be able to say use their imagination to try give them hope in life and try resume some of those activities that they might have stopped doing after their disability, injury or whatnot. (p. 4)  Participant 14 asserted that OTs not only assess limitations of the Sense, Imagination and Thought Capability through self-expression activities, but also evaluate their limitation of executive functions such as problem solving and planning, and decision making. We do a lot of cognitive assessment and intervention and external and internal compensatory mechanisms to help mediate any deficit, so I do think it is. ?Like assess for the limitation, like executive functions like problem solving and planning and pacing, and moderating themselves and being able to assess for that and speak to their abilities; what deficits they have because of their illness or what they?ve still have retained through their illness; like decision making is often a really tough one with our population. (p. 4)  Participant 6 noted that assistive technologies provide opportunities for promoting self-expression and enable clients to do what they choose to do. Well again, that?s another area that I think I address a fair bit with the technology, because you?re really just giving them tools to allow them to develop their own unique expressions. But you?re figuring out ?OK, for a lot of them, they may have sensory impairments, vision, hearing, cognitive impairments? so figuring out what are the best tools to allow them to do the things they want to do. So physically, they might not be able to...if art is something they want to be able to use to express themselves, they may not be able to physically do what everybody else does, but if you hook them up to a computer, and you have the right software, and you do the right access method, with the right level of instructional support, they?re able to produce incredible pieces and it?s their own self-expression. The technology is just facilitating that... (p. 4)  	 ? 71	 ?Participant 6 also stated that this capability would apply to both clients and their families with respect to their expressing themselves in meaningful ways.   ?with respect to my area specifically, this would certainly apply to the families, the adult and the children of the families?Well, there are aspects of how the family might want to relate to the child that would inform, that might involve using art, it might involve using music, it might involve using therapeutic massage, it might involve speaking freely to the medical staff, things like that, and the occupational therapist, I have been involved in situations where parents may have wanted to do particular artwork related to the baby, have their siblings involved in that, how would we display that art, things about that art that would be particularly meaningful for the child and particularly the family. If the family wants to read to children, it? not going to over stimulate the baby, that kind of thing. So it?s a matter of allowing the family to express themselves freely within a context of what the infant can manage, and OT is definitely involved in that kind of thing. (p. 4)  Participant 10 highlighted OTs have an ethical responsibility to avoid unnecessary pain in their clients, advocating pain relief to minimize their clients? pain, acknowledge and mitigate the impact on their families, and to promote more pleasurable experiences. And the issue about avoiding unnecessary pain, one of the big things about my own job is reminding people not to do tests if they don?t need them because they?re painful, and then figuring out how to manage that, teaching the family how to help the baby manage that, teaching the staff how to manage it, so that?s what we do every day.  And with respect to having pleasurable experiences, there are OTs of things that you can do for a very sick baby that are pleasurable.  There are also a lot of things you can do for a very sick baby which you would think would be pleasurable which are not because their brains are not ready, and so an OT would know, and be able to evaluate how a baby is responding to various things that the family might want to do and can help manage that interaction so that it actually ends up being pleasurable as opposed to being stressful. (p. 5)  Participant 10 also mentioned that OTs advocate for their clients and their families by providing feedback to service providers and organizations involved with their clients? care. OTs may be an advocate for the family to speak to the medical staff about how the system works or doesn?t work and OT?s may be that person who the family connects with and talks to about that, and so the OT would facilitate, providing feedback to the larger system and so that would be a political way that OT?s could be involved, for sure. (p. 4)    ii) People with mental health issues      Some participants mentioned that Sense, Imagination, and Thought Capability is more related to the mental health practice area in occupational therapy and suggested that people with mental 	 ? 72	 ?illness lack or partially lack this capability. Thus, improving this capability can be a focus of occupational therapy intervention.  ?in mental health, this is very much a big part of what we?re doing. (Participant 1, p. 3)   I think this one that?s in my area with mental health, a lot of people struggle with their imagination and thought process, so this is definitely an area of intervention, is trying to see what someone?s thought patterns are and whether they have a sense of imagination and they have the insight to know if their senses are compromised? (Participant 14, p. 3)  Sense, Imagination, and Thought connection is often a key component of mental health issues. Participant 2 noted that people who live with mental health issues do not have opportunities to express themselves as others do. According to her, they often become ill early in their lives, so finishing school and education is often challenging for them. She asserted that OTs help those individuals express themselves through restoring their lives and developing skills to experience worthwhile living.  [Occupational therapy practice] covers a whole lot of things. I think part of the role of an OT through a recovery framework is to help people often re-story their lives to help people to express that purposes and meaning as a result of living with mental health issues such that they?re able to see themselves outside the illness so it is helping people develop self-efficacy though activities such that they?re able to see a better future for themselves. So two things, restoring all life and also re-skilling people such that they are able to be more self-determined, more involved in their own care and more committed to their own recovery. Really coming to that place that they perceive that life is worth living, because that is an act of choice for many people who live with mental health issues. (p. 6)  Some participants noted that OTs often improve the Sense, Imagination, and Thought Capability for people with mental health problems and cognitive dysfunction. Occupational therapists are involved with cognitive retraining using relaxation training, helping clients decision making, learn compensatory strategies to cope with their new situations, and teaching them basic skills. OTs work with the development, mentally delayed with cognitively impaired, with those with mental illness to help them use, to help them maximize their own ability to function in the area of thought, cognitive process, reasoning, planning. (Participant 8, p. 5)  Participant 13 said that improving the Sense, Imagination, and Thought Capability is important for people who live in residential care: Well, I?m thinking of particularly in mental health for example, for somebody who is very depressed, maybe tapping into music or drawing and drawing them out that way and allowing people to express that part of them and then I think is residential care where 	 ? 73	 ?people are usually quite disabled by that time and, that making sure they have an ability to experience and to express themselves even if they have limited cognitive capabilities, that they have those outlets. (p. 3)  iii) Children with disabilities       A number of participants asserted that having this capability is a basic skill for children when learning to express themselves. They mentioned that this capability is relevant to occupational therapy practice as it is critical for child development and learning. They also noted that OTs consider this capability in their practices from educational and multisensory point of views. I think it is relevant. I think, you know, even for example, we?re trying to teach kids motor skills. And they need to be able to use all of their senses, their imagination their thinking process?You know, that sense of, just imagination and thinking and everything, I think it?s fundamental to development. Yeah, so I think it actually has a strong sense in OT, in education and sort of the combination that I see with both, sort of health and education merging in the practice area that I?m working in. (Participant 3, p. 5)  Participant 4 indicated that OTs work closely with children with autism who lack this capability. She also mentioned that OTs help such children promote this capability by helping them connect with the world in a range of ways. Oh well the population of kids that I work with, do have disordered senses and they do have disordered thoughts which is part of their diagnosis, children with autism have processing issues related to how they make sense of the world, and what we see are kids who are very isolated and don?t make those human meaningful connections with family or friends, peers, and that?s the most important piece of my job, cause I don?t work with many children with physical disabilities, I work mostly with kids with autism, being able to improve how they make sense of the world and to be able to connect and communicate in meaningful ways, is what I do in a nutshell, that is my job, sort of in a very short way of saying it. (pp. 4-5)  Participant 7 noted that OTs enhance the Sense, Imagination, and Thought Capability with interventions to strengthen communication skills and promoting literacy as well.  I think, one of the things around literacy is that I think we need to really think about, for me that comes around the way that we communicate both in writing and verbally with clients.  I mean, in pediatrics, a lot of what I do is promoting literacy in children around visual motor, fine motor functioning, so there?s kind of a direct coloration, I guess, there (p. 5)   	 ? 74	 ?3.4.5     Emotions Capability This part is intended to explain the OTs? views about the Emotions Capability with respect to their understandings and perceived relevance of this capability to their professional practice.  Question I) What are OTs? understandings of Emotions Capability?       In response to this question, the researcher?s analysis revealed the main theme pertains of this research question was: Basic needs and rights. The following describes the quotes that support this theme. i) Basic needs and rights      A number of participants state that Emotions Capability is a basic human right that is critical for well-being. It means the right to be loved and to belong.  So for me that would be a basic. It comes across to me as a very basic human right. Again, that all children and people have the right to have a sense of safety, love and belonging. (Participant 7, p. 5) So I guess this is about the right to love and be loved and I think it?s a very basic, basic need and basic right. (Participant 11, p. 3)  Some participants indicated that the Emotions Capability reflects baseline and fundamental needs connected this to other capabilities. I think it?s in a way it?s sort of like Bodily Health.  Like, you need the basics in order to be able to move on to other goals. (Participant 3, p. 5)  Well, I think it?s a basic human need. For a person to be able to express emotions and also to have their emotions acknowledged by other, right?  (Participant 6, p. 5) I guess just that people have an innate right I guess, to be able to express the feelings that they have. (Participant 10, p. 5)  Question II) How may the Emotions Capability be relevant to occupational therapy practice?     Six themes emerged across the OTs? perspectives on the relevance of the Emotions Capability to occupational therapy practice. These were: People with mental health issues; Children with disabilities; All those seen by OTs; Finding support systems; Helping people manage their emotions; and Teaching anxiety management skills. The following describes the quotes that support these themes.   	 ? 75	 ?i) People with mental health issues       Some participants reported that the Emotions Capability is more relevant in the mental health area of occupational therapy, as many people with mental health issues are emotionally vulnerable.  ?sometimes people lose family as a result of their mental health issues and studies seem to change a little bit these days, but perhaps 50% of people may lose their families as a result of their mental health issues.  So because of the illness, they remain isolated without contact and without the chance to experience those emotions? Definitely, when people become ill, 16, 17, that emotional development is blighted. (Participant 2, p. 6)  Definitely, certainly in mental health. I think a lot of what the mental health part of OT is really looking at helping people deal with their emotions, effectively. So whether that?s, recognizing what their emotions are, and then being able to express them. (Participant 6, p. 5)  ? so, it?s something that I think is really important if you work in mental health (Participant 5, p. 5) A number of participants noted that OTs help people with mental health issues to manage their emotional health and overcome their emotional problems, and help to improve individuals? daily activities through enhancing the clients? capabilities to overcome their emotional problems associated with the activities. Right, in the emotional side of things, I think a lot of this is worked on in group work in mental health. In engaging people into activities with others who, perhaps, can support them, in educating the people who are in the individual?s life who is working with somebody in mental health. And I think it?s in teaching about how these kinds of emotional things. (Participant 5, p. 5)  This is certainly relevant to occupational therapy in general and an example would be mental health, because you?re helping people manage their emotions and how that may or may not facilitate or not facilitate their goals and how they view life and things like that. (Participant 10, p. 5)  ii) Children with disabilities   Some participants reported that the Emotions Capability is particularly important in early childhood development and contributes to the development of a healthy personality. They noted it is a fundamental component of children?s well-being. I sort of saw this as like, looking at attachment and appropriate behavior and sensory processing, just having a good, solid, early childhood development. I think it is relevant 	 ? 76	 ?to OT.  I think it?s in a way it?s sort of like Bodily Health. Like, you need the basics in order to be able to move on to other goals. (Participant 3, p. 5)  Participant 3 also mentioned that children with behavioral issues often have problems with emotional development. In these cases, OTs focus their attention at basic emotional developmental to help minimize its impact and enable the child to develop healthier emotional strategies. ?because when they don?t have the basics in that area, they don?t participate in things appropriately and so, they?re delayed in everything anyway. So, environmental modification, just around even positioning, or sensory distractions, or sensory strategies that will help them attend or focus.  Still putting things in place for gross motor and fine motor practice, because they have had so many things going on. They haven?t had a typical childhood to get out and explore and trying things. (p. 6)  Some participants stated that OTs work on Emotions Capability in early childhood development; such as attachment, appropriate behavior, and sensory processing. For example, participant 4 mentioned that children with autism lack the capacity to develop meaningful relationships and attachments. According to her, OTs facilitate the development of meaningful relationships by finding new ways of connecting with others, such as involving them in playful interactions.  a lot of these kids are unable to really form meaningful attachments, they become much more interested in things like spinning objects or something non-human, but it?s not a particularly meaningful relationship or connection. A lot of it is facilitating a dynamic or a relationship with the child and being able to make that bridge with the child and the parent, so it?s helping that parent find a new way to connect by starting at a very, very basic level with being able to develop that flow to be available, to be there. (p. 6)  A few participants stated that everyone including children has the right to feel safe emotionally as well as physically, to feel loved and that they belong. For example, Participant 7 asserted that confidentiality issues related to care would be included in this capability. She mentioned that OTs ensure the emotional safety of their clients during care.  Again, that all children and people have the right to have a sense of safety, love and belonging. And I think in occupational therapy, I think we do indirectly think about the, maybe the emotional safety. (p. 6)    Participant 10 noted that by considering the level of illness, OTs facilitate appropriate interaction as necessary for infant?s emotional development while they are in acute care hospitals.  Another thing about that?s listed here is that supporting the ?forms of human association that can be crucial for development?. One of the issues in the nursery is that parents are separated from the baby; I mean that?s just a fundamental problem. It?s not such a 	 ? 77	 ?problem in other countries but certainly in North America, it is a problem and the OT is definitely involved in providing parents ways of having, if they can?t be there all the time, when they are there having high quality interaction with the baby, knowing what that baby?s saying, what their movements mean, how much the baby can interact, what can they see, what can they hear, when is their seeing and hearing improved, all of those things that facilitate a relationship between the baby and the parents and that?s appropriate for their development and it changes over time depending on their development and their level of illness. (p. 5)  iii) All those seen by OTs      Some participants suggested that the Emotions Capability is relevant across areas of occupational therapy practice as it impacts all areas of a client?s capacity for occupation. I think Emotions is huge, because we often see people at their lowest, when their emotions are very vulnerable and there is a lot of grieving, whether it?s grieving from a loss of function, or loss of independence, or whatever it might be and so being able to sort of work around that and sort of work at the persons own pace is really important.  So I think, emotion is quite important because your emotions impact everything. You can?t separate emotion from body. (Participant 9. p.4)  A number of participants stated that The Emotions Capability is relevant across occupational therapy settings from hospitals, institutional, schools, and private clinic settings. For example, a few participants who worked in the acute care hospital setting noted, Yes, it?s relevant to my practice, in that my patients have undergone massive emotional trauma. On Tuesday, they?re at work and they?re not feeling quite well so they go to the doctor to get a sick note, the doctor does a blood test, and two days later they?re facing life and death decisions about their leukaemia, so they?re emotionally very traumatized. (Participant 8, p. 6)  In my practice, the whole experience is traumatic, just the nature of it is traumatic for families and for the baby. It is filled with fear and anxiety. It isn?t something that can be avoided because of the nature of the experience. This is the person?s offspring who could die at any minute. (Participant 10, p. 5) A few participants indicated that in different practice settings, OTs acknowledged the effectiveness of culture when working with a range of clients from culturally diverse backgrounds. They explained the impact of cultural factors in development of emotions. For example, participant 7 asserted that OTs need to create an environment that is emotionally safe when working with ethnic minority population. I know that in my practice with Aboriginal families, there are risks involved in accessing occupational therapy because of the historical relationship between indigenous people 	 ? 78	 ?and institutions including health care, and so, I?m very conscious of people?s emotional safety within our relationship and the need to give time to allow that to develop because unless somebody is feeling emotionally safe with you, then it?s very hard to go anywhere else with them in terms of therapeutic value. ?in community context when you?re having potentially some long term relationships with people, gaining emotional safety on both sides is really important. (p. 4)  Participant 14 noted that the Emotions Capability is relevant to occupational therapy practice from both the client?s point of view and that of the clinician. She stated that the Emotions Capability impacts both clients and therapists.  So emotions, regardless of where you?re working, you?re always working with people in a traumatic. The reason why you?re an OT is to work with people to get them back to finding meaning and purpose in their life; and when you lose that meaning and purpose and role, you?re going to be emotional about it. There?s going to be anxiety and grief; and even if you?re working with a child, it?s their parents, so you?ve got that secondary emotion that you need to be dealing with, and with mental health outpatients, it?s often the family. So, it?s emotions on all levels, and also for yourself, because I find that sometimes I often just wish I worked at a coffee shop and didn?t have to deal with anyone who?s going through anything traumatic because it really wears on you, as much as you don?t think it does, I think emotion is really relevant to OT, both for the clinician and the client. (p. 5)  Occupational therapists need to be aware of his or her emotions and feeling to prevent them interrupt the therapy process, as participant 8 noted, Sometimes you have to get off the emotions to help the emotions heal. (p. 5)  iv) Finding support systems     Some participants indicated that OTs improve the Emotions Capability by identifying social, emotional, educational supports for clients, and help to incorporate family members and make use of the client?s support networks and develop new ones.  Thankfully, we?re doing a better job these days, where one of the roles that OTs play are developing family education sessions with their loved ones and we have literature to say that that?s making a huge difference in recovery for people, so hopefully keeping families together, keeping support systems, as we know when people lose their family support, often homelessness is one of the first issues and homelessness becomes a cycle where people remain isolated without contact and without the chance to experience those emotions. ..So yes, for some it?s really, it?s really, once again trusting people, once again finding support systems, once again learning how to broaden their social support system, natural supports that people might have and OT?s very much do that. (Participant 2, pp. 6-7)  	 ? 79	 ?Yah, I think it make sense. It?s applicable. The idea of having attachments to things and people we know from research as well that people who have good family support, who have been adolescents, who have been able to develop strong attachments to one person that they feel they fit with, and can promote better outcomes, so the way services are organize also, we?re trying to sort of incorporate family members and support networks into the work that we do. (Participant 1, pp. 3-4)  Participant 12 noted that OTs try to be aware of their clients? situations to maximally augment this capability and avoid inadvertent decisions that impact the client negatively.  What I would think that the role of the OT there would be to identify for sure what?s going wrong?could help that person grow and develop in a proper way. I wouldn?t as an OT want to do anything that would impair that ability. I would want to be very sensitive to it.  For example, I?m suggesting some help that they would get from a loved one or a family member. ..They have a different relationship with that person, so I need at the very least to be aware of that and to look at consequences for involving and finding ways of checking in, because maybe my client doesn?t know how to express that to me and they see me, who knows, they see me coming in and telling them this is what they?re supposed to do and that?s not on. I mean I?ve had, so, I think, at the very least, do no harm with that, don?t make it worse, the next step up would be identifying what the issues are, finding some appropriate resources; the third would be OTs who are trained to help people move through different emotional stages, and transitions. (p. 6)  v) Helping people manage their emotions       Some participants asserted that OTs help people manage their emotions through developing communication skills to allow their clients to express themselves including their emotions.  I think it has to do with helping them through communication skills, expressing their, I think a lot of it has to do with communication skills and sometimes it has to do with communication skills and also, I guess, depending where problem solving, where it?s being and looking it how it?s affecting other parts of the person?s life. (p. 4)  A few participants stated that OTs provide communication strategies to improve the Emotions Capability. For example, Participant 6 reported that OTs develop healthy emotional expression in their clients consistent with their wishes, engaging them in activities, and educating them. She 6 noted that communication devices allow clients to be able to make choices, communicate, and express their emotions. OT is really looking at helping people deal with their emotions, effectively. So whether that?s recognizing what their emotions are, and then being able to express them. And certainly from my point of view, more directly, for the people that have communication issues, providing them with strategies that will allow them to share...First of all, recognise those emotions, so some of the work we do is really talking about, helping them recognise when they?re angry, what their behaviours is like, and what do they do 	 ? 80	 ?when they?re angry or when they?re upset or whatever. And sometimes, they?re not making those connections, so helping them identify that, and then allowing them to be able to say about it. So when I?m having a page on their communication device that says ?I am happy/sad/anxious/worried? and allowing them to be able to make those choices and to be able to say to somebody ?you?re pissing me off, get out of my face!? where physically they may not be able to express those; they may be expressing them but other people aren?t recognising them. A lot of why we get people, a lot of reasons people come to us for communication devices is because there?s a behavioural issue. ?So I think a lot of what we do, we?re trying to allow healthy emotional expression. Right? In a way that is both respectful for the individual and for the people that are around them. (pp. 5-6)  vi) Teaching anxiety management skills      Participant 14 noted that OTs work with people experiencing emotional trauma, and help them reintegrate into their lives after a traumatic event.  I think this one really ties into the psycho-social Module that the psycho-social element that we deal with, obviously working in mental health right now. I can see very concrete evidence of someone?s emotional development hindering them to meet their full potential and the fear and anxiety and a lot of what we do is helping people reintegrate into their lives after a traumatic event, which is usually a psychotic break so, I really like this one a lot, and to me although it?s generalist, it really is concrete enough to tie into OT. (p. 5)  Participant 10 reported that OTs along with the other professionals provide knowledge, and sympathy and support to help their clients and their families to manage their fears and anxiety. In my practice, the whole experience is traumatic, just the nature of it is traumatic for families and for the baby. It is filled with fear and anxiety. It isn?t something that can be avoided because of the nature of the experience. This is the person?s offspring who could die at any minute. It is filled with fear and anxiety, that being said, the occupational therapist is there to provide knowledge and compassion and support along with the rest of the team, about how that baby is doing or will do, and help the parents manage as best they can the fear and anxiety. We don?t try to have it go away. It?s not realistic not to have fear and anxiety so I guess one of the problems I had with this definition is sometimes overwhelming fear and anxiety is a normal response to a situation and it isn?t something that is a negative; it?s what you?d expect, so how do you then kind of manage it. (p. 5)  Participant 1 asserted that OTs help clients to manage stress and anxiety with activities such as yoga, meditation, and breathing.  I think that OTs do work on anxiety and helping clients find ways in which they can cope and manage with stress, maybe through various activities, like yoga, meditation, breathing. (p. 4)  	 ? 81	 ?According to Participants 2, OTs rebuild the Emotions Capability as a basic skill to overcome anxiety and fear through teaching clients about anxiety management skills and how to control their emotions when re-engaging in previous activities or engaging in new activities.  ?we didn?t encourage people to go get a job or to go get volunteer work and it caused stress vulnerability model, which is how we developed a lot of our service in the early days. Thankfully, these days we look at things much more through a strength, strength based approach. ?an occupational therapist, has developed a wonderful, ah and their team, a wonderful thing called ?action over inertia? that teaches people about anxiety when they?re about to take new activities, and teaches people that, that is to be expected. So, I think that is one of the first places that we?ve seen a focus from occupational therapy on the emotional impact of reengaging in activities, in my opinion. So, it?s a very fairly systematic way to look at emotions as people look at activities. (p. 7)  3.4.6     Practical Reason Capability       This part describes the analysis of the semi-structured interviews with respect to the two questions: Question I) What are OTs? understandings of Practical Reason Capability?         In response to this question, the researcher?s analysis revealed one theme: Making personal decisions. The following describes the quotes that support this theme. i) Making personal decisions   Some participants defined the Practical Reason Capability to be the ability to make decisions and to make good choices. I guess my understanding is just sort of making good choices and using the idea of reflection to impact future choices that you?ll make. (Participant 3, p. 7)  ?so I guess it?s around choice and I guess it?s around being given enough, being given the information that you need to make good decisions  that fit for you?(Participant 13, p. 4)   A few participants described the Practical Reason Capability as a kind of reasoning and autonomy to control one?s environment. I guess for Practical Reason in terms of planning one?s life, being able to have control over your own environment is huge I think and engaging in critical reflection so just the individual choice and autonomy is really big in that one. (Participant 9, p. 4)    	 ? 82	 ?Question II) How may the Practical Reason Capability be relevant to OT practice?      Three themes emerged from the analysis of the OTs? perspectives on the relevance of the Practical Reason Capability to occupational therapy practice. These were: A client-centered perspective; Helping clients to make personal decisions; and Providing educational and supportive strategies for caregivers. The following describes the quotes that support these themes. i) A client-centered perspective      Some participants asserted that because occupational therapy is a client-centered practice, the Practical Reason Capability is highly applicable to occupational therapy practice.  ?as a concept, it?s something that maybe underlines client-centered care. That the individual themselves is able to have insight into them as a separate being and having meaning in their life by doing certain things. (Participant 6, p. 7)  Some participants reported that in client-centered practice, clients are considered as knowing what they want from therapy, and OTs respect their clients? values, beliefs, and reasoning related to this position.  It is in terms of allowing people to live how they want to live, even if it goes against something you might personally believe in, or it might be going against something that you think is ok? (Participant 9, p. 5)  ? I think that OTs are and should be interested in what peoples values are, I am definitely have always been interested in what people?s values are and I try not to impose my own values on somebody. (Participant 1, p. 4) Participant 1 noted that in client-centered practice, the goals of the clients and OTs are aligned. And I think planning is an area that OTs are also do help. ?well I mean the therapist?s goals need to match the patient?s goals. You shouldn?t have different goals. Your goals shouldn?t be that different from what the patient, ? whatever, formulate your goals that support get helping the patient gets his goals? your goals may be a little bit different because your strategies or interventions maybe something specific but I mean, so it is relevant. (p. 5)  Some participants stated that OTs respect the client?s autonomy and their independency, and assist them with both what they want to do and are able to do. Well to some extent, it?s a matter of engaging in critical reflection of planning one?s life. So having some autonomy and some recognition of them as an independent person with the unique set of circumstances and recognising that they have ideas around what they want to do and where they want to go, and what they want to be. And being able to, if 	 ? 83	 ?they so choose, having us assist them in reaching some of those goals? (Participant 6, p. 7)  OT is highly involved in that. We have a client-centered practice and so our whole operation is about how that client is going to achieve the goals they want, have the spiritual development they want, engage with occupation that they want, and having a meaningful life and that?s kind of our bottom line. (Participant 10, p. 5)  Participant 13 mentioned that in client-centered practice, the references of the client have priority in determining goals. She stated that OTs provide clients with necessary information to enable them to make their decision and choices.  Well I mean that?s, well I?m reading it here ?engage in critical reflection and planning of one?s life? and so I guess it?s around choice and I guess it?s around being given enough, being given the information that you need to make good decisions that fit for you, versus what may fit for me as a therapist? and I think that?s an important component of OT. (p. 5)  Participant 14 noted that in client-centered practice, OTs are regarded as facilitators who only assist their clients to make decisions and give them opportunities to control their environment as much as possible to achieve their goals and independence.  ? I think often people don?t know where to go next, and even if they have an idea to, they?re so petrified of doing it, that the OT is a ?facilitary? role. (p. 5)  Participant 7 reported that despite client-centered practice being valued as the preferred approach in occupational therapy, ambiguity remains regarding the extent to which the therapist?s power and assumptions guide client-centered process. Well, certainly, I mean, the client-centered focus, the client-centered philosophy is aligned with that, but that philosophy comes with some assumptions around who decides, again, who in the end has that power to decide for that client and how much is the therapist guiding it. So, you know I? m kind of, I wonder when it comes to client- centered practice, which is I think what this possibly could relate to in OT, is, again the preconceptions from the therapists about that process, and how that?s undertaken. It is about the assumptions and the ideas that the therapist has on what client-centered practice looks like. Is that what it looks like from the perspective of the client, or is it from the perspective of the therapist? I don?t think sitting down doing a COPM is a way of necessarily understanding a client?s life and of helping them to plan, but I think it?s very relevant, but I think we just need to be really critical about that, more so. (p. 6)  Participant 7 also mentioned that there are barriers affecting individuals? ability to plan for themselves including social, political, and economic problems, and factors related to disability, gender, culture, and age. 	 ? 84	 ?Again, if you?re living in chronic poverty or you?re living in vulnerable conditions, reflecting on planning one?s life, it gives a sense that you that you actually have the ability to plan your life and yet I think for some people, there are many forces and structures that impact their ability to plan their life that it?s not something that is just under one person, an individual?s control? that actually, can act as barriers to some people who are vulnerable, to be able to have a sense of autonomy in their life. (p. 5)  Some participants stated that the Practical Reason Capability is relevant to occupational therapy practice from an outpatient perspective.  ?but in general, when somebody?s more coming in from an outpatient point of view, yes I think it?s relevant. (Participant 1, p. 5) A few participants asserted that the ability to exercise autonomy and planning of one?s life depend on a person?s health condition. For example, participant 12 noted that persons with physical disabilities are capable of making decisions about their lives. Being able to form a conception of the good and to engage in critical reflection about the planning of one?s life. That to me is to be able to help self-direct and even if a person can?t enact everything they want about their life, at least they have a way of managing that. So for example, if you have a person who is very physically disabled but they have a clear idea of what they want to do, then they can be capable of making those choices about their life. (p. 8)  Participant 5 also reported that individuals who are living with a chronic long-term health issue, they have serious problems that affect their ability to plan for themselves. Or, people with severe mental health issues, and cognitive impairments are less capable of reflecting on their lives and making effective decisions.  Wow, there?s a lot of people who don?t have this. [laughing] A lot of people aren?t planning one?s life. It?s something I might have to work on. So I just thought, yeah, that?s a nice thought, but I didn?t see it as being something that applies to everyone. I really don?t think that that?s something we could expect of everyone. And in particular, someone who has had a brain injury, or a mental health problem. You know any kind of difficult life transition or change, expecting this of everyone is... (p. 6)  ii) Providing educational and supportive strategies A few participants noted that the Practical Reason Capability is relevant to occupational therapy practice from an educational perspective. Um, yeah, I suppose it?s relevant in thinking about it from an educational standpoint, so understanding this as a capability is something that would be important. (Participant 5, p. 6)  	 ? 85	 ?more I saw it as relevant to education and that part of my job?So more from an education point of view. (Participant 3, p. 8)  Participant 12 asserted that OTs need to be able offer options to the clients at their level of ability, and need to be aware of clients? problems and have realistic expectations. About the planning; I think we need to be able offer options to clients so that they can see beyond make choices. It really depends on the person?s, what is it?  OTs of control, if they are really someone who has an internal sense of control, then we need to work with them and how they can enable it and what choices might be possible? we have to just offer options and choices and work with someone at that level. We can do that it very mundane ways.  We do that in very mundane ways everyday just around practical things, just every day ADL. (p. 7)  For example, Participant 6 mentioned that people with mental illnesses may be less able to make critical decisions and their capacity for practical reasoning may be deficit. Nonetheless, they may be capable of making simple decisions in daily life. She noted that OTs can work at a basic level to improve the Practical Reason Capability of a client by providing opportunities and strategies. And then there?s also people that physically or cognitively can?t understand; then being able to understand, to help them figure out what is important, what isn?t. They?re not maybe able to make those big life decisions, but they?re able to make decisions around a very concrete activity. Or being able to say ?I like it this way, not this way.?... So I?m going to give them the opportunity to decide. We give them the strategies; the tools to use, their partner?s still aren?t giving them those choices. Even though they?re capable of making them. I think you can, that?s very relevant in a lot of ways. (p. 9)  Participant 12 reported that OTs enable their clients to develop the Practical Reason Capability to identify barriers and to achieve what they want to do. I think OT could do a lot more with enabling people to reach their own goals by helping them figure out what those goals are and helping them shape it, and helping them, enabling, and finding out what the barriers are now?( p. 8)  Participant 4 asserted that OTs provide educational and supportive strategies not only for their clients, but for their caregivers as well. Well again I think that this would maybe be more appropriate to the mother, the parents, being able to have an understanding of how to make sense of their child?s diagnosis and then how they can engage in a new process through information and education from an OT and that way they?re able to promote more independence for their kid. (pp. 7-8)  	 ? 86	 ?Participant 10 mentioned that OTs develop some strategies to better ensure the families have the opportunity to plan their care.  ?in my area of practice, I would say it?s about supporting the family and the baby to have the opportunity to plan their life and that maybe, the life might be 5 five minutes, the life might be a month, the life might 89 years.  It?s still what it is for the time that it is and again what we would be involved in is how they engage with the baby, how that baby is brought into the family, who the family structure is and how the life that they have will be as good as quality as they can have it for the time that they do have it. (pp. 6-7)  3.4.7     Affiliation Capability      This part is aimed at describing the OTs? views about the Affiliation Capability with respect to the two questions: Question I) What are OTs? understandings of Affiliation Capability?       In response to this question, the researcher?s analysis revealed two overarching themes: Basic needs and rights, and Social relations. The following describes the quotes that support these themes. i) Basic needs and rights      One of the perspectives from which a number of participants described the Affiliation Capability was to see it as ?basic needs and rights?. Here, basic rights and needs means being treated with dignity, being considered equal to others, being able to have compassion for situations, having friendships, being able to meet freely and speak freely with respect to politics, and being able to work with people in a mutually respectful way.  [It is] talking about self-worth and dignity to some extent that individuals of all different variations have the basic, same basic needs and rights. (Participant 6, p. 9)  According to some participants, there were two types of comments about basic human rights and needs: those referring to basic rights, such as being treated with dignity, and those referring to basic needs, such as the sense of belonging. For example, participant 10 described the Affiliation Capability as an important aspect of being treated with dignity. She explained it in terms of equality and rights.  So, again, this is about being treated with dignity, being considered equal to others?we are very much involved in our clients and their relationships with other people and seeing them as having their own rights to engage the life they want to have and being treated with respect and with equality.  That?s right, and we?re super involved politically with equal rights for those who are disabled?(p. 7) 	 ? 87	 ? Participant 7 defined the Affiliation Capability as a sense of belonging in terms of being a basic need.  Again it goes back to that sense of belonging, possibly as a basic kind of human need. (p. 7)  ii) Social relation      The second perspective from which some participants described the Affiliation Capability was to see it as ?social relation?.  I mean this is key to living, I think and so being able to engage and being involved in, being in a social group really, and being able to live with others in a way that?s effective, that the people you are living with are benefiting and that you, yourself benefit as well, so it?s ?you give and you get?. (Participant 13, pp. 4-5)  In other words, it means seeking out positive social support that is a key component of healthy living as described by participant 5: ?That social relations are important for general health and function. (p. 6)  Participant 7 stated that the Affiliation Capability is critical for maintaining relationships and achieving their needs as human beings are social beings.  Ok, so the first one, Affiliation, it?s really talking about being part of a social group.  So I think the first part for me is looking at the importance of the social connectedness, within society as well as for individuals, and that feeling like that you?re a part of some sort of group, in which you?ve got a shared identity, or there?s something that you have in common with the people in that group, I think that?s a really important part. (p. 7)   Participant 9 also asserted that this capability it is about one?s social network and having relationships that are mutually respectful. I think having a social network is huge and the social interaction, being able to nourish friendships and what OTs and where it?s an equal friendship and where one person doesn?t have power over the other one, but its having that social network and people who care for them or whatnot, I think is what the Affiliation is talking about. (p. 6)  Some participants mentioned that the Affiliation Capability is about belonging and how people belong. It was noted as being about seeking social support through healthy attachments and pursuing social support through others. ... so it?s about belonging, so that?s friendship, social interactions. It gives us some ideas I think about how we can be, how people belong, so belonging maybe in relation to having compassion for others or for a situation. (Participant 1, p. 5) 	 ? 88	 ? Participant 14 explained the Affiliation Capability from the empathy perspective. She mentioned that OTs try to understand the clients? situations and problems in order to better contribute to their well-being. This speaks to like, perspective taking; so can someone show concern for other human beings, can someone interact with others. This is like the empathy perspective taking part?I think is really big in people with both personality disorders and I mean this is why we are so good at our job, is we try so hard to have that empathy and imagine the situation of another, compassion for that situation. (p. 6)  Question II) How may Affiliation Capability be relevant to occupational therapy practice?      The results describe the four themes that emerged from the analysis of the OTs? perspectives about the relevance of the Affiliation Capability to occupational therapy practice. These were: Helping clients to identify their interests; Developing friendships; social network and social skills; Advocating for their clients; and Working with clients with mental illness. The following describes the quotes that support these themes. i) Helping clients to identify their interests       Some participants noted that the Affiliation Capability is relevant to occupational therapy from a client-centered perspective. They asserted again that occupational therapy is client-centered practice, so OTs need to identify their clients? values and interests, and respect what their clients want to do. And the intervention with those individuals who have some interest is really helping people to identify interest, to participate in experiences that may, that may nurture them, that may give them possibility for future, so OT?s are heavily involved in that? (Participant 2, p. 9)  And they should be in the driver?s seat; not us. They determine what they?re ready for, what would be useful for them...(Participant 5, p. 7)  Participant 12 noted that OTs help people with what they want to do by identifying goals and the barriers.   ?I could do a whole lot of different things, depending on what this person wants to do; ?as an OT, I?m trained to help identify what goals are, what are barriers, what are facilitators, and I don?t have to know a lot of content in area to start, I just need to get going on that. (pp. 9-10) 	 ? 89	 ?Participant 13 asserted that OTs are responsible for reintegrating their clients back into society after an event or an illness. She stated that OTs help their clients to identify their interests, and help them redefine what is his or her new role is after trauma or disability. I think with someone who?s living with a physical disability, you?re talking to say a father who has lost his ability to work maybe and provide for his family, helping him redefine what is his new role.  He?s still a father, but he may be not the bread winner anymore, so then helping him sort through, you know, what is a father and how can he maintain that role even though maybe one of his primary jobs or duties was to make sure everyone, to make the money so that the family could live. (pp. 5-6)  ii) Developing friendships, social network, and social skills      Some participants noted that OTs promote the Affiliation Capability through supporting the notion of social networks and friendships. They mentioned that social relationships and friendships have effects on both mental and physical health. So I thought that this affiliation is important and how it might relate to OT would be...really looking at how do we help people to think about their social relationships. How do they protect some of their social network and friendships; how do they expand it if it?s shrunk down to such a size that it?s just not working for them. That social relations are important for general health and function and so, looking at that, is something that I think is really important for occupational therapy. (Participant 5, pp. 5-6)   Participant 4 asserted that many people with disabilities lack the opportunity to interact with others to develop social relationships.  Yeah, so a lot of these kids have no friends, they don?t know how to socially interact. And it?s heartbreaking for a mom that their child never gets invited to a birthday party, you know, they?re not included in social gatherings, because they?re just difficult kids to take out. (p. 8)  Participant 3 noted that OTs are responsible for promoting social support systems for their clients which include friendships and fostering social skills.  And then, I guess, just even, for our students [clients] being able to live with others and manage well and have friendships and things, just that social interaction piece with children, which sometimes comes into our role, and I think some of our kids who really need a lot of practice with social interaction that are not developing naturally, they have referred to other OTs for more private work for group type intervention where they might build skills as well as social skills. (p. 9)  Participant 4 reported that one occupational therapy intervention for fostering social skills and friendship is educating the client?s family members as well as the client. 	 ? 90	 ?So promoting friendship and affiliation among, among other families and among children is a big part of my job. I might ask them to bring one of the siblings into an appointment, and then I might help that sibling and the autistics child that I was working with, develop maybe a very simple skill, like, you know, maybe, being able to take turns?you would help that sibling and that child work on winning and losing, or waiting and turn-taking, how to co-operate with working on maybe building a puzzle together so we would facilitate that friendship through the activity, so the child with the, um, who had difficulties, you know, very impulsive, very easily anxious and frustrated, starts to develop the skills. (p. 8)   Participant 4 stated that OTs promote the Affiliation Capability by providing support for caregivers, e.g., shared information and education.  I think affiliation is a huge part? a lot of the families I saw, particularly, the poorly educated, to have a severely disabled child, to have a child with a mental health or cognitive challenges; they were so sheltered from the community. And there was a lot of blame of the mother,...and the mothers were very much isolated from the community and their families?.I find that mothers and mothers with children with disabilities are an enormous support for each other?so it was promoting shared information, shared education for moms, yeah. (p. 8)   Participant 6 reported that OTs facilitate the Affiliation Capability by providing assistive technology and giving devices to their clients to provide opportunity to do things they want to do. Certainly with the work that I do, a big part of what we?re trying to do is allow or facilitate the skills and the tools to allow them to interact with others, as they wish. So whether it be providing a para-mobility device so they can get around and do the things they want to do, with the people they want to do it with or, from a communication point of view, giving them supports so that they are able to express what they?re needing and wanting and feeling or not, refusing to participate in and to be able to do it both, ?as a therapist, I?ve facilitated an understanding of communication among those individuals. (p. 9)  Participant 6 also stressed that para-mobility devices empower the clients to do what everybody else does Assistive technology gives them support to express their feelings, promote their mobility and the opportunity to communicate. Para-mobility can provide opportunities for freedom and independence, provide opportunities for making independent decisions, and provide opportunities for inclusion and social relationships. Para-mobility empowers individuals to be able to do what they want to do. She mentioned that OTs also educate others to treat them with respect.  	 ? 91	 ?And hopefully, when you talk about the social basis for self-respect and not humiliation, so a lot of what we do is educating others around this individual as an individual is worth putting energy towards. So giving them the information and strategies to help them see this person in a very different way. To gain respect, or to have consideration and appreciate diversity? those kinds of things. (p. 9)  A few participant stated that OTs help clients to learn skills to develop and maintain friendships through educational process for both client and their social networks. Participant 8 claimed that OTs not only help their clients to develop relationship with others, but also help others to interact with them in appropriate ways.  helping patients learn to live with others, show concern for other human beings, act in a way that is behaviourally appropriate, enables others to act in a way which is behaviourally appropriate to the patient?(p. 7)  Participant 8 also mentioned an example of how OTs helped others to interact with a child who was severely burned and was having difficulty forming friendships.  The other area where I know of OT?s getting specifically involved is, it was the OT?s and the social workers at the burn unit, have produced a video, for parents to take to a school so that a child who has been badly burnt, especially if they have facial scaring, they have a video to take to introduce a classroom, and the other students and the teachers and what to expect, to answer a lot of the questions so that the kids are not terrified when they see this Johnny coming back looking like an alien and that makes a huge difference to a child being able to function in that environment and being able to maintain friendships. (p. 8)  According to some participants, developing the Affiliation Capability needs to be based on meaningful relationships and mutual respect.  OT?s really try to help people develop meaningful relationships and mutual recognition, So, I would say that that?s a big area for OTs. But, for recovery, within the recovery framework helping people find meaningful relationships and mutual recognition is part of the journey of recovery, People may end up being very isolated and not feel worthy sometimes of friendships. (Participant 2, p. 9)  Participant 5 noted that OTs help their clients to rebuild their social networks during recovery. She stated that OTs try to provide opportunities to build social relationships and friendships in new ways. But people recover from mental illness. Building that back up again, is where an OT might intervene. How do you go about doing that? How can you start to get new life? Back on track; build up that social network again. Maybe not, maybe in a different way, maybe in an altered way. But in a way that works. (p. 6)  	 ? 92	 ?iii) Advocating for their clients       Some participants asserted that improving Affiliation as ?having the social bases of self-respect and non-humiliation; being able to be treated as a dignified being whose worth is equal to that of others? is relevant to occupational therapy as advocacy role piece.  To me this is the same as Bodily Integrity. This to me is that advocacy piece..; so knowing when someone needs to draw a boundary, what they?re entitled to as a human being and so to me. (Participant 14, p. 6)   Participant 9 reported that OTs advocate for their clients and refer them to available resources to make sure that their clients are not being discriminated against.  I think just being cognisant of discrimination that might be happening and encouraging them to support services if needed if there?s discrimination that is happening or there?s some sort of power imbalance somewhere in their life, connecting it with social work, and other...I think probably more referral if needed, and sort of advocating on behalf of the client. (p. 6)  According to some participants, self-respect and non-humiliation are important issues in people with disabilities. One participant highlighted that many people with disabilities do not feel that they are treated equally. She asserted that OTs can develop the Affiliation Capability by serving as advocates for their clients in various ways. Some of it relates to advocacy like being part of organization and protecting organizations that support people?s ability to have freedom of assembly and political speech. ?as an OT, trying to help people go back to school, go back to work  or engage to activities and things they need to do and things issues like self respect, humiliation, stigma, you can?t really help them without addressing those issues as well.  And we could address them in different ways. We can address them by doing advocacy with employers, advocacy with educational system. The OTs can do that, or we can support broader movements that are like community awareness campaign, and things like that, we can support them. That?s really our role specifically...(Participant 1, p. 5)  Participant 10 noted that OTs are involved politically, for example to help ensure people with disabilities have equal rights. She mentioned that OTs advocate for treatment for their clients, and help caregivers advocate for their children to access services. we are advocates and/or help the parents advocate for their own children with respect to receiving services that their children might need as a result of being born early or with a disability of some sort. (p. 7)  Participant 6 reported that some OTs are involved in advocating at a societal level, and an institutional policy level to advocate for their clients in a respectful, inclusive way.  	 ? 93	 ?And I know of other therapists that do that on a more of societal level, more on an institutional level, where they?re going in and looking at policy changes. (p. 6)   iv) Working with clients with mental illness       The majority of participants agreed that the Affiliation Capability is relevant occupational therapy practice in mental health.  This would be something you would see a lot more in mental health and there?s a lot of OT?s who work strongly in mental health? in mental health I think this is very, very strong. (Participant 8, p. 7)   Participant 13 stated that OTs who work people with mental health issues work to reintegrate their clients into society through the development of social skills.   Well, mental health is the easy one right, because often those individuals may have some difficulties interacting, so the OT, with some populations might be working really on helping people develop socials skills, so that they can interact in a reasonable way with individuals so that they?ll be accepted by the social group that they would like to be belong to. (p. 5) Participant 2 noted that people with mental health lack of having the Affiliation Capability.  ? so OT?s are heavily involved in that and if I?m to bring into affiliation, part of that would be developing friendships, or going to social groups or just sometimes being around other people. Sometimes it?s hard for people who live with significant mental health issues to tolerate being around other people, to be able to negotiate, conflict at work, and that may be immensely stressful for people.  So it?s providing the right supports, possibilities for people within those environments and OT?s do a lot of that. To engage in various forms of social interaction, to be able to imagine the situation of another and to have compassion for that situation. (p. 9)  She also mentioned that OTs provide services that help people engage in healthy social relationships and activities, e.g., embedded in self-respect and non-humiliation.  so people who live with mental health issues are not only stigmatized within the community, but also stigmatized themselves. Often people feel less than, feel ashamed an unable to connect with people in the community. So, OT?s try to help people to take next steps around that to have the right support and structures to help people to take the next steps. So, to help people develop meaningful relationships and mutual recognition, So, I would say that that?s a big area for OT?s?(Participant 2, p. 9)  Participant 5 noted that although the Affiliation Capability is relevant to occupational therapy practice, its role in mental health services in particular, is not as visible as it might be.  	 ? 94	 ?This is one that I thought was most applicable to mental health and is one that I think is relevant to occupational therapy. One that we haven?t always perhaps discussed enough in education of OTs. (pp. 6-7)  3.4.8     Other Species Capability       This part describes the OTs? views on the Other Species Capability with respect the following two questions: Question I) What are OTs? understandings of the Other Species Capability?      In response to this question, the researcher?s analysis revealed one theme: The idea of environment. The following describes the quotes that support this theme. i) The idea of environment       A number of participants noted that Other Species Capability is about the relationship a person has with the living environment.  My general understanding is that it seems like the idea of working in the environment, so to be relevant of your impact on another things, even if they?re not people. I think it?s very important. (Participant 3, p. 9)   I think just the fact that we are part of a bigger world than just ourselves, where creation matters where plants and animals in the world, it is important, and we don?t just lure over these things we?re all sort of in it together. (Participant 9, p. 7)  Some stated that it is about sense of belonging and attachment to other creations. In other words, it is about your relationship with animals, plants, and nature. Is that kind of affiliation with the world other than people? That?s my interpretation. (Participant 13, p. 6)  Well I guess it?s being able to appreciate that we?re not the only species on this Earth, and that there are, Being able to respect and maybe foster relationships with animals and plants and nature. (Participant 6, p. 10)  Participant 7 mentioned that the concept of health is deeply affected by human-environment interactions in some client populations.  I work with, Aboriginal people, connectivity and relationships with animals, plants, the land, nature, is an important part of I think how health is perceived and experienced. (p. 9)    	 ? 95	 ?Question II) How may Other Species Capability be relevant to occupational therapy practice?       Five themes emerged from the analysis of the OTs? perspectives on the relevance of Other Species Capability to occupational therapy practice. These were: Relationship with animals and nature affects health; A client-centered perspective; A spirituality perspective; An environmental perspective; and Not the main focus of occupational therapy practice. The following describes the quotes that support these themes. i) Relationship with animals and nature affects health      For some participants, Other Species Capability is relevant to occupational therapy practice because human-animal interaction and relationship with nature affect health. I think it?s important because a lot of people talk about relationship with their animals, their relationship with nature as being important for their health and human being. (Participant 1, p. 5)  According to some participants, there were two types of remarks about the impact of human-animal interactions on health: those referring to developing social skills, and those referring to animal-assisted therapy. Some participants noted that pets, specifically dogs, can make the first connections that is needed for a therapeutic relationship. For example, participant 4 said that a dog can help autistic children develop social skills and induce a sense of clam. Well this big dog of mine is a therapy dog. So when the children come to see me, they come to see him. The children prefer animals to me sometimes, and the kids love my dog. They feel so safe and he usually lies down and they may lie down beside him, they may talk to him, they may read a book. (p. 10)   Participant 4 asserted that the effective relationship with pets depends on factors such as the cultural background of the family, the child?s characters, and the training of the dog.   I have one family from Korea, and they don?t like dogs. At all. In Korea, and so the mum and the dad are like ?OOOH, get the dog away from me!? But the little girl is beginning now to...With the dog, and that?s very interesting for her parents to see, because that?s not what they grew up with in Korea. It really depends on the family, because you have to take really good care of the dog, and so many parents are so overwhelmed with looking after their children. It depends; it really just depends on the child, and the family and the dog. You have to have a really well-trained dog, and not just any dog. (p. 10)   She also mentioned that for autistic children having pets such as dogs not only improves their social relationships, but can help keep them safe.  	 ? 96	 ?I have one kid that?s not safe in the house; he?s like a Houdini, a magician. He?ll figure out how to undo all types of locks on doors, and he runs, but he can?t speak. He?s very unsafe, but that dog is always with him. So where he goes, the dog follows. Like a guard, he keeps the child safe, so if they?re out on the streets or in town. The dog and the boy...But that dog?s job, with training, is to keep that child off the street; safe. (p. 11)   In addition, she mentioned the role of other animals such as horses in an individual?s health. She noted that horseback riding therapy can be considered as an intervention to develop relationships for children with autism, and to assist children with cerebral palsy as well.  Horses are very big; a lot of my kids do riding therapy. And the riding is not just getting on the horse and riding; it?s the grooming. Yeah, yeah so the children will become part, they?ll go in, they?ll put the bridle on, they?ll do the brushing, they?ll clean the hooves, and then they?ll ride the horse, but eventually, and these kids with autism, a lot of them have posturing difficulties, and mild to moderate motor impairment, so riding on the horse is also a way to work on their trunk and stability and balance. And you know, holding the reins and being able to initiate the horse to move. Um, and it?s also a social thing, because, you know, there?re other kids who?re on horses. And then they develop that rapport with their own horse over time, so the therapeutic riding is actually a big thing here. And, with the CP kids. And, with the CP kids, too. The riding is huge with our kids. (Participant 4, p. 11)  Participant 6 referred to the importance of animal-assisted therapy for physical disabilities. Yeah, so these are people who are in wheelchairs themselves and they use a dog to assist them. And the dogs are much more efficient than any of the tools that I would maybe provide for them. The dog is just that much smarter, and that much more intuitive. And so for that individual, it?s a really good match, right? (p. 11)  Participant 3 also mentioned the benefits of animal-assisted therapy for autistic children or people with visual impairments. I don?t generally work with animals, unless one of my clients, will have a dog due to a visual impairment, or I even have a student with autism who received a dog for safety in the community. It actually worked quite well, so far anyway. He actually has a visual impairment, as well as autism, but he was a bit of a bolter, so he would just run off and now that he has the dog, I think it?s given him sort of something to lead him, that isn?t an adult telling him what to do. So I think it actually worked out to be quite a nice relationship. (p. 6)  Some participants mentioned that not only the relationship with animals, but one?s relationship with nature, affect physical and mental health.  And I also think that for, especially with mental health, just the value of being in nature and connecting with nature. So being able to walk outside, you can use it from a physical 	 ? 97	 ?disability?s point of view ? someone being able to walk over rough ground is a different skill than walking on a flat, indoor surface, right? (Participant 6, p. 11)  Participant 1 noted that the relationship with plants may be important for a client?s health but it likely depends on a client?s age and interests.   Community gardening can be important for people?s well being...so I think it depends again like, your clientele. (p. 6)   She also addressed the impact of our connection with nature on our health.  Animals being very important to people and being in nature. Taking walks in nature, various good ways to reduce people?s anxiety, calming, meditations and things like that. (Participant 1, p. 6)  A few participants mentioned that although the relationship with nature is important to health, accessing nature for people with disabilities can be challenging. For example, participant 2 mentioned the lack of community support and poverty as challenges for accessing natural environments.  So, I guess I?m saying that people certainly have the capacity but maybe not the opportunity to function in that area because of life circumstances, because of poverty and not having a little green space which they can call their own, and if people are living in smaller communities, sometimes mental health supports are not as strong as they would be in the city. (Participant 2, p. 11)   ii) A client-centered perspective      Some participants noted that peoples? beliefs are related to their health and well-being. As client-centered practitioners, participant 5 stated that OTs are trained to identify their clients? beliefs, values and interests and respect them in management planning.  It?s totally driven by the client and then you say ?OK, that matters to them. How do we help support that?? (p. 7)  Some participants mentioned that the Other Species Capability is more relevant to occupational therapy practice from an individual point of view. They asserted that if the relationship with the living environment is something important to the client, OTs help the client to explore what they want to do, what activities are meaningful to them, and how to achieve these.  If that is something that is meaningful to the client, I will be doing that to help the patient do what is meaningful to them. (Participant 8, p. 8)  	 ? 98	 ?So if somebody feels it?s really important to walk with nature, for whatever reasons they are experiencing some kind of a barrier and I think it is important for OT to kind of explore that with them. (Participant 1, p. 5)  Participant 6 also affirmed that the Other Species Capability has relevance to occupational therapy practice with respect to pet therapy and horticultural therapy, but improving this capability depends on the clients? interests.  ?but I know of related to pets and pet therapy and horticultural therapy. If those are areas that an individual has identified as being something of interest for them, then maybe using those as a way to work with the individual on developing their interests or their skills. (p. 11)  Some noted that improving the relationship with animals is only of value with someone who likes animals and is capable of caring for them. They reported that OTs help clients to care for their pets if it is important to the client.  Sure, if that?s what the client wants to do. If they want to have a pet, yes?(Participant 12, p. 11)  So again just helping people, I mean if they have pets, helping them care for their pets, if there?s been a change in their ability to do that, and looking at different options, or if they were interested in, or if they can?t have a pet because they?re living some place that they can?t have a pet, looking at what are some other solutions or options to do that. (Participant 13, p. 6) Participant 12 mentioned that there are two considerations regarding the relevance of the Other Species Capability to occupational therapy practice. The first is to look at it from a client-centered perspective and what the clients want to do. The second is to look at it from animal-assisted therapy. There?s two ways of looking at that. One is if they are a person with a physical disability and they love their pet but they?re finding it difficult to care for the pet, then yes, I would definitely see that as a role for OT and the reason being that it?s really important to their client which I can understand because a lot of people are very very attached to their pets and they get emotional gratification from having a pet around, companionship, all of that, that stuff; So I would see that, if you?re talking about an animal that?s assisting a client, to me that?s quite different; a person has a physical disability either visual loss, or physical loss and  they need help to do regular ADL and managing in the community, and a pet is kind of like a, not a pet but a dog, an animal, is an intervention to help them do that. (p. 11)    	 ? 99	 ?iii) A spirituality perspective      For some participants, the Other Species Capability can be defined beyond the physical relationship with animals and plants, and nature. They asserted that it can be explained from the spirituality perspective. According to them, OTs are involved in enabling clients to live with other species to improve spirituality. I think for some is part of their spirituality, and spirituality is the center or our model. (Participant 2, p. 11)  Some participants noted that the Other Species Capability is related to people?s spiritual beliefs. For example, participant 7 asserted that aboriginal people connected it with spiritual beliefs, and the power they have in healing. According to her, this population believes in the substantial roles of animals and environment in healing. So, OTs need to understand their clients? beliefs and values and respect them.   Is it relevant to how I, only in, again, only in my understanding and appreciating the importance that that has for some of my clients, so connectivity to the land, and it also, for some of my clients it?s connected with spiritual beliefs around inanimate objects and the power they have in healing, so for me, it?s a matter of learning and respecting other peoples world views, how they see their beliefs? In terms of the environment that the persons and animals, people have used animals in therapy but I think it?s going beyond that, I don?t know. (p. 9)   iv) An environmental perspective      Some participants noted that the occupational therapy profession focuses on the idea of living and working within the environment. According to them, understanding the person-environment interaction is a fundamental premise in occupational therapy practice.  My general understanding is that it seems like the idea of working in the environment, so to be relevant of your impact on another things. I think it?s very important. (Participant 3, p. 9)  Oh absolutely, I think you should be able to live happily with animals, plants and nature but what?s interesting about that, and OTs in general have a very clear conception of what the environment is and it includes all of these aspects of the environment and we?re not just talking about the physical depths and things like that. (Participant 10, pp. 7-8)   Participant 10 asserted the benefits of including aspects of the environment for improving human health, for example, including living environment in a nursery unit.  So my personal view is the babies would be healthier if they had plants and little animals crawling around and so maybe someday that will happen. But I would be an advocate for 	 ? 100	 ?the benefits of those aspects of the environment for the health of the neonate and for the family and it may be that there is a compromise that is made that the waiting area where the families wait would have some aspects of this which were allowed. I want the babies to have plants in their room. I really do, I think it would be fantastic, so we?ll see what happens. (p. 7)  v) Not the main focus of occupational therapy practice       For some participants, the Other Species Capability is not consistent with mainstream occupational therapy practice.  ?it?s an important component of, it might not be the main thing we do, with as OTs. (Participant 13, p. 6)  Some participants noted that OTs are too busy to include this capability in their practices.  ?it?s not OT and we?re so busy trying to redefine who we are that if we start bringing things in like helping people interact with other species and helping them end life with normal length I think it doesn?t do our profession justice. (Participant 14, p. 7)  On the other hand, others noted that OTs do not pay sufficient attention to other species; perhaps, because we believe that human beings are more important than other species.  I think it?s not such a huge of a role because I think that there?s still a mindset that just generally in society that humans are important and plants and animals and things are not, and so I think that hasn?t been an area historically that OT has been in it. (Participant 9, p. 7)  Some participants mentioned a number of barriers for including the Other Species Capability in occupational therapy practice. For example, participant 2 said that although there are advantages for some clients having animals such the opportunity to communicate with others and love another being, there are challenges such as cost, housing structure, and nature of a person?s illness. We?ve talked about that saying that because of poverty or because of housing structures within the large cities that for people to be around animals, to care and love for animals is prohibited because the landlords, but also the cost involved. (p. 10)  Some reported that sometimes the structure-nature of an illness does not allow people to develop their Other Species Capability. For example, Participant 1 mentioned that the clients who have unstable conditions have difficulty keeping animals.  when as they were becoming a bit unstable, then they did not know what to do with the pet... (p. 6)  	 ? 101	 ? 3.4.9      Play Capability  This part describes the OTs? views on the Play Capability with respect to theses questions: Question I) What are OTs? understandings of Play Capability?      In response to this question, the researcher?s analysis revealed three themes:  Human happiness; Quality of life; and Work/life balance. The following describes the quotes that support these themes. i) Contributes to human happiness       One of the perspectives from which participants described the Play Capability was to see it as recreational activities. This perspective appeared often in interviewees? statements.  ?I think it?s important to look at play in terms of recreational activities. (Participant 9, p. 6) So this is the ability to enjoy recreation. (Participant 11, p. 6) A few participants reported that recreational activities and happiness are closely intertwined. Happiness means different things to different people. For them, happiness means the ability to pursue ?your joy?. depending on what?s important to you and what gives you joy and they can be recreational activities, they can be at home or out in the community.  It could be things you do alone or it could be things that you do with other people in a social settings. (Participant 12, p. 10)  ii) Preserves quality of life       Some participants noted that improving quality of life means helping the client to identify activities that are meaningful and recreational. ?promoting sort of quality of life connected to play?helping people clarify their values and their interests and their goals and then helping them to achieve what they want to do and what they feel they need to do. (Participant 1, p. 1)  Participant 9 asserted that recreational activities can be considered meaningful if they enhance the individual?s quality of life. She noted that the ability to engage in recreational activities support the individual?s quality of life and its well-being.  Being able to engage in leisure activities and recreational activities is huge, in maintaining a sense of self and of quality of life, and so I think that is something that is quite important. (p. 6) 	 ? 102	 ? iii) Achieves a work/life balance       According to some participants, we play various roles in our lives and achieving a balance among our roles is difficult. There is often imbalance. one thing we don?t spend enough time on I think that?s related to all of these things is the balance. So say for example: personal care, like daily routine of personal care is something that needs to be done. I could do it myself with a lot of time and energy and equipment, but I?m exhausted by the end of it and then I have no time or energy left to do other things in this area. (Participant 12, p. 10)    For participant 3, the Play Capability helps establish work/life balance. ?if you don?t have play, so to speak, in your life, then I think there is a huge part of life that is missing. (p. 7)  Participant 13 noted that achieving work/life balance and bringing joy into your life, improves happiness and life satisfaction.  So I think, I mean not just focusing on self-care and productivity but make sure that you have a balance in your life and that you?re doing things that you enjoy, that you?re having fun, that might make you laugh, and that you get other good feelings of feeling able or feeling capable. (p. 6) Participant 6 mentioned that the Play Capability not only can bring joy and balance in life, but can reduce stress and pressure. So, she stated, it can be described from therapeutic perspective as well. It?s a very important part of life. And I think looking at balance, from a therapy point of view, to be able to say OK. For individuals who may identify that as a problem that they don?t have enough of that in their life, or that they don?t have the skills or the abilities to develop the areas that they want; to be able to say ?OK, alright, you can?t walk now, but you can still go sailing, or go hiking, or there?s other ways of doing that.? And then with kids, just play-based therapy, right? (p. 11)  Question II) How may the Play Capability be relevant to occupational therapy practice?        Three themes emerged from the analysis of the OTs? views about the relevance of the Play Capability to occupational therapy practice. These were: Pediatric practice; Working with people with mental health issues; and Its important for everyone. The following describes the quotes that support these themes. i) Serving as a primary therapeutic approach in pediatric practice  Many participants asserted that Play is key for children development and participation. They emphasized the importance of play-based therapy in pediatric occupational therapy. 	 ? 103	 ?Oh, that?s one for kids, that?s a key. With kids, just play-based therapy, right? (Participant 6, p. 11).  Occupational therapy is a play-based functional model. Everything, I mean. People who don?t know what I do just think ?Oh well, you know, she just plays with kids all day!? And I do play with kids all day and it?s the vehicle through which we help develop the new skills, right? (Participant 4, p. 9)  I think it?s often emphasized in the pediatrics practice where play is so important as part of the life development stages. (Participant 9, p. 6).  A number of participants reported that interactions with children are largely through play. For children, as they mentioned, play is a way they learn about themselves and their world.   Play: big, very big. Children have to play, we play through learning. So absolutely, probably up there with Bodily Integrity, Bodily Health, Senses Imagination. I mean, play is how children interact, it?s how they learn. (Participant 4, p. 9)  Oh I think OTs have a huge focus.  I mean pediatric for sure, I mean it?s probably one of their major focuses, making sure children can engage in play and do engage in play because they learn so much. (Participant 13, p. 6) Participant 3 asserted that play is a way to connect body and mind, and it is necessary for childhood development and growth. From her perspective, it is also seen as a way to enable therapists to build therapeutic relationships.  Play, I think it?s so important?I just think play is so key to the development of gross motor skills, fine motor skills, visual motor skills, social development, everything.  Imagination, desire to learn, and everything. I think it?s?And I think, really, that?s why I enjoyed working with children so much. It?s because all of our interventions, usually, as much as we can anyway, are play dates. And if the child is not enjoying it, then we are missing out on something. (p. 7)   Some mentioned the Play Capability also can be considered as a way of enabling parents to connect with their children. Participant 4 noted that in children with severe disabilities, such as autistic children, the Play Capability can be considered as the primary level of connection that affects the relationship between parents and child. Well a lot of my work is helping a parent understand why their child does what they do, so it?s being able to?for example a child that just flips, can?t sustain any kind of eye contact?so these children are non verbal, they have no language skills, they have no eye contact, they?re completely self absorbed, completely withdrawn, unable to really show any kind of interest in a parent figure, for example, and so then we have this play based activity where the mother is taking the child?s lead and following the lead in something that they may be interested in, the practical application is that she?s beginning  to have a 	 ? 104	 ?different way of understanding  how her child is being in the world and she can start to take some steps to understand that differently, and know how to engage with her child to have maybe for the first time in her life, some sort of nurturing mother role, ?(Participant 4, p. 5) Some participants reported that OTs provide a range of activities to engage clients of all ages and abilities. Participant 4 noted that OTs modify activities in various ways to be appropriate and accessible for their clients by breaking down activities, adapting the environment, and using the simple and clear instructions. A lot of my kids don?t know how to play. You know, if you?ve got a kid who?s got a severe motor impairment, he doesn?t know how to interact with objects or people, because of his physical challenges, right? So, it?s about adapting play. To being able to produce that higher level of learning, and with my children with autism, they don?t have a meaningful relationship to objects. They don?t know how, it doesn?t mean anything to them. So it?s being able to develop those concepts, through umm, I use movement a lot because those kids really like to move, so I use swings, and different types of suspended pieces of equipment, because they like to move, and then we would start to add onto that with something simple like throwing a beanbag and knocking over a tower, while they?re moving. And um, starting to develop some meaningful relationship to play. (p. 9)   Participant 10 indicated that play not only affects children? developmental growth and improves social skills, but it was thought to contribute to family happiness.  Play, pretty obvious, I?m a pediatric person, being able to laugh and play and have lots of fun, I think is super important for families. And for the neonates, we don?t have play until they?re a little older, but if they happen to stay in the nursery, we provide access to toys, we educate parents about what toys would be appropriate to promote development, that kind of thing?(p. 7)  ii) Serving as a therapeutic approach when working with persons with mental health  Some participants mentioned that the Play Capability in terms of recreational and meaningful activities is important for improving mental health. Participant 5 stated that the Play Capability can support individual?s well-being.  Again, I think it?s very important. And so, it?s part of what I think in mental health, we try to integrate into some of our treatments by making some of the learning part of what we did fun. Like I can remember in our group about stress management, we always connected it to an activity, a game or something we could play. To help people remember the actual activity and the learning of what we were doing. So an example might be, when we talked about stress and having all these balls to juggle of family, home, finances, all the things that can be very stressful. We did this juggling activity and it was interesting because people remembered the learning of that group, based on the juggling, based on the play. So it was very interesting. So it is relevant, I would think. (p. 7)  	 ? 105	 ?Participant 8 noted that improving the Play Capability is an important part of mental health occupational therapy practice. In mental health, in extended cares, in other places, it is done a lot more, but it is supposed to be a very significant part of OT. It?s a very significant part of life. (p. 8)  Participant 14 also asserted that recreation or leisure activities are important in mental health practice for establishing effective therapeutic relationships between the clients and the therapists, and other effects.  I think this one is definitely important for occupational therapy, mostly for building a therapeutic relationship. I don?t actually enjoy the recreation or leisure component of my work, but obviously working in mental health is very important as well as other, it expands other areas as well. I just think that?s a way you get in with a client, you go through the route of what?s meaningful to you, what do you enjoy and then you can actually work, and it?s different because other professions want to be seen as very goal focused and they talk about medications and they?re talking about housing, and we?re talking about what?s important to you, so we cannot avoid the recreational activities, but I look at it like in the CMOP. Obviously leisure is there, I don?t like leisure but I use it as a means to an end. (pp. 6-7)  iii) Its important for everyone      The majority of participants stated that the Play Capability is not only important for pediatric and mental health occupational therapy practices, but it is important across occupational therapy settings and clients. ?I think it?s important for everyone to be able to laugh, enjoy life and to do something that is joyful just for the sake of doing, not because it?s expected, or they have to do this before they can do that. (Participant 6, p. 11)  Some participants asserted OTs familiar with the Play Capability and they use it in a range of practice settings.  ? OT always, I think, been very much interested in trying to understand people?s interest and try to facilitate, their ability to engage in the things they want to do in recreation, in pleasure, and in enjoyment, things like that. So that?s one that I think that we?re pretty familiar with it. (Participant 1, p. 1)  ?[Play Capability] is about social connection, it?s about engagement, it?s about helping somebody to develop their own identity again, and these are all areas OTs are involved in. So, recreation, participating in recreational activities is definitely a focus for OT and the notion of enjoyment and developing awareness and language around enjoyment I think. (Participant 2, p. 12)  	 ? 106	 ?Participant 13 mentioned that play is not only a focus of pediatric occupational therapy, but it is important for older adults to augment happiness. According to her, OTs can adapt activities for people with cognitive and physical disabilities to promote fun.  Oh I think OTs have a huge focus.  I mean pediatric for sure, I mean it?s probably one of their major focuses, making sure children can engage in play and do engage in play because they learn so much, and then I think for the older adult, again, what kinds of activities or leisure activities are of interest to you and that you can participate in and that you feel good about it and then in what role. ?So again, I think we have a huge role to play. We can talk about physical capability and cognitive capability and kind of match that with interests and help people kind of explore and come up with their ideas of how they?re going to have fun and what are they going to do with the rest of their life, kind of thing. (p. 6)  Some participants mentioned that OTs have a role in enhancing the Play Capability. They stated that OTs need to consider play across ages as it has a important role in promoting health.  It?s a really interesting one, to have it in this list, in terms of looking at this list as basic human rights, the right to play, the right to laugh, the right to enjoy recreational activities for all ages, not just for children, I think it?s a really interesting concept, and I definitely think it?s something that we need to look at beyond pediatric populations, especially that  we?re going to have more aging people who are maybe not  working full time or not working, the role of recreation in promoting health. I think OT?s have a big role to play in that, so I think play across the ages is a really important concept. (Participant 7, p. 8)  And I think it is also very important through all aspects of occupational therapy, even with the adult population, I think the whole idea of play or leisure kind of gets missed sometimes because we are so focused on work and activities of daily living ? self care, and all those things that are important, but if you don?t have play, so to speak, in your life, then I think there is a huge part of life that is missing. (Participant 3, p. 7)  Participant 10 noted that play activities can be used in various occupational therapy settings including acute care. We?re one of the few areas of the hospital that still does a lot of leisurely activities in acute care, but then our patients can be in there for months but in most OT areas of acute care unfortunately this has been lost because it comes well after survival and all that, most OT?s are allowed to do now is survival. The patient has had their surgery, now get them out.  Now, you worried about is that they can get home, get on the toilet, get them food, in and out of bed and not fall over or hurt themselves or starve, so leisure, someone else has to deal with. (p. 7)    A few participants asserted that despite advantages of developing the Play Capability in occupational therapy practice, it may be precluded in some settings. For example, participant 2 	 ? 107	 ?cited that a therapist-consumer relationship makes consumer expectations high, so it may be difficult for clients to take play seriously.  I think we don?t pay enough attention to play, to be perfectly honest. And I thought this were a long, long time and I think in that interaction with people often we are a little bit restricted by, historically by our relationships. Being in a therapist-consumer relationship, I see that changing with the recovery model that we can become more authentic with people and have an opportunity to but I think that is a very powerful therapeutic tool that we don?t maybe pay enough attention to. (p. 12)  Participant 9 also mentioned workload issues may contribute to OTs paying less attention to the Play Capability.  In adults, we often don?t have time for it, just that things are so busy and there are so many people to see. (p. 7)  Some noted that it is important to have some guidelines to include the Play Capability in occupational therapy practice. So this is a good thought that play should be part of what we do. How do people then put that into their practice? It either doesn?t happen. They say ?we don?t have time; it?s nice in theory, but we don?t have time.? So it?s getting beyond some of these roadblocks that tend to put into practice. (Participant 5, p. 7)  3.4.10     Control over One?s Environment Capability  This part describes the analysis of the semi-structured interviews with respect to the two questions: Question I) What are OTs? understandings of Control over One?s Environment Capability?        In response to this question, the researcher?s analysis revealed three themes: Decision-making; A basic human right; and Political opinions. The following describes the quotes that support these themes. i) Decision-making      One of the perspectives from which a number of participants described the Control over One?s Environment Capability was the capacity for decision making.  Being able to recognize that the individual does, is empowered to make decisions over things and decide politically or decide about sort of their material environment, just being able to have the ability to make decisions for themselves, and not have someone make those decisions for them. (Participant 9, p. 7) 	 ? 108	 ?I would say that the idea that people are able to participate in their decisions making, in their treatment decision making?(Participant 1, p. 6)  Some participants mentioned that some people do not have control over their environments and are unable to make decisions.  My sense is that many people living in mental health issues feel that they don?t have a lot of control over their environments?(Participant 2, p. 12)  ?sometimes when people becomes patients, family makes the decision, people in authority make decisions for them. They start to lose the power in making decisions?(Participant 1, p. 6)  ii) A basic human right      For some participants, the Control over One?s Environment Capability is about human rights. Here, basic human rights include both citizenship rights and basic needs. It means as citizens, everyone has a right to exercise control over his/her environment and meet his/her basic needs. This perspective appeared often in interviewees? statements. There were two types of statements about basic human rights: Those referring to basic rights, and those referring to basic needs. ?this reminded me the concept of citizenship. So ?being able to participate effectively in political choices?- I mean, again, there are good human rights. (Participant 7, p. 10)  So this is being about being able to own property and participate in political events, having the right to seek employment on an equal basis so it means that you wouldn?t be discriminated against, so again I think it?s largely human rights. (Participant 11, p. 5)             It?s the idea that you feel like you have that as part of your human right (Participant 3,                p. 10)  Some participants mentioned that it is necessary to ensure that people of vulnerable populations can access to resources to address their basic needs.  but I?m not expecting my clients to do that when they?re in a vulnerable position, when they?re in a vulnerable position they have to get their immediate needs met. (Participant 12, p. 11)  So part of it, was making sure the individuals had the needed supplies and resources, food, shelter, meaningful occupation, that kind of thing? a lot of these individuals need diapers, they need feeding tubes, they need feeding supplies...Very basic needs! (Participant 6, p. 12)    	 ? 109	 ?iii) Political thought      Some participants mentioned that the Control over One?s Environment Capability is about political thought and political choices.  So, and it has more of a political connotation to it. (Participant 13, p. 7)    So, being political or having influence politically around the policies and procedures that support participation. (Participant 6, p. 12) Some participants indicated that the Control over One?s Environment Capability implies the right to privacy and freedom of expression consistent with political thought about being able to govern, contribute, and participate in your environment.  So, all of us need to be able to feel like we can speak up and impact political choices. (Participant 3, p. 10)  So again, you should be able to choose who?s governing you and be able to have free speech and participate in politics if you so choose and that you should also be able to hold property?that?s important. (Participant 10, p. 8)  Participant 3 noted that political choices and costs affect the delivery of health care and the delivery of education as well. ?identify more with the political side of things I think in this capability, just because I think that you do need to feel like you have some sense of participation and choice in political outcomes and if you don?t agree with things that you are able to speak up without feeling like that it?s going to be detrimental to you and I think that political choices impact the delivery of health care and the delivery of education and both of those areas are so significant in my area of work. (p. 10)   Some participants noted that Control over One?s Environment Capability is about political thought, but OTs do not tend to work from this perspective. They mentioned that OTs are not usually politically active in relation to their professional responsibilities. That is, OTs should stay out of politics, professionally. (Participant 8, p. 9)  The political one, I really thought, was not very relevant to OT.... So, which again, I think is very theoretical, and it isn?t very practical. (Participant 5, p. 10)  Question II) How may Control over One?s Environment Capability be relevant to contemporary practices of occupational therapy?       Three themes emerged from the analysis of the OTs? perspectives on the relevance of the Control over One?s Environment Capability to occupational therapy practice. These were: 	 ? 110	 ?Developing decision-making; Helping clients gain and retain employment; and Advocating for their clients. The following describes the quotes that support these themes. i) Developing decision-making       Some participants claimed that OTs have a major role in enabling clients to exercise control over their environments and empower individuals in order to independently participate in their society and make their own decisions. Participant 1 noted that one of the OTs interventions for the Control over One?s Environment Capability is to empower people with disabilities in decision-making process. ? and I think that I guess in my practice that was one of the things to try to ensure that people becoming empowered in the decision making process of their lives. (Participant 1, p. 6)  I think it comes up primarily when, when it comes to competency assessments, and is the person able to make those decisions and have control over their environment, when often they may not be due to cognitive impairment, or dementia or whatever it might be, so I think that?s where often OT does come in. (Participant 9, p. 7) Participant 2 stated that occupational therapy interventions include developing awareness, self-determination, and decision-making to help clients exercise control over their environments.  My sense is that many people living in mental health issues feel that they don?t have a lot of control over their environments, and OT?s often help people articulate what are they unhappy about, or what are they happy about within their current situation, developing an awareness and then developing the self-determination to effect change if needed. So it goes from developing an awareness to a place of shared decision-making, to a place of self-determination?(p. 12)  ii) Help clients gain and retain employment      Some participants noted that people with disabilities do not have equal opportunities to seek employment. They claimed that OTs play important roles in helping their clients seek employment.  That?s a huge piece. We work, we help people return to work or to find productive activities, be it paid or unpaid, I guess this is kind of looking more probably at a paid, on a paid basis but, I think OTs work in that area for sure?(Participant 13, pp. 7-8)  Participant 2 also said that there is a shortage of employment opportunities for people with mental illnesses, and a shortage of OTs involved in this area. 	 ? 111	 ?Only approximately 15% of people who live in significant mental health issues actually work at this point, part-time for the most part. We know we can improve that to 46, even 60% with the right interventions, and OTs are involved in that. (p. 13)  Some participants also indicated that equal access to employment opportunities is important, people are not equal as they have varying abilities. So, it is important to be realistic about disability issues.  Employment on an equal basis with others is a contradiction in terms.  A person, who is disabled needs or has a right to work but they need to be realistic in doing work that their disability doesn?t affect. A person in a wheelchair does not have a right to be a fireman because a fireman has certain physical capabilities that they need to carry out. Access to work, OT?s get involved in vocational rehab, in helping a person figure out what they can do and helping prove to employers they are able to do these things, and they also get involved when they know what the job needs in helping a disabled person get to that physical or mental ability but that?s not about equal rights, that?s about maximizing the persons function. (Participant 8, p. 10)  Yeah, I thought that was important and I thought, certainly, but we?re not all equal, we?re different and so people should be able to seek employment on wherever they want to. But it doesn?t mean they necessarily should gain employment in every...(Participant 5, p. 10)  iii) Advocating for their clients       The majority of participants stated that OTs have a role in promoting their clients? capabilities to exercise control over their environments by advocating for them. They asserted that OTs advocate for the basic needs of their clients, and their access to the services and resources.  This one also speaks advocacy for me?(Participant 14, p. 7)    I think obviously that?s a big role that OTs could play a role in promoting, but also in informing, in terms of advocacy?(Participant 7, p. 10)  ?that I think it?s a big thing for children and for adults and for OT in general that we need to be able to, if you feel like you ?re going to be persecuted for speaking up and for fighting for something, or if you see that there?s something in health care which isn?t funded right now, then we should be able to advocate for that. (Participant 3, p. 10)  Participant 6 described that OTs advocate for their clients in two ways: first, by building their skills and by empowering them to advocate for themselves:  I think a big part of that was political and recognizing and a big part of it is the people themselves organizing and being able to speak up for themselves around ?this isn?t 	 ? 112	 ?acceptable, right? ? that for me, it?s a matter of supporting the individuals to allow them, if that?s their interest to be able to do that. And I have a couple of individuals that I support that have been part of government committees that are listening to them around how should we change things. So I had a very small role and I was able to set up the computer so that they could use the computer independently. And now they?re using the computer for written output so that they can participate in these committees and schedule. So, it?s a small little part, but I?m facilitating their capability to be political. (p. 12)    Second, as she mentioned, OTs advocate for their clients by accessing resources and identifying financial and other resources for them.  And then also, around the material, I think a big part of, now, I think a lot of the individuals I work with are supported through the CLBC (Community Living BC Program, which has so many issues) and a big part of that is that they just don?t have the funding required to support these individuals and the lifestyles that they have been saying that they will support them in. So, my job is to advocate for my clients and to say ?listen, the equipment they need, the supplies they need, the kind of housing situation they?re in...So you know, from a material point of view, sometimes it?s like jumping up and down and saying this is not OK! We need to keep working on a solution that?s going to be better. And I can do it individually for my client or I could as an individual be involved in voting for the government, or raising those issues around ? this is appalling! The decisions you?re making around these major life issues for these individuals where they already have way too much on their plate already. So I definitely think that?s very applicable. (Participant 6, p. 12)    Participant 3 noted that OTs have a major role to assist clients advocate for access to OT services, funding, and other resources.  I guess it?s more with the kids that I work with. There is sometimes funding through our general medicals unicare, but there is a lot of things that aren?t funded, and so we are looking at the advocacy side of things and putting in justifications for a piece of equipment that may not fit the typical description or maybe it needs to be customized or, I mean, even in there lies more of, like, medicines or other just funding, I guess. It?s more of an issue, and the funding of programs and things too. So, all of us need to be able to feel like we can speak up and impact political choices. (p. 10)  Participant 10 mentioned that OTs support families to advocate for their children?s needs. Occupational therapists might provide guidance to the families to be politically active. Politically, I think we can support clients to pursue political avenues if that?s going to help them, and we can be political ourselves if we want to be. In the nursery, we?re kind of down, ?yes, you can have a blanket and a toy and a mirror?.  We do support families to talk to their members of parliament or their MLA?s about advocating for their children?s needs.   They actually have more power than we. As OTs, we might provide 	 ? 113	 ?guidance, and typically it?s to guide the families to be politically active, in my setting anyway. (Participant 10, p. 8)  Participant 4 mentioned that OTs advocate at various levels: individual, family, school board, provincially, and nationally. Yeah, I think that?s very much what we do. And again, for the kids that I see, it?s being able to make sure they have access into writing programs, or being able to be included into typical school programs with peers. So it?s enabling their independence to participate fully within their community. And we have all kinds of laws and umm, school policies that promote the inclusion of all kids within the school boards, on a provincial level, on a national level. Certainly with parents, a big thing that I do is help parents become more knowledgeable so they can go into the school and say ?This is my child?s disability and this is what we can do to help him manage more successfully in the classroom.? So parents being able to understand how that disability impacts their child and to be able to know how to help the teacher, for example, work with their child. (p. 10)  Participant 12 asserted that OTs help advocate for changes in external sources. She mentioned that OTs advocate for their clients at an organizational level to identify efficient ways of accessing services and resources. Now in the bigger picture, as an OT, I probably have a responsibility to advocate for better services or better processes, but I?m not expecting my clients to do that when they?re in a vulnerable position. ? the way I think that we need to advocate is to say; this is making me inefficient and not very productive and I can?t provide as much OT service to my clients because I?m tangled up in all this other stuff. So, also my clients in the meantime are living in risky situations without this or not very good situations while they?re waiting for you to decide whether or not you are going to give them this particular thing, service, so let?s get together and figure out how we can smooth it out for everybody so the clients get served better, our services, our public services are more efficient.  Now, if it?s something really big, then we have to work with our organizations and see what our organization?s mandates are and see if they can help. (p. 12)  Finally, some participants noted that OTs can play a major role for enabling individuals to exercise control over their environments by identifying effective occupational therapy interventions and resources to fund them.  I think OTs have a much broader role and could contribute in a lot of areas, but because they haven?t traditionally in those areas, it?s difficult to make inroads, and unless there are models for them to consider?I think OTs could do a lot more and need to do a lot more, we just have to find a way to get it in the system?(Participant 12, pp. 12-13)    	 ? 114	 ?3.4.11      General Views       This section describes the OTs? general views about the CHFCs with respect to their general understandings and perceived relevance of these capabilities to occupational therapy philosophy, models, and approaches with respect to the two questions: Question I) What are OTs? general senses of the ten CHFCs?       Six themes emerged: Constitutes a novel approach; Encompasses a range of occupational therapy practices; More theoretical than practical; More related to mental health practice; The construct of function is common to the CHFCs as well as occupational therapy models; and They overlap. The following describes the quotes that support these themes. i) A novel concept      Almost all participants mentioned that they were unaware of the Capabilities Approach or the ten CHFCs: Yeah, I?d never heard of it. (Participant 5, p. 1) Well, I?ve never heard of it before. (Participant 7, p. 1) I think I don?t know about it. (Participant 2, p. 1) ii) A range of occupational therapy practices      The majority of participants mentioned that the ten CHFCs are applicable to occupational therapy practice. According to the participants, although the Capabilities Approach was described as a new concept in occupational therapy, the principles embedded within the ten CHFCs were not seen as new ideas. So What I am saying is that I see, I feel that it is applicable, yes, and at the same time I feel that some of I think that many of these things we kind of de-familiar, not familiar to OT? I think the concepts are not necessarily new. They?re framed maybe differently, for sure, but I can see bits and pieces in them in the various models. (Participant 1, pp. 1-2)  I think some of the terminology is different but I think the ideas are related, definitely and to some extent?(Participant 10, p. 2)  Some participants affirmed that the CHFCs encompass many areas of occupational therapy practice. For them, it is a broad perspective that reflects many areas of occupational therapy practice.   When I had a glance over it, it seems to encompass all the different areas that we would be looking for. It seems like as far as our models that we use, it would be like a conceptual model that we kind of have but a little bit more detailed, so I think it?s 	 ? 115	 ?something we would possibly use in practice but it?s interesting to see it all written out. (Participant 14, p. 1)  Well, I guess what I would say is that all areas of practice have clients associated with them. (Participant 10, p. 8)  A number of participants mentioned that CHFCs are close conceptually to occupational therapy conceptual models, and reflect shared models and approaches. It does fit in quite nicely with a lot of the models of OT, where you?re looking at physical, emotional, spiritual, all the different arenas of OT that practice that we look at and the different approaches. (Participant 9, p. 2)   .. so I do see that there is a fit with occupational therapy?Probably philosophy and approaches, so you know I mean if you look at some of our models?(Participant 13, p. 1)  iii) More theoretical than practical      Some mentioned that although the majority of participants asserted that CHFCs are relevant to occupational therapy models and approaches, they described them as more theoretical than practical constructs.  So, which again, I think is very theoretical, and it isn?t very practical. So in a practical sense of what an occupational therapist does, I didn?t see. (Participant 5, p. 8)  So I?m looking at this more from an academic than as a clinician. (Participant 2, p. 1) Some participants were also concerned about how the CHFCs could be applied in practice.   ? but there is no real guide to action. How do we apply it in services? (Participant 1, p. 7)      I?m not sure how it would guide my practice. As a theoretical?s perspective around social justice, I think one of the challenges is how do we enact social justice, so we have these ideas around social justice. (Participant 7, p. 2)  ?it kind of delegates how we should approach working with our clients, but it doesn?t necessarily guide practice as much as some of the other models do. (Participant 14, p. 1)  iv) More relate to mental health practice Some participants who work in mental health practice agreed that CHFCs are related to occupational therapy in the mental health area more so than other areas. They mentioned that the CHFCs include important issues in mental health practice. 	 ? 116	 ?.. [CHFCs relates to] models in mental health. Now, when I look at some of the more psychological models and theories, I think this relates fairly closely to more of a psychological model, a large part of it. (Participant 5, p. 2)    ... OTs are working on that already. In mental health a lot of these things I think are very, as I am saying, it might be important also to talk to people who are working in physical rehab, because in mental health, this is very much a big part of what we?re doing. (Participant 1, p. 3)  That?s the issue I think is very common, like we have the same thing with recovery philosophy in mental health. The recovery philosophy we know that people and a lot of these things are actually reflects recovery philosophy as well. (Participant 2, p. 7)   v) Function is common between CHFCs as well as occupational therapy models      A number of participants acknowledged that OTs enable clients to enhance occupational performance of daily activities. They mentioned that ?function? is a shared goal between the CHFCs and occupational therapy approaches and models.  I do see a fit with occupational therapy? you know, that we?re helping people develop, maintain or regain the capabilities to function effectively in society. (Participant13, p. 8)   According to some participants, OTs attempt to maximize the persons function and to compensate for loss of function.  I think in general, it fits quite well with occupational therapy because I think, our big thing is that we want to be client-centered and that we want to find things meaningful to an individual and that are function based. (Participant 3, pp. 1-2)  Participant 5 indicated that the CHFCs constitute a basic theory of human function.  ?So what I thought was that this was a theory that could overarch our understanding of basic human function and interaction with others ?then obviously that might be much more of a functional issue that OT might address in practice. (p. 1)  Participant 2 noted that the CHFCs aim to restore function as much as possible. To me it is very related to recovery, very much related to recovery,.., because it is about function and it is about best possible function that somebody can have, so that?s the end point is where I see where they come together?(p. 2)   vi) CHFCs overlap       Some participants described that the CHFCs are closely interrelated, with many overlapping each other. 	 ? 117	 ?I think it sounds great, because they are all things that are quite important to look at in an individual?s life and they all impact on a person. So if someone is having issues with bodily integrity then it will impact all the other areas. So, they?re all very interlinked. (Participant 9, p. 1)  The only other thing that I was thinking of, they are all obviously interconnected. (Participant 7, p. 9) For example they asserted that there is overlap between the first and the second capabilities (Life and Bodily Health), and between the fourth and the fifth (Sense, Imagination, and Though, and Emotions) capabilities.   Question II) How CHFCs may be relevant to occupational therapy philosophy, models, and approaches?      Overall, the ten CHFCs were described as being highly relevant to contemporary occupational therapy practice. Thus, the participants were asked how the ten CHFCs may be related to current occupational therapy philosophy, models, or approaches. The results describe the ten themes that emerged from the analysis of the OTs? perspectives on the relevance of the ten CHFCs to occupational therapy practice. These were: The Canadian Model of Occupational Performance; The Human Occupational Model; The Person Environment Occupation Model; A client-centered approach; A recovery philosophy; A framework for health and wellness; A human rights model; Maslow?s hierarchy of needs; A social justice model; and An advocacy approach. The following describes the quotes that support these themes. i) Canadian Model of Occupational Performance       Many participants stated that there are similarities between the Canadian Model of Occupational Performance model and the CHFCs.  I can see various parts of what?s being said here in the Canadian model of occupational performance?(Participant 1, p. 3)  Yes, absolutely. I think that, I haven?t really looked at it closely to see how it maps but on the Model of Occupational Performance for example a number of these areas would definitely be huge environmental areas that would impact the person?s occupation for sure. A number of them would be in the inner-circle or the inner-triangle related to the person?s, probably cognitive and effective areas, maybe physical as well...(Participant 12, p. 1)   Some noted that the CHFCs focus on more areas than the Canadian Model of Occupational Performance areas (self-care, productivity, and leisure). They asserted that the CHFCs help OTs 	 ? 118	 ?to analyze a client?s status in greater detail than the Canadian Model of Occupational Performance. There are some that focus more on the areas that we look at like the self-care productivity and leisure.  I think that this kind of expand those, like explodes each of those, you know like self-care being