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The experience of activities and their meaning for people who live with schizophrenia : a phenemenological… Casey, Regina 2013

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THE EXPERIENCE OF ACTIVITIES AND THEIR MEANING FOR PEOPLE WHO LIVE WITH SCHIZOPHRENIA: A PHENEMENOLOGICAL INVESTIGATION    by REGINA CASEY   Diploma in OT St. Joseph?s College of Occupational Therapy Dublin, Ireland, 1986         MA Royal Roads University, Victoria BC, Canada, 2006  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Rehabilitation Sciences)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) August, 2013  ? Regina Casey, 2013 ii  Abstract BACKGROUND: This study aims to answer the call to advance knowledge within the occupational therapy and occupational science literature to explore the experience and meaning of occupation/activity participation from both ontic and ontological perspectives.   OBJECTIVE: This phenomenological inquiry sought to understand the meaning of activity participation for 10 adults who live with schizophrenia on the west coast of Canada  METHODS: Rich descriptions of people?s lives were collected by means of multiple in-depth interviews over a period of two years. The analysis process was guided by the hermeneutic writings of Husserl (1859-1939), Heidegger (1962), and Gadamer (2004), and drew on occupational science and occupational therapy concepts such as doing, being, belonging and becoming (Rebeiro, Day, Semeniuk, O? Brien & Wilson, 2001; Hammell, 2004; Wilcock, 1998). Analysis involved writing, reflecting and re-writing the findings such that themes and aspects of meaning showed themselves over time.   RESULTS: Three interrelated themes that show aspects of meaning are presented. They include: (1) activities of citizenship, recognition and skill development for social inclusion, (2) activities for health and well-being and for justice, and (3) activities that resonate with the call to be ?more fully human.? Findings provide understanding of the ways in which others can influence the experience and meaning of activity participation. Study findings also provide a hopeful discourse regarding participants? engagement in productive activities.  CONCLUSION: This study adds to the literature as it analyses the range of activity participation over a two year period for participants. It is unique in that it is the first study within the field of occupational therapy and occupational science to inquire about the meaning of activities related to citizenship with and for people who live with schizophrenia. The conclusions are that: (1) activity participation is a source of hope and is influenced by notions of inclusion and justice, (2) all activity has meaning, positive and/or negative and (3) meaning in activity is connected to, and has implications for, meaning in life and well-being. This work opens space for further dialogue and research on the topic.  iii  Preface  This research was approved by the University of British Columbia, Behavioural Research Ethics Board (Reference number: H10-00451) on April 12, 2010. Institutional Approval was from the Vancouver Coastal Health Research Institute (Vancouver Community) (Reference number: VC- 10-00). I wish to acknowledge the collaborative efforts of my committee. The primary intellectual contributions were made by myself (Regina Casey), who wrote, conceptualized and developed the research protocol, analyzed the data and wrote this manuscript with feedback from my committee. I wrote the following manuscript. It was based on a paper written for a graduate level course that I completed.  It is referenced in chapter 1 of this manuscript. Casey, R. (2008). Towards promoting recovery in Vancouver community mental health services, BC, Canada. International Journal of Psychosocial Rehabilitation. 12(2), from the International Journal of Psychosocial Rehabilitation website:  http://www.psychosocial.com/IJPR_12/Promoting_Recovery_In_Vancouver_Casey.html   iv  Table of Contents Abstract .......................................................................................................................................... ii Preface ........................................................................................................................................... iii Table of Contents ......................................................................................................................... iv List of Tables ..................................................................................................................................x List of Figures ............................................................................................................................... xi List of Abbreviations .................................................................................................................. xii Glossary ...................................................................................................................................... xiii Acknowledgements .................................................................................................................... xiv Dedication .....................................................................................................................................xv CHAPTER  1: SETTING THE STAGE ................................................................................................ 1 1.1 SCHIZOPHRENIA ........................................................................................................... 1 1.1.1 Schizophrenia and the course of the illness .......................................................... 2 1.1.2 A glimpse of the experience ................................................................................. 3 1.1.3 Relationship to the study ....................................................................................... 4 1.2 RECOVERY ................................................................................................................... 4 1.2.1 Background ........................................................................................................... 4 1.2.2 A short history....................................................................................................... 5 1.2.3 Recovery conceptualizations ................................................................................ 5 1.2.4 Linking recovery to social inclusion and citizenship and rights ........................... 6 1.2.5 Formalizing recovery for measurement ................................................................ 7 1.2.6 Recovery approaches to skill development, managing illness and well-being ...................................................................................................................... 8 1.2.7 Recovery and meaning .......................................................................................... 8 1.3 POSITIVE PSYCHOLOGY .............................................................................................. 10 1.4 PSYCHOSOCIAL REHABILITATION .............................................................................. 11 1.4.1 Psychosocial rehabilitation approaches and strategies ....................................... 11 1.4.2 Psychosocial rehabilitation and meaning ............................................................ 12 1.5 OCCUPATIONAL THERAPY AND OCCUPATIONAL SCIENCE ........................................... 13 1.5.1 Occupational therapy approaches ....................................................................... 14 1.5.2 Schizophrenia in the occupational therapy and occupational science literature .............................................................................................................. 15 1.5.3 Phenomenological studies that set the stage for this research ............................ 16 1.6 MEANING IN ACTIVITY .............................................................................................. 17 1.7 OVERVIEW OF THE THESIS ......................................................................................... 18 v  CHAPTER  2: METHODOLOGY .................................................................................................... 20 2.1.1 Philosophical positioning .................................................................................... 20 2.1.2 Phenomenology................................................................................................... 22 2.1.3 Edmund Husserl and the origins of phenomenology .......................................... 22 2.1.4 Core contributions ............................................................................................... 22 2.1.5 Martin Heidegger ................................................................................................ 23 2.1.6 Core contributions ............................................................................................... 24 2.1.7 Hans-George Gadamer and the contribution of hermeneutics ............................ 26 2.1.8 Max van Manen and the four existentials ........................................................... 28 2.1.9 Making the case for hermeneutic phenomenology ............................................. 28 2.2 METHODS .................................................................................................................. 29 2.2.1 Ethical considerations ......................................................................................... 29 2.2.2 Research question and objectives ....................................................................... 30 2.2.3 Recruitment ......................................................................................................... 30 2.2.4 Inclusion and exclusion criteria .......................................................................... 31 2.2.5 Pre-interview meeting or screening .................................................................... 32 2.2.6 Participants .......................................................................................................... 32 2.2.7 Orientations to the phenomena ........................................................................... 33 2.2.8 Pre-proposal collaboration .................................................................................. 35 2.2.9 Interview procedure ............................................................................................ 35 2.2.10 Narrative interviewing ........................................................................................ 36 2.3 ANALYSIS .................................................................................................................. 38 2.3.1 Analysis phase one .............................................................................................. 39 2.3.2 Analysis phase two ............................................................................................. 40 2.3.3 Deepening understanding through anecdotal narrative ....................................... 41 2.3.4 Additional considerations for phase one and two of the analysis ....................... 42 2.3.5 Reflection of how I shaped the data analysis process ......................................... 43 2.3.6 Trustworthiness ................................................................................................... 44 2.3.7 How do these criteria relate to others cited in other phenomenological research? ............................................................................................................. 47 CHAPTER  3: MEANING AND DAILY ACTIVITIES IN CONTEXT .................................................... 48 3.1 SECTION 1: A BRIEF INTRODUCTION TO PARTICIPANTS .............................................. 48 3.2 SECTION 2: WHAT PARTICIPANTS DO ......................................................................... 63 3.2.1 Philosophical tensions present in categorization. ............................................... 64 3.2.2 Beginning to understand the horizon of activity ................................................. 64 3.2.3 Some tensions in charting such a horizon for activity participation ................... 73 3.2.4 What the categorization achieves ........................................................................ 74 3.2.5 The challenges of such a categorical horizon ..................................................... 75 3.2.6 Reflection and next steps .................................................................................... 76 3.3 SECTION 3: THREE POSSIBILITIES OF FINDING MEANING ADAPTED FROM FRANKL (1959/2006)................................................................................................ 77 vi  3.3.1 Experience of activity participation over time .................................................... 79 3.3.2 Athena ................................................................................................................. 79 3.3.3 Jonathan .............................................................................................................. 81 3.3.4 Hammy ................................................................................................................ 82 3.3.5 Reflection: Activities, parts whole and salutatory meanings .............................. 83 CHAPTER  4: ACTIVITIES OF CITIZENSHIP, RECOGNITION AND SKILL DEVELOPMENT FOR SOCIAL INCLUSION ............................................................... 85 4.1 CITIZENSHIP AS BELONGING ....................................................................................... 86 4.1.1 Rights and acts of citizenship ............................................................................. 87 4.1.2 Receiving financial support ................................................................................ 89 4.1.3 Committing to and influencing citizenship expectations through activities for inclusion ......................................................................................... 91 4.1.4 Disclosure ........................................................................................................... 93 4.2 BEING RECOGNIZED AS BELONGING ........................................................................... 95 4.2.1 Being recognized quietly by doing ..................................................................... 98 4.2.2 Recognizing the self and being authentic ........................................................... 99 4.2.3 Freedom to belong inside and/or outside mental health communities .............. 100 4.2.4 Getting recognition, to belong and be included ................................................ 102 4.3 DEVELOPING SKILLS ................................................................................................ 103 4.3.1 Developing skills for work and inclusion ......................................................... 104 4.3.2 Developing skills through further education..................................................... 106 4.3.3 Developing skills through painting ................................................................... 107 4.3.4 Developing spiritual and wellness skills for being and doing self and others ................................................................................................................. 109 4.3.5 Developing relationship skills........................................................................... 110 4.3.6 Developing skills to manage money ................................................................. 112 4.3.7 Developing skills as angst ................................................................................. 113 CHAPTER  5: ACTIVITIES FOR HEALTH, WELL-BEING AND FOR JUSTICE ................................. 116 5.1 DEVELOPING STRATEGIES FOR HEALTH .................................................................... 117 5.2 MEDICATION AND HEALTH ....................................................................................... 118 5.2.1 Being and medications ...................................................................................... 120 5.2.2 Managing medication change, sleeping pattern, activities and meanings ........ 120 5.2.3 Being burdened by weight gain ........................................................................ 123 5.3 BEING INVOLVED IN DECISIONS FOR HEALTH ........................................................... 124 5.4 INSTRUMENTAL OR PRACTICAL SUPPORT ................................................................. 125 5.4.1 Friends and family ............................................................................................ 126 5.4.2 Health care professionals .................................................................................. 128 5.5 REHABILITATION PROGRAMS FOR HEALTH AND WELL-BEING................................... 130 vii  5.6 ACTIVITIES FOR HEALTH AND WELL-BEING .............................................................. 132 5.7 HABITS AS HARMONY WITH INTENTION AND PERFORMANCE .................................... 133 5.8 NOT DOING, EMBODIMENT AND WELL-BEING ........................................................... 134 5.9 BOREDOM A THREAT TO WELL-BEING ...................................................................... 134 5.9.1 Lifeworld essentials and disruptions ................................................................. 136 5.10 JUSTICE AND ACTIVITY PARTICIPATION .................................................................... 138 CHAPTER  6: ACTIVITIES THAT RESONATE WITH THE CALL TO BE ?MORE FULLY HUMAN? ............................................................................................................ 139 6.1 KEY CONCEPTS ........................................................................................................ 140 6.2 CENTERING ACTIVITIES ............................................................................................ 141 6.2.1 Centering as freedom ........................................................................................ 141 6.2.2 Centering for well-being ................................................................................... 143 6.2.3 Centering as an unmet need and at times angst ................................................ 143 6.3 CONTEMPLATION ..................................................................................................... 145 6.3.1 Contemplation as transcendence ....................................................................... 146 6.3.2 Awakening the self through contemplation ...................................................... 147 6.3.3 Contemplation as giving meaning to existence ................................................ 148 6.4 CREATION ................................................................................................................ 148 6.4.1 Creation as honoring the self ............................................................................ 149 6.4.2 Creation to help the self and others transcend the impact of the illness ........... 149 6.4.3 Creating as a way of being ................................................................................ 150 6.5 CONTRIBUTION ........................................................................................................ 151 6.5.1 Contributing and the call to give back .............................................................. 152 6.5.2 Connecting past present and future ................................................................... 153 6.5.3 Finding ways to contribute................................................................................ 154 6.5.4 A contribution to others who live with schizophrenia ...................................... 155 6.6 CONNECTEDNESS ..................................................................................................... 156 6.6.1 Connectedness as a call to a meaningful life .................................................... 156 6.6.2 Connecting as a couple ..................................................................................... 157 6.6.3 Missed connections ........................................................................................... 159 6.7 ACTIVITY CHOICE AND CONGRUENCE WITH VALUES ................................................ 160 6.8 APPLYING THE VALUES AND MEANING IN OCCUPATIONS MODEL ............................. 161 6.8.1 Resonance of data to the values and meaning in occupation model ................. 162 6.9 HOW VALUES MATTERED FOR PARTICIPANTS ........................................................... 164 6.10 FAMILY VALUES AND PERSONAL MEANING .............................................................. 165 viii  6.11 INTEGRATING PAST PRESENT AND FUTURE ............................................................... 166 6.12 ACTIVITIES MAY CHANGE BUT MEANINGS MAY REMAIN SIMILAR ............................ 167 6.13 EMBRACING MULTIDIMENSIONALITY OF OCCUPATION AND MEANING ..................... 167 CHAPTER  7: DISCUSSION ........................................................................................................ 173 7.1 MEANING AS SITUATED IN THE CONTEXT OF PARTICIPANTS? RECOVERY .................. 173 7.2 FINDINGS SUMMARY IN LIGHT OF THE LITERATURE .................................................. 174 7.3 THE MEANING OF ACTIVITIES OF CITIZENSHIP, RECOGNITION, SKILL DEVELOPMENT FOR INCLUSION ............................................................................... 176 7.4 THE MEANING OF ACTIVITIES FOR HEALTH, WELL-BEING AND FOR JUSTICE ................................................................................................................... 177 7.5 THE MEANING OF ACTIVITIES THAT RESONATE WITH THE CALL TO BE ?MORE FULLY HUMAN? ........................................................................................... 179 7.6 KEY TERMS THAT SHAPED THE RESEARCH REVISITED .............................................. 181 7.7 A NOTE ON RIGHTS, INCLUSION AND JUSTICE ........................................................... 183 7.8 CONSIDERATIONS FOR PRACTICE ............................................................................. 184 7.8.1 Well-being......................................................................................................... 184 7.8.2 Centering and creative activities ....................................................................... 185 7.8.3 Suicide............................................................................................................... 185 7.8.4 Reflection on becoming more ?fully human? ................................................... 186 7.9 CONSIDERATION FOR STUDENT EDUCATION ............................................................. 188 7.9.1 Assessment ........................................................................................................ 188 7.9.2 Occupations to attend to social inequities ......................................................... 188 7.9.3 Attunement to possibilities ............................................................................... 189 7.10 POLICY CONSIDERATIONS FOR SOCIAL INCLUSION, JUSTICE AND CITIZENSHIP ............................................................................................................ 189 7.11 CONSIDERATIONS FOR FUTURE RESEARCH ............................................................... 191 7.11.1 Approaches for justice and social inclusion...................................................... 191 7.11.2 Building on existing models of occupation to include meaning ....................... 191 7.11.3 Research and volunteering ................................................................................ 192 7.12 STUDY STRENGTHS AND LIMITATIONS ...................................................................... 192 7.13 CONCLUSIONS .............................................................................................................. 193 References ...................................................................................................................................195 Appendices ..................................................................................................................................215 ix  APPENDIX A MEANING IN OCCUPATIONAL SCIENCE AND OCCUPATIONAL THERAPY STUDIES - FEB. 2010 ........................................................................... 215 APPENDIX B RECRUITMENT POSTER ........................................................................................ 216 APPENDIX C INTERVIEW PACKAGE .......................................................................................... 217 C.1 LETTER OF INVITATION ............................................................................................ 217 C.2 PARTICIPANT CONSENT FORM .................................................................................. 219 C.3 FRIEND CONSENT FORM ........................................................................................... 222 C.4 HEALTHCARE PROFESSIONALS CONSENT FORM ........................................................ 224 C.5 NON-DISCLOSURE AGREEMENT ................................................................................ 226 C.6 PROTOCOL TO SUPPORT INDIVIDUALS WHO MAY BE EXPERIENCING STRESS DURING THE INTERVIEW .............................................................................. 227 C.7 INTERVIEW GUIDE .................................................................................................... 228 APPENDIX D MEANING UNITS (MUS) SAMPLE ......................................................................... 231 APPENDIX E CATEGORIZATION TABLES .................................................................................. 232 APPENDIX F THE STRUCTURE OF THE EXPERIENCE OF DRIVING HER CAR: ATHENA ............................................................................................................. 242 APPENDIX G ACTIVITY MAPS ................................................................................................. 243  x  List of Tables TABLE 1: FIVE CRITERIA ? ADAPTED FROM PARK LALA (2011) .................................................... 45 TABLE 2: MAXIUM VARIATION- DEMOGRAPHICS ........................................................................... 49 TABLE 3: APPLICATION OF VALUES AND MEANING IN IN OCCUPATION MODEL ............................. 162 TABLE 4: ACTIVITY PARTICIPATION ? CATEGORIZATION ? PERSONAL CARE ........................... 232 TABLE 5:  ACTIVITY PARTICIPATION ? CATEGORIZATION ? PRODUCTIVE ACTIVITIES ............. 235 TABLE 6: ACTIVITY PARTICIPATION ? CATEGORIZATION ? LEISURE ACTIVITIES ..................... 239 TABLE 7: ACTIVITY PARTICIPATION ? CATEGORIZATION ? REST ACTIVITIES .......................... 241 xi  List of Figures FIGURE 1: ATHENA LOVES TO LEARN ............................................................................................ 53 FIGURE 2: HAMMY FEELS LIKE A BROKEN MACHINE .................................................................... 54 FIGURE 3: JONATHAN "SCUFFS AROUND" ...................................................................................... 55 FIGURE 4: LISA THE ARTIST ........................................................................................................... 56 FIGURE 5: PAINTER ........................................................................................................................ 57 FIGURE 6: PETER THE SPIRITUAL SEEKER ....................................................................................... 58 FIGURE 7: REBEL GIRL LOVES MUSIC ........................................................................................... 59 FIGURE 8: ROBERT THE COMPUTER GUY ....................................................................................... 60 FIGURE 9: SAM THE ENGINEER....................................................................................................... 61 FIGURE 10: SYLVIE LOVES CLOTHES ............................................................................................. 62 FIGURE 11: MEANING IN ACTIVITY .............................................................................................. 181 FIGURE 12: ACTIVITY MAP - ATHENA ......................................................................................... 243 FIGURE 13: ACTIVITY MAP - JOHNATHAN .................................................................................... 244 FIGURE 14: ACTIVITY MAP - HAMMY .......................................................................................... 245 xii  List of Abbreviations  ACT Assertive Community Treatment  BRIDGES  Building Recovery of Individual Dreams and Goals through Education and Support OS Occupational Science OT Occupational Therapy or Occupational Therapist PORT Patient Outcomes Research Team recommendations PSR  Psychosocial or Psychiatric Rehabilitation  RAS Recovery Assessment Scale RCT Randomized Control Trial  SAMHSA Substance Abuse and Mental Health Services Administration  SE Supported Employment interventions ValMO Values and Meaning in Occupations WRAP  Wellness Recovery Action Plan       xiii   Glossary  Key Heideggerian terms  Being is the core aspect of Heidegger?s work and an essential element of being human.  Being-in-the-world refers to engaging in (in our totality) in the world Care refers the how of our existence so that we become all that we can. Dasein refers to our being in the world as a self-interpreting being, open to the world as we move into our futures.  Presence or present at-hand (Vorhandenheit)  renders tools available for  inspection as we engage with them through theoretical doing, this kind of manipulation leads to science  and a pure interest in examining things as they are ?bracketed from their connections and engagements with our interests ?.They are simply there? (Moran, 2000, p. 233). They are detached from one?s involvement with them (Inwood, 2000).  Readiness or ready-to-hand (Zuhandenheit) describes how we tamper with objects or tools based on our interests and goals and in this instance they are available to us (Moran, 2000, p. 233). World refers to a context, any context. Lived existentials  Lived body as described by van Manen (1990) is the experience of one?s body or corporality. Lived other as described by van Manen (1990) is the experience of another or rationality. Lived space as described by van Manen (1990) is the experience of space or spatiality. Lived time as described by van Manen (1990) is the experience of time or temporality.  xiv  Acknowledgements Several people helped to make this study possible and I am deeply grateful for their support. Firstly, my sincere thanks to the participants of the study who shared your voices and your hearts during our conversations together.  Thank you for the gifts you have given me. It has been an honor to learn alongside you. Thank you staff and family members who made the recruitment process possible. To my PhD committee I owe a large debt of gratitude: Dr Lyn Jongbloed for your consistent strength-based approach and your phronesis; you will always be an inspiration ? thank you.  To Dr Melinda Suto, I thank you for your consistency, your keen attention to detail, and your questioning stance that brings new and valued insights. Thank you to Dr Simon Davis for sharing a seemingly boundless knowledge of mental health practice and for your ability to smoothly integrate emic experiences and needs within large systems planning process. To Dr Krupa, I thank you for demonstrating the splendor and the power of the simple yet essential. Your client-centered way of being cultivates sage and powerful action. I would like to thank Renea Mohammad for your courage and wisdom in sharing your experience of meaning in activity. Thanks also to the scholars who shared their passion and learning in ways that enhanced and stretched my thinking. Thank you to Dr D. Sutton, Dr S. Smith, Dr M. McDonald, Dr J. Higenbottam, Dr K. Reed, Dr M. Jansen, Dr K. W. Hammell, Dr E. Dean and Dr J. Rozanova. I would like to acknowledge the tremendous support and resources provided by the department of occupational science and occupational therapy at UBC.  My thanks also to Dr Susan Forwell for your caring and insightful questions.  Thank you to Professor Michael Lee and for the opportunity to teach and learn with you, and to Charlotte Beck for your librarian support.  I appreciate the support of Tracy Henderson, Tiffany Moore, Rehana Frankland and Kathryn Lewis. Thank you to my colleagues who shared much of this journey with me. In particular, thanks to Dr Mineko Wada, Dr Shalini Lal, Sanda Hale, Rona McDonald, Alison Gerlach and Dr Hana Albannay. Thank you to Tahereh Mosavi and Dr Houssain Mosavi for your stimulating and instructive philosophical and phenomenological conversations. Thanks to Angela Flannery and Monica Moran for your proof reading. My thanks also to Heather Swallow for your magical formatting abilities. Thanks to several colleagues at Vancouver Community Mental Health Services and Addictions. Thanks to Kim Calsaferri, Tom Heah, Deborah Simpson, Sue McDonald, Sue Garries, Monica Budac and Ann Webborn for your constant encouragement and challenge. Many other people have provided support and allowed me room from other commitments so that I could complete this study. Thank you to our ?emergency cocktail mamas? for much needed respite and for the warmth of your friendship. Thanks also to Erin Marks, Grace Moloney, Tony McHugh and Juanita Spurrell. I am deeply indebted to my late father for being a role model in helping others deal with their illness experiences in his own pragmatic and non-judgmental fashion. Thank you Mum for your love and encouragement. I am also indebted to my husband, Elton (who became a psychiatrist after we met), for your unwavering ?client-centeredness? and the gift of challenging my ideas and philosophies regarding mental illness and rehabilitation interventions. To Niall, Niamh and Conan, ?best children in the world? thank you for your love and encouragement. xv  Dedication  To Dad and Raphie,  We miss our host of golden daffodils.    1  Chapter  1:  Setting the stage  ?Man has his future within ?, dynamically active at this present moment? (Maslow, 1960/1969, p.56). Introduction  The goal of this study was to contribute to the literature regarding meaning1 in daily activity for people who live with schizophrenia. The central question for the study was what activities do participants engage in and what are the meanings of these activities for participants? People living with schizophrenia were interviewed four times over two years. Rich descriptions of people?s lives are presented to show aspects of meaning that participants experience as they go about their daily lives. The phenomenological writings of Edmund Husserl (1859-1939), Martin Heidegger (1962), Hans- George Gadamer (2004), and Max van Manen (1990), guide the analysis process.  The intention was to invite participants to share their experiences and seek detailed descriptions of the 10 participants? lived experience to show something of the significance of the activities that participants engaged in and the meanings of those activities for participants. Multiple perspectives are acknowledged, and otherwise hidden or taken for granted meanings are made explicit. This study adds to knowledge pertaining to meaning in activities for persons who live with schizophrenia. Findings will be of value for occupational therapy practitioners, students and those interested in recovery for people who live with significant mental health issues. This chapter begins by reviewing the context and the associated literature regarding schizophrenia, recovery, psychosocial rehabilitation, occupational therapy and occupational science. The concept of meaning is situated in the aforementioned bodies of knowledge and is specifically defined for this study (as that intended and that signified, Smith, 2009). 1.1 Schizophrenia  Schizophrenia is one of the top 10 leading causes of disease-related disability throughout the world (World Health Organization, 2001) and has devastating impacts on individuals and families living with this illness. From a scientific perspective schizophrenia is characterized by profound disruption in                                                  1 Meaning for the purposes of this study is defined as: 1) ?That which is intended? and 2) ?That which is signified?, of ?import? or ?significance? (Webster's Dictionary, 1992, p. 607). 2  cognition and emotion, affecting the most primary human attributes such as thought, language, perception, affect, and sense of self. Positive symptoms of schizophrenia include hallucinations, delusions, disorganized speech and behaviour. Negative symptoms are classified as primary (enduring features considered inherent to the illness) or secondary (to depressive features, drug side-effects or positive symptoms). The negative symptoms of schizophrenia can include challenges in emotional responsiveness, spontaneous speech and motivation or volition. Primary negative symptoms are demonstrated in flattening of affect, poverty of speech, disruption of volition, social withdrawal and decreased spontaneous movement and may be the most disabling and persistent component of the illness (Tandon, Keshavan & Nasrallah, 2008). Medication is effective for up to 75% of people (Liberman, 2008) however, ?antipsychotics are most effective at reducing psychotic symptoms, and they have minimal effects on negative symptoms, cognitive impairment, or functioning? (Mueser, Deavers, Penn & Cassisi, 2013, p. 467). 1.1.1 Schizophrenia and the course of the illness  The course of schizophrenia varies a great deal but it is often episodic in nature i.e., recurrent exacerbations with periods of remission (Andresen, Oades & Caputi, 2011). Depression and motor challenges (such as tardive dyskinesia) result in approximately one-third of individuals who live with a diagnosis of schizophrenia attempting suicide; approximately 5% are successful (Tandon, Keshavan, & Nasrallah, 2009). Obsessive-compulsive symptoms are present for approximately 25% of ?patients? (Schirmbeck et al., 2012), social phobia, and generalized anxiety disorder and anxiety symptoms are also prevalent (Tandon et al., 2009). Co-morbid cognitive impairments (executive function, memory, psychomotor speed, attention, and social cognition) also constitute a core component of the illness and have a significant impact on functioning (McGurk, Mueser, DeRosa, & Wolfe, 2009).  The physical health of people who live with schizophrenia is significantly compromised i.e., a notably shorter life span, prevalence of metabolic changes, and increased risk of coronary heart disease (Cook, 2011; Jeste, Wilkowitz & Palmer 2011). The prevalence of schizophrenia is 1% with the direct and indirect cost of schizophrenia in Canada estimated at approximately $5.35 billion in 1996 (Public Health Agency of Canada, 2012).  Male gender, early age of onset, prolonged periods of untreated illness and severity of cognitive and negative symptoms predict poor outcomes. Indeed, since it was first identified by Kraeplin, schizophrenia has often been constructed as a disorder with progressive deterioration in cognitive, behavioural and social functioning (Folsom et al., 2009). This proposition is supported by recent neuro-imaging investigations that indicate a progressive reduction in brain tissue in the early 3  years (Zipursky, Reilly, & Murray, 2012). However, in 1997 Schultz et al. reported that positive psychotic symptoms and disorganized symptoms are likely to be less present in older patients with schizophrenia, although negative symptoms tend to be consistent.2 Folsom et al. (2009) and Jeste et al. (2011) contend that quality of life may improve overtime for people who live with schizophrenia. Further, Zipursky et al. (2012) posit that for the smaller percentage for people who are not able to reach functional recovery, this outcome may be due more to poor access to or inadequate treatment, the effects of medications or concurrent disorders, or the impact of social and financial impoverishment rather than an increase in cognitive decline. Zipursky et al. (2012) assert that some of the initial brain changes may be reversible, that further work needs to occur to confirm the possibility that people with schizophrenia experience a steeper decline in cognitive function than the general population. Although there seems to be some differences between late and early onset schizophrenia, Jeste, et al. (2011) acknowledge the paradox that while physical ageing is more marked in this population psychosocial function improves with age.  1.1.2 A glimpse of the experience  Chadwick notes that ?science as we know it ? can say little about the meaning of the schizophrenia experience? (1997, p. 1). According to participants in Geannello?s (2005) study, ?living with schizophrenia is ? [at least initially] ? confusing, exhausting,  [and] overwhelming[,] and results in an inability to function ? disconnection from meaningful relationships is compounded by fear and confusion and people are left facing inexplicable chaos alone ? dividing the self from the self? (p. 11).  Such intense anguish and hopelessness is described by Deegan (1988) as a ?past with no future,? a ?wound with no mouth,? and an ?inertia which paralyzes the will to do and accomplish because there is no hope? (p. 13).  As people who live with schizophrenia interact with the biomedical world, they may become less able to explain their symptoms to medical personnel, and medical personnel may be more likely to disregard their complaints and assume that they are simply part of the illness (Sutton, 2008).  Other issues for those living with the diagnosis include the effects of medication, (including significant weight gain), and homelessness, which make people more susceptible to accidents and disease. Additional challenges include poverty, loneliness (Deegan, 2004; Nilsson, N?den, Lindstr?m, 2008), the perception of violence from society, and the fact that people who live with schizophrenia are                                                  2 Of note Schultz et al., 2007 excluded people who also lived with dementia and cognitive impairment and authors acknowledge that given their inclusion criteria the latter assertion may require further investigation. 4  often the target of violence, trauma, unemployment and underemployment (Young & Passmore, 2007). Further, despite potential employability (Scheid & Anderson, 1995) and a desire to work, UK and US studies indicate that only 15% to 25% of people with serious mental illness work (Marwaha & Johnson, 2005),  yet 55% to 70% of adults with schizophrenia indicate they are interested in work (McGurk et al., 2009). Thus, the impact of social exclusion and stigmatization, are important issues requiring examination from the perspective of lived experience (Rethink, 2008). Despite these challenges, people who live with schizophrenia can and do recover (Borg & Davidson, 2007; Carten 2006; Davidson, 2003; Harding & Zahnister, 1994). Living with schizophrenia requires ??a self that has learned about its own nature?? and about the need for fundamental and profound change based on purposeful action, tenacity, and courage (Geanellos, 2005). In other words, recovery involves learning and transformation though engaging in activity within ?the social world? (Doubt, 1996).  1.1.3 Relationship to the study In summary, the symptoms of schizophrenia make it difficult for people to engage in certain activities and in their possibilities for the future (Mueser et al., 2013). These difficulties are compounded by the fact that ?it?s nearly impossible to make your own future when you are not part of the economic fabric of the culture you live in? (Deegan, 2004, p. 7). Deegan also reflects that in the same way as other people ?our need, indeed our ontological vocation, is to become more fully, more joyously, more complexly human? (2004, p. 11). Thus as people live with schizophrenia there is a sense of becoming through engagement in everyday activity (Sutton, 2008). Slowly, people become aware of possibilities, find meaning, hope and begin to recover while engaging in valued activities and roles. This study will add to knowledge pertaining of the meaning in activity for persons who are engaging in the recovery process (Davidson & Roe, 2007).  1.2 Recovery 1.2.1 Background The concept of recovery from mental health and addictions is an essential philosophical driver in key policy documents that influences mental health service design, delivery, evaluation and research in many English-speaking developed countries including Canada. Specific Canadian documents published by the Mental Health Commission of Canada (MHCC) include: Toward Recovery and Well-Being: A Framework for a Mental Health Strategy for Canada (2009) and more recently Changing 5  Directions, Changing Lives, released in May, 2012. These guiding documents aim to ensure that the concept of recovery remains an essential feature of health for all Canadians and advises access to services, reducing stigma and ?helping people be fully engaged citizens and active participants in all aspects of economic life? (MHCC, 2012, p. 12). 1.2.2 A short history  It is important to note that the body of knowledge regarding recovery is under construction and the meanings of terminology remains fluid (Casey, 2008; Resnick & Rosenheck, 2006). Literature was at least initially generated by people who had received services, some of whom were deeply critical of those services (Mueser, et al. 2013; Slade & Davidson, 2011). This ?consumer/ex-patient movement? became active in the 1970?s as a direct result of deinstitutionalization (Anthony, 1993). Early initiatives included work on advocacy, action, and self-determination (Resnick & Rosenheck, 2006). The innovative and hopeful work of this movement was also bolstered by findings from seminal longitudinal studies indicating that recovery was possible (Liberman, 2008).3  Work in the area was supported by civil rights organizations, self-help groups and 12-step programs of the time (Mueser et al., 2013). In this way recovery may be seen as closely aligned to the civil rights movement (Davidson & Roe, 2007). In summary, as Andresen et al. (2011) assert, recovery ?grew from diverse ideological standpoints? (p. 3) that laid the necessary ground work for diverse perspectives on recovery. 1.2.3 Recovery conceptualizations  Patricia Deegan (a consumer leader and scholar) became an important champion of the recovery vision. She defined recovery existentially as ?rediscovering meaning and purpose after a series of catastrophic events [and describes it as] a process, a way of life, an attitude, and a way of approaching the day?s challenges? (1988. p. 15). Deegan (1996) conceptualized recovery as a journey of the heart and in so doing insisted that mental health practitioners consider the person first before the illness. The message of the movement thus grew to include empowerment and self-management. It became apparent that people in recovery wanted a sense of belonging, a reasonable income and a home, engagement in various life roles (and being able contribute to communities of choice) and also to resolve trauma as a means to experience a sense of health and well-being (Swarbrick, 2012). These                                                  3 According to Bellack & Drapalski (2012) up to 20 current studies of the long-term outcome of schizophrenia indicate ?50% of people with careful research diagnoses appear to have a good outcome, with substantial reduction of symptoms, and good quality of life and role function over extended periods of time? (p. 156).   6  aspirations would have specific relevance for each individual, for example one person may wish for an intimate partner, another may also be interested in working.  Defining recovery is not straightforward and consideration needs to be given to who is offering the definition (Liberman, 2008). For example, recovery can also be seen as a guiding vision for orienting services (Anthony, 1993). Anthony (1993), former director of the center for psychiatric rehabilitation in Boston defines recovery as a ?deeply personal, unique process of changing one?s attitudes, values, feelings, goals, skills and/or roles ? a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness? (p. 527). Similarly, the influential Substance Abuse and Mental Health Services Administration ([SAMHSA], 2011) describes recovery from mental health and addictions as a ?process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential? (n. p.).  All of these definitions are similar in that recovery is seen as a personal process for which the person is responsible (Andresen, Caputi, & Oades, 2006; Andresen, Oades, & Caputi, 2011). However, they also differ in terms of the aspects of recovery they focus on i.e., illness, human potential and/or goals. Some of them include mental health and addictions while others are representative of a time when these services were considered to be separate domains. Bellack and Drapalski (2012) point out the absence of a consistent operational definition of recovery, making it challenging to accumulate evidence when terms are not objective and do not measure community functioning or illness course.4   1.2.4 Linking recovery to social inclusion and citizenship and rights5 Important to this study, is the above integrative approach to defining recovery that extends past both clinical and rehabilitative practice to a more ecological approach to recovery. This integrated definition                                                  4 Bellack & Drapalski (2012) present a model of recovery as related to Bandura?s social cognitive theory of human agency and developed a new measure based on the SAMHSA recovery domains called the Maryland Assessment of Recovery in People with Serious Mental Illness (MARS, in press).  5  Several relevant international documents exist to support individuals? human rights (see, for example, by the United Nations General Assembly, 1948, and the High Commissioner for Human Rights, 1966, 1975).  The United Nations Principles of Care and the Improvement of Mental Health Care (United Nations High Commissioner for Human Rights, 1991) called for a holistic approach to health care. Recently, the Convention on the Rights of People with Disabilities by United Nations High Commissioner for Human Rights, 2006 seeks to support full, equal and enjoyable participation for disabled people in communities of their choice. Closer to home the Canadian Charter of Rights and Freedoms (Correctional Services Canada, 1982) is based on supreme law and as such generally overrides federal and provincial statutes including the mental health act. Essentially this law seeks to secure life, liberty and security of the person (Davis, 2006, p. 272). Being socially included as a full member of society is an important aspect of recovery.   7  in many ways brings us back to what is essential  i.e., to address ?fundamental issues of human and civil rights, or the lack thereof, in determining the everyday lives, opportunities, and health of people with serious mental illnesses? (Davidson & Roe, 2007 p. 464-465).  The concept of recovery holds a space for meeting the needs of people who live with mental health issues from both personal and civil rights 6 viewpoints thus allowing attention to be focused on health, illness, well-being and citizenship (Krupa, 2014). These views culminate in the belief that people who live with mental health issues have the same rights and responsibilities as any other citizen to engage in valued activities within communities of their choice.7  1.2.5 Formalizing recovery for measurement  Beyond the scope of this review are several frameworks and models developed to guide recovery practice, some of which have garnered some success with research outcomes. However, briefly, one such framework is the collaborative recovery model, built on experiential accounts of people receiving services (Andresen, Oates & Caputi, 2003). Four key processes of recovery are identified: (i) finding hope; (ii) re-establishing identity; (iii) finding meaning in life; and (iv) taking responsibility for recovery. Five stages of recovery are identified: (i) moratorium; (ii) awareness; (iii) preparation; (iv) rebuilding; and (v) growth (Andresen, Oades & Caputi, 2003). By linking recovery to positive psychology and well-being the authors assert an empirical bridge may be created between the lived experience of recovery and empirical science (Andreason, Oades & Caputi, 2011; Resnick & Rosenheck, 2006). 8 9  Well-being also links to a more inclusive definition of health as being more than just the absence of disease (WHO, 2010).  (See, for example, Campbell-Orde, Chamberlin, Carpenter & Leff, 2005 for recovery evaluation tools).                                                     6 The notions of rights and social inclusion are closely linked (Boardman, 2010a) and will be taken up in chapter 4 and 5 and 7.  7Ashcraft (2013), purports that social inclusion does not happen when people are simply tolerated in their communities but rather when the community values the efforts and contribution of people. 8 Aldrich (2011) asserts that well-being has not been defined explicitly in the occupational science and occupational therapy literature and recommends that the concept is reviewed for how it may be applied to practice.   9 See section on positive psychology for additional details. 8  1.2.6 Recovery approaches to skill development, managing illness and well-being Whatever the identified service delivery model, Swarbrick (2011) notes that in general service users have significantly influenced the service delivery towards recovery and wellness through the application of their expertise and experience. Examples of consumer-led recovery self-help wellness services include the Wellness Recovery Action Plan ([WRAP], Copeland, 1997). This recovery approach is used to help people develop wellness strategies and an awareness of peer support services. Cook, Copeland et al. (2012) recently completed a randomized controlled trial on this peer-led wellness intervention and it is now seen as part of a group of evidence based recovery-oriented services. Positive results included increased hopefulness and quality of life (Cook, Copeland et al., 2012). Krupa (2014) adds that a range of intervention approaches and strategies have been developed in response to the notion of the recovery process and usually aim to enact key elements of recovery oriented practice.  Krupa (2014) cites a pilot study undertaken by her team using a randomized controlled design and a modified version of the Recovery Workbook (Spaniol, Koehler & Hutchinson, 1994). Similar to the WRAP program, the workbook provides education about the recovery process and helps participants develop an individualized action plan. Results suggested an increased sense of perceived hope, empowerment and general measures of recovery as measured by the Recovery Assessment Scale (RAS) (Barbic, Krupa, & Armstrong, 2009).  Building Recovery of Individual Dreams and Goals through Education and Support (BRIDGES) is a curriculum written by people with serious mental illness, advocates from the National Alliance on Mental Illness of Tennessee and staff from the Tennessee Department of Mental Health and Developmental Disabilities (Diehl & Baxter, 2001 cited in Cook, Steigman et al., 2012). The intent of this program is to teach people about the illness and how to cope. Findings from a recent randomized control trial (RCT) suggest an increase in perceived level of recovery and in some aspects of hopefulness (Cook, Steigman et al., 2012). This innovative group of program developers and researchers assert that taken ?together, these studies provide support for the notion that peer-led recovery education may be an important augment to traditional services? (Cook, Steigman et al., 2012, p. 37). 1.2.7 Recovery and meaning  Important to this study, is the acknowledgement that recovery is also a deeply philosophical issue (Davidson, 2003; Rudnick, 2012) heralding important conceptual challenges and opportunities (Rudnick, 2012). Andresen, et al., (2011) describe meaning in life at each of the five stages of the 9  recovery process. They assert that meaning is conceptualized in the recovery literature as relating to the illness (and identity10) and to meaning and purpose in life (i.e., loss of goals and roles). Similar to Deegan?s (2005) work on personal medicine, Andresen et al. (2011), assert that having a ?purpose in life gives meaning to a person?s recovery efforts ? [and developing meaning in life is] a task of the recovery process? (p. 38).11   Andresen et al. (2011) extend the recovery discussion in that they consider some specific activities and meaning (and not just roles) and posit that meaning ascribed to an activity can vary greatly between individuals and that meaning may change over time. These authors describe participation in activities such as writing a doctoral dissertation, working and engaging in creative activities. In so doing the meaning experienced in discrete activities is implicitly linked to meaning in life. It is also implied that activity participation may be modified if not congruent with values or life goals. Andresen et al. (2011) posit that meaning in life is different at each stage of recovery. During the first stage of recovery, called moratorium, there is loss of purpose in life and loss of meaningful goals and roles which may impact future possibilities. During the second stage of awareness in the words of Frankl (1959/2006) one begins to experience a sense of ?will to meaning? that becomes apparent through identifying a purpose. The third stage of preparation involves taking stock and living in a way that is congruent with personal values. The fourth stage of rebuilding a sense of self and purpose occurs through goal attainment. It is noted at this stage ?occupations provide ... more than a reason to get out of bed; they provide a reason to live? (Andresen et al., 2011, p. 97). Characteristics of the activity and the quality of the activity are described as being autonomous therefore intrinsically motivating, pleasurable and congruent with the person?s sense of self. Finally the growth stage is about living an authentic meaningful life through engagement in meaningful mutually beneficial occupations such as peer support roles. This stage may involve new learning and being able to use the resulting wisdom (Andresen et al., 2011). This work articulates some expressed meanings that people who live with mental illness experience at various stages of recovery.                                                    10 Andresen, et al. (2011) also link identity to early work by Davidson and Strauss, (1995) on the way in which a person reacts to the illness will impact the recovery process (p. 63).   11 Deegan (2005) ?Personal medicine was found to be those activities that gave life meaning and purpose, and that served to raise self-esteem, decrease symptoms, and avoid unwanted outcomes such as hospitalization? (p. 29).  10  In summary, the concept of recovery contributes to understanding consumer experiences and mental health practice. However, there is limited information in the recovery literature regarding how people who live with schizophrenia experience their daily activities (such as cleaning, shopping or doing tai-chi for example) and how these discrete activities may relate to patterns of activity such as painting or developing friendships and how people experience possibilities regarding activity participation. 1.3 Positive psychology  Moran, Russinova, and Stepas (2012) assert the ?need for future research on recovery processes from the perspective of positive psychology? (p. 376). As a positive psychologist, Keyes (2007), in his Model of Total Mental Health conceptualizes health and ill health on a continuum. These concepts are intersected (on a separate axis) with concepts of flourishing and languishing also on a continuum. Keyes and colleagues challenge our existing understanding of the deleterious effect of mental illness and propose that one can live with a mental illness while at the same time flourishing (Keyes & Simoes, 2012; Westerhof & Keyes, 2010). This work contributes to a more promising understanding of human potential. Flourishing is described as a state where people experience positive emotions, positive psychological functioning and positive social functioning, most of the time. Flourishing is also related to the development of character strengths and virtues as a means to being able to live, not just a good life, but a meaningful life (Seligman, 2011). An important aspect of flourishing is that it makes health and mental health the concern of society rather than solely an individual concern.12 From this perspective Rapp and Goscha (2012) developed an evidence-based Strengths Model for case management. This approach is invested in supporting people who live with a psychiatric disability to set, and achieve, meaningful and important life goals. The intent is to move away from a more traditional problem-focused approach to care to more recovery-oriented service models that: 1) do not oppress individuals, 2) move away from disease and deficits toward identifying strengths, potential and well-being and, 3) the inclusion of more purposeful services that strive for interdependence.                                                   12 Barry, (2009) a leading Irish academic in mental health promotion, in her role as Global Vice President for Capacity Building, Education and Training (2007-2010) with the International Union for Health Promotion and Education claims that positive mental health is essential to population wellbeing and ?the long-term social and economic prosperity of society? (p, 12). 11  1.4 Psychosocial Rehabilitation  Recovery from serious mental illness and addiction it is the desired outcome of psychiatric rehabilitation (PSR) service provision (Farkas, Jensen & Penk, 2007; Mueser, et al., 2013). Clay (2012) cites Jansen (n.d., a member of the Recovery Advisory Committee for the American Psychological Society), who offers that ?in the same way that cardiologists might encourage heart attack patients to stop smoking, start exercising ?  [we] use psychosocial rehabilitation interventions to assist people with mental health conditions .. .[to] try to gain ? or regain ? a meaningful life, however they define it? (p. 52). PSR is a set of practitioner techniques and program practices that are based on specific values, and have evolved based on trial-and-error learning, important personal accounts and more recently, empirical evidence over 30 years (Pratt, Gill, Barrett & Roberts, 2007). With a strong value of consumer involvement, people receiving services are encouraged to be part of the design, delivery and evaluation/research of PSR service delivery. The desired end result is for people who live with significant mental health issues to be included as full citizens of their communities.  1.4.1 Psychosocial rehabilitation approaches and strategies Corrigan Mueser, Bond, Drake and Solomon (2009) advocate the use of evidence on which to base practice. In general, the source of current best evidence for psychosocial rehabilitation is based in Patient Outcomes Research Team recommendations ([PORT], Dixon et al. (2010). Although these recommendations have been slow to influence practice (Hogan, 2010; Lehman, 2010) and fall short of providing perfect and culturally diverse and competent interventions (Rogers, Restrepo-Toro & Gao, 2006) they do provide ?robust? evidence for ?supporting people in occupying normative roles? while living alongside significant mental illness (Davidson, 2010, p. 108). The eight PORT psychosocial treatment recommendations (an adjunct to medication recommendations) draw on data from randomized controlled trials (RCTs) and consideration is given to promising practices. PORT recommendations include the development of assertive community treatment teams (ACT), supported employment interventions (SE) skills training for daily living, cognitive behavioural therapy, token economy interventions, family-based services, interventions for alcohol and substance use disorder and interventions for weight management. Promising practices include cognitive remediation, peer support and peer delivered services, interventions to support medication concordance and psychosocial treatments for recent onset schizophrenia (Dixon et al., 2010).  12  Farkas and Anthony (2010), point out that an overreliance on evidence based practices could lead to a single model approach to practice thus excluding promising practices and context specific needs. Farkas and Anthony, (2010) are proponents of a specific model of psychosocial rehabilitation: namely, the Boston choose-get-keep model of psychiatric rehabilitation, which is based on three interrelated phases, or process of rehabilitation: 1) choosing a valued role and identifying a relevant goal (i.e., establishing hopes and assessing, and developing readiness for change and identifying level of engagement with allies); 2) getting a valued role (i.e., by the removal of barriers, reduction of stigma and receiving additional opportunities for success with desired goals) and; 3) keeping a valued role (i.e., obtaining specific and needed skill development and support).  Importantly the British Columbia Ministry of Health is set to release a more generic framework for PSR services that will provide the impetus for needed advancements for mental health service delivery, education, and research in this province (in press).  1.4.2 Psychosocial rehabilitation and meaning  Farkas and Anthony, (2010) contend that PSR?s commitment to support a person?s chosen roles within settings of their choice allows people to recover based on a person?s vision of a meaningful life, as opposed to merely helping people develop skills and abilities. Early PSR research was focused on establishing the feasibility of interventions. However, success and satisfaction regarding role attainment remains an important aspect of PSR service evaluation (Liberman, 2008; PSR/RPS Canada, 2009). Some early and seminal studies did consider meaning such as Drake et al. (1999) who looked at concepts such as satisfaction, self-esteem, quality of life. Another early study by Bond et al. (2001) compared self-esteem, satisfaction with employment, finances and leisure time between sheltered workshop study participants and those participants in competitive work situations. However, few studies in this area consider meaning specifically as it related to activity participation. One study that considered meaning from Mansbach-Kleinfeld, Sasson, Shvarts, and Grinshpoon, (2007) contends that meaning of supported education for people with psychiatric challenges should be focused on considering identity for participants rather than looking at skill development alone. Participants in this study attributed recovering lost roles and capabilities to positively influencing their identity. A second study by Dunn, Wewiorski and Rogers (2008) found that meaning experienced through work contributed to recovery for their 23 participants. Meaning of work included an opportunity to reclaim or affirm a valued sense of self, improve a sense of esteem and a recognition of 13  status and for some an opportunity to give back. Work also helped people to manage their illness by providing structure, stimulation, social skill development and improving social inclusion. In summary, providing choice is an essential aspect of psychosocial rehabilitation from the perspective of rights and full citizenship in society.  Thus, from this review it is apparent that little research exists in the PSR literature specifically looking at the experience of meaning in daily activities from the perspective of people living with schizophrenia.  The next section of this chapter will describe the field of occupational therapy (OT) and occupational science (OS). Before proceeding it is acknowledged that much of the OT and OS literature refers to occupation. Occupation is defined as ?an activity or set of activities that is performed with some consistency and regularity that brings structure, and is given value and meaning by individuals and a culture? (Townsend & Polatajko, 2007, p. 19).  I have chosen to use the term activity (often interchangeably with occupation) to describe everything that people do (including thinking) as they go about their daily life.    1.5 Occupational therapy and occupational science   Hooper and Wood (2014) contend that the philosophy of occupational therapy today remains concordant  with Mary Reilly?s 1962 original hypothesis of occupational therapy i.e.,: ?That man, through the use of his hands, as they are energized through mind and will, can influence the state of his own health? (as cited on p. 38). Hooper and Wood (2014) conclude that the central ontological position of occupational therapy is that humans are in a state of constant change interacting with ever-changing environments, occupying time with ever changing activities and reciprocally transform and are transformed by their actions, environments and health status. Health is regarded as ?being able to engage in valued occupations? (Hooper & Wood, 2014, p. 39). In sum, as humans we need activities that are carried out in order to grow and thrive. This dynamic view of humans in context is as new as it is old. It is aligned with phenomenology?s insistence that we are beings connected to, acted upon and in turn who act on the world in ways that may be harmonious or not on a continuum, and may be autonomous and or interdependent on a continuum. Central to this idea is that people may be thwarted and unable to develop their potential for doing and when unable to express their capacities for doing, ill-being, ill health, depression and boredom may result. The belief is that one can cultivate a better life both for the self and for others through occupation (Hooper & Wood, 2014; Thibeault, 2009; 2011).  14  Occupational science is an academic discipline tasked with generating knowledge regarding the form, function and meaning of human activities or occupations (Zemke & Clark, 1996). Zemke and Clark, (1996) credit Yerxa for establishing this new discipline in the University of Southern California in 1989 which at the time was conceptualized as a separate science discipline and not concerned with application to occupational therapy practice. Zemke and Clark, (1996) outline initial areas of occupational science investigation which included understanding the importance of occupation from different standpoints such as anthropology and the classification of relevant terms.  Deepening the understanding of the dimensions of occupation such as time, space, routines, habits, emotions and past experiences was also fruitful as was considering biology and how humans share process with other living things (Wiclox, 1998). Various theories informed these investigations. One such theory that has relevance to this work is social learning theory and activity theory in particular (Vygotsky, 197813). Links to occupational therapy were studied, as were particular topics such as balance and occupation (Zemke & Clark, 1996). Of late, the benefits of occupational science theory informing occupational practice not only from a basic science perspective, but also from an applied science perspective is proposed by Wright-St Clair and Hocking (2014). The intent here is to help occupational therapists guide their practice in ways that are evidence-based. Important to this study is the link between occupational science and phenomenology and the development of concepts such as doing, being, belonging and becoming (Hammell, 2004; Rebeiro et al., 2001; Wilcock, 1998, 2006). In addition, the work of several occupational therapists and occupational science scholars such as Park Lala, (2011), Reed, (2008), Smith (2009) and Sutton, (2008) (described in more detail below) have also contributed to my thinking. 1.5.1 Occupational therapy approaches  Occupational therapy theoretical models focus on the ?dynamic interwoven relationship between persons, environment, and occupation over a person?s lifespan; the ability to choose, organize and satisfactorily perform meaningful occupations that are culturally defined and age appropriate for looking after oneself, enjoying life, and contributing to the economic and social fabric of a                                                  13 Vygotsky, 1978) attests that?? human learning presupposes a specific social nature? (p 88) and as we act in our world we are created by it through culture i.e., language. Vygotsky also describes the zone of proximal development as being ? what children can do with the assistance of others might be in some sense even more indicative of their mental development than what they can do alone.? (p. 85). This idea shows that people can change, try new things and grow if given the right scaffold or support. 15  community? (CAOT, 1997, p. 181). The dimensions of occupation present in the Canadian Model of Occupational Performance and Engagement Model (CMOP-E) are self-care, productivity and leisure, and the term occupational performance, refers to the dynamic interaction of three variables: person, occupation and environment (Townsend & Polatajko, 2007, p. 23). Christiansen (1999) notes that occupation is closely linked to the development of personal identities; i.e., we are created by what we do and thus can integrate our past, present, and future identities.  The American Occupational Therapy Association (2011), states that occupational therapists? concern is with a person?s ?engagement in meaningful occupations that support their participation in life situations. Occupational therapy practitioners conceptualize occupations as both a means and an end to therapy. That is, there is therapeutic value in occupational engagement as a change agent, and engagement in occupations is also the ultimate goal of therapy? (S65). As mentioned, of late, occupational scientists have engaged in helping solve a range of occupational therapy clinical issues with good outcomes (Wright -St Clair & Hocking, 2014).  1.5.2 Schizophrenia in the occupational therapy and occupational science literature  Krupa (2014) asserts that ?the connection between occupation and recovery is fairly explicit? (p. 570), and cites Davidson, Rakfeldt and Strauss (2010) who call for a return to occupational therapy and science in the recovery movement. This call is based on the belief that it is by being supported to engage in meaningful activities and roles that people who live with mental health issues recover (Davidson et al., 2010). Sadly, several studies show how people with mental health issues continue to experience significant disruptions to their activity participation (Bejerholm & Eklund, 2007; Chugg & Craik, 2002; Edgelow & Krupa, 2011; Krupa, 2007; Leufstadius & Eklund 2008; Minato & Zemke, 2004; Nagle, Cook, & Polatajko, 2002; Yanos & Robilotta, 2011). Twenty-four hour time-use studies have indicated that predominant activities for people who live with schizophrenia include ?sleeping, eating, personal care, and quiet activities such as sitting or resting and watching other people or objects? (Leufstadius, Erlandsson, & Eklund , 2006, p. 125). Krupa (2007) describes occupational disengagement as low participation in activities, lack of investment and commitment to personally meaningful activities, poorly defined identity through occupations and negative feelings, such as anxiety when engaging in activities. Thus, there is a marked qualitative and quantitative difference in the participation of individuals who live with a diagnosis of schizophrenia and those who do not. In addition, having a poor connection with specific occupations or a decreased sense of meaning regarding occupations makes recovery particularly challenging. The lack of opportunities results in 16  exceptional levels of disadvantage for individuals (Krupa, Fossey, Anthony, Brown, & Pitts, 2009). It seems that participants in these studies had difficulty reaching their possibilities. Indeed, together these studies lend support to the notion that activity participation is a public health concern and an important determinant of health (Krupa, Edgelow & Radloff-Gabriel, 2009).   An occupational therapy intervention using temporal adaptation attends to human activity patterns with a view to improving health and social participation (Krupa et al., 2010).  Edgelow and Krupa, (2011) reported on this intervention that was explicitly designed to assertively develop the occupational potential of people who live with significant mental health issues. Results of their related randomized controlled pilot study indicated that participants increased their occupational balance by engaging in activity for approximately 47 minutes more per day in than the control group. Overall changes in occupational engagement were not shown, but evidence of clinical utility was found (Edgelow & Krupa, 2011). 1.5.3 Phenomenological studies that set the stage for this research  Reed, Hocking and Symthe, (2011) built on Reed?s (2008) original work and examined occupation, for 13 people who experienced some disruption to their occupational participation. Their work renders interrelated and contextually influenced themes of occupation that include the call (related to ones? interests), being with (that creates a bond and a mood and subsequently influences meanings) and possibilities14 (meaning is created depending on opportunities that are opened up or closed). Their conclusion is that the meaning of occupation is complex and demonstrates to others and ourselves that we are capable of moving into our futures and of becoming more than we currently are. Reed (2008) recommends exploring more about ?meaning in occupation from the perspective of lived experience? (p viii).  Borg (2007) examined the nature of recovery for people who live with mental illness (24 out of 35 participants live with schizophrenia). Borg (2007) challenged society to support people with mental health issues in real ways, such that people may seek and secure the help they need in the community. She contends that recovery from mental illness is unpredictable and should not be taken lightly. Borg                                                  14 Heidegger describes the notion of possibility in terms of how Dasein (described in more detail in chapter 2) projects itself into the future. The asserting is that as people we understand ourselves best in terms of what is open to us in the future i.e., we are always pushing into our future possibilities (Heidegger, 1962/2008, p. 185/145).      17  supports further research involving everyday life and occupations, ?remembering that the trivial is not so trivial? (2007, p. 54). Smith (2009) looked at the experience of spirituality and/or religion with nine people who live with schizophrenia.  Smith (2009) engaged participants in a powerful discussion about spiritual practices, principles, choices, experiences and roles topics that have challenged health care workers and researchers for a long time. She also suggests that experiences of spirituality and or religion may provide a sense of hope for people and that occupational therapists can support this journey of freedom (and perhaps possibility) for people receiving services.   Sutton (2008) involved 13 people with a mood disorder and/or schizophrenia in a study about the meaning of ?doing? or activity participation in recovery. He presented five phases of recovery and described the experience of activity at each stage. ?Everyday activity was found to be an important medium for change as well as a recovery outcome in itself ? the study highlights the dynamics at play in different modes of doing and the way in which carers can influence the experience and meaning of activity? (Sutton, 2008, p. vi). Sutton contributes to our body of knowledge a greater understanding of the need for various play states in the therapeutic relationship; being mindful of how one?s ?presence, tone, tempo, language and actions influence the mood of the other? (p. 174). He adds that everyday being in the world is about participating in small projects that allow for a variety of possibilities while recovering one?s sense of becoming in the process. Sutton, Hocking and Smythe (2012) conclude that all forms of ?occupational engagement including disengagement can be meaningful in the recovery process? (p. 142). 1.6 Meaning in Activity A definition of meaning as it relates to activities or occupation is important to this study. Before embarking on this work, I identified the various definitions of meaning used in the occupational therapy and occupational therapy literature (please see, Appendix A  for a comprehensive list of definitions identified prior to the beginning of data collection in February, 2010). This study followed Smith (2009) and considered meaning in two ways i.e., that which is intended and that which is signified. In addition, work by Thibeault (2009; 2011) drawn from positive psychology identified core existential elements of meaning as compassion-love, gratitude, forgiveness, justice and temperance. Work by Rebeiro et al., (2001) Hammell, (2004, 2009) and Wilcock (1998, 2006) regarding concepts of doing, being, becoming and belonging, further influenced my understanding of meaning in activity.  18  Hammell (2004) notes that occupational therapists often consider meaning and purpose as one and the same thing; extolling meaning in occupation, but actually focusing on purpose as opposed to meaning. Similarly, Leufstadius, Erlandsson et al. (2008) note that the concept of meaning, meaningfulness, value and purpose has been used ?interchangeably in recent research? (p. 27). Hammell asks the critical question; ?whether engagement in purposeful occupations is sufficient to imbue life with meaning? (2004, p. 300). In the same vein Reed (2008) asserts that in occupational therapy the concept of meaning has been overshadowed by defining and defending practice. Additionally, according to Reed, occupational scientists focus on the conceptual meaning of occupation as opposed to the ontological meaning (i.e., the philosophical inquiry into the nature of being or truth). The call to better understand meaning in activity as situated in the literature is the central area of concern of this investigation. The compelling rationale for this work stems from a need to understand the lived experience of ontological meaning in activity from participants? perspectives and to gain a deeper understanding of how participants experience their possibilities with regard to occupation or activity participation as they live with schizophrenia. The end goal is to advance a situated understanding of meaning in activity that may advance practices and models that could be useful in recovery.   In conclusion, the literature review focused on central concepts relevant to the study, namely schizophrenia, recovery, psychosocial recovery, positive psychology, occupational science and occupational therapy. Throughout this review the concept of meaning was presented as it related to the aforementioned concepts and relevant studies were presented. Links were made to concepts such as social inclusion, human rights and existentialism. Justification for the study was offered by relating to occupational science and occupational therapy studies in particular. The following chapter presents the study methodology and methods.  1.7 Overview of the Thesis Chapter 1  The aim of this study (this thesis) is to deepen the understanding of experienced meanings in activity for people who live with schizophrenia. This study was situated in a large urban Canadian city with a complex mental health system whose philosophies and practices are ever changing.  This chapter began by reviewing the context and the associated literature regarding schizophrenia, recovery, psychosocial rehabilitation, occupational therapy and occupational science. The concept of meaning 19  was situated in the aforementioned bodies of knowledge and is specifically defined for this study (as that intended and that signified, Smith, 2009). Gaps in knowledge regarding the need to better understand meaning in activity for people who live with schizophrenia were also identified.  Chapter 2  This chapter presents the essential philosophical concepts used to guide the research process for this study. It also provides the reasons for choosing this approach.  Details regarding the study design are presented including recruitment and analysis of participants? stories. The final portion of the chapter discusses the issue of trustworthiness. Chapter 3  This chapter begins by situating individual participants in the study within their respective contexts; and then reviews a broader perspective view of activity participation for all study participants. Finally, three participant accounts are selected to show a more situated understanding of meaning in activity across these participants over time.  Chapters 4, 5 and 6 Chapter 4 focuses on how participants experience a sense of social inclusion through activities such as becoming a citizen and receiving a variety of government financial supports, as well as the experience of being recognized, or not, through activity participation (i.e., by developing skills).  Chapter 5 turns to the notion of social justice and experiences of engaging in activities for well-being. The positive experience of receiving enduring support from others is discussed, as are experiences of not doing and boredom. Chapter 6 focuses on experiences of being more fully human through activity participation. Chapter 7 The final chapter summarizes and discusses findings regarding the study in relation to practice, education and further research. Study strengths and limitations are also discussed. 20  Chapter  2: Methodology  This is the true joy in life, the being used for a purpose recognized by yourself as a mighty one; the being thoroughly worn out before you are thrown on the scrap heap; the being a force of Nature instead of a feverish selfish little clod of ailments and grievances complaining that the world will not devote itself to making you happy (George Bernard Shaw, 1903). Introduction This chapter presents the methodological and theoretical perspectives informing the research process and will outline the study methods. The study is situated in the philosophy and methodology of hermeneutic phenomenology. This chapter articulates the relationship between the research question, the philosophy of Edmund Husserl (1859-1939) and Martin Heidegger (1962/2008) and the use of hermeneutic phenomenology throughout the study. Relevant concepts will be outlined and justifications for the methodology and emergent research design will be provided. 2.1.1 Philosophical positioning  This study holds the position that meaning is made by the participants as they share their stories, by the researcher in considering the data and finally by the reader who interprets the findings through their particular historical and social horizons.  As Gadamer (2004) notes ?all reading involves application, so that a person reading a text is himself (sic) part of the meaning he apprehends? (p. 335). Van Manen (1990) acknowledges the importance of being able to articulate the epistemological or theoretical implications of doing phenomenology and hermeneutics. This ?set of beliefs,? or world view, (Denzin & Lincoln, 2005) of the researcher includes the articulation of a philosophical point of reference that provides a basis for defining truth regarding knowledge (ontology) and identifying how knowledge is generated and also identifying how the researcher is situated in the inquiry process (epistemology). Beliefs also shape the methodology (how one acquires knowledge) and the values stemming from philosophy guide the research process including ethics, aesthetics, and spirituality (also known as axiology) (Guba & Lincoln, 1994; 2005). Guba and Lincoln (2005) offer a taxonomy of key paradigms that include: positivism, post-positivism, critical theory, constructivism, and participatory axioms. The latter four axioms are presented as interpretive forms of inquiry (p. 200). Consistent with the call for 21  axiomatic congruence or resonance, this study cautiously blends elements of ?one paradigm into another? in order to generate research findings that benefits from the ?best of both world-views? (p. 201). Specifically, this ?open paradigmatic? stance enables the study to draw from neighboring paradigms, in particular in the interpretation and representation of findings and in the discussion chapters. The purpose of this study was to explore the kinds of activities people living with schizophrenia are involved in and to seek an understanding of the meanings these activities hold for them.  The research question (in two parts) was what activities do participants engage in and what are the meanings of these activities for participants? The study is therefore situated in a constructivist paradigm (Guba & Lincoln, 2005) with an interpretative epistemological underpinning (van Manen, 1999), as it seeks to understand participants experiences15 of meaning with regard to their daily activities. Ontologically, this stance accommodates an understanding that the world can be understood as a construction of experiential interactions that are context dependent. It can also be understood in relativist terms i.e., by embracing different perspectives those individuals bring to their existence. The position asserts there is not one truth but rather many perspectives on a phenomenon while at the same time acknowledging that there may be some shared essentials to experience. Within this study, knowledge is created from a subjectivist position i.e., it is co-created with the research participant and the researcher and is concerned with Verstehen (understanding) rather than Erkl?rung (scientific explaining) or explaining causal relationships (epistemology). Methodologically this study engages in dialogic methods and hermeneutics, which focus on written and unwritten data, human practices, events and situations, as a way to bring understanding of phenomena. Finally, from an axiological standpoint, constructivism values transactional knowledge, the formative nature of findings and the inclusion of multi-voiced texts (Guba & Lincoln, 2005). The next section will describe phenomenology and hermeneutics.                                                   15 Experience translated as Erlebnisse (or Erlenis ) is ?seen as the enduring residue of moments lived in their full intimacy ? (i.e., something you have) (Gadamer, 2004, p. xiiii) Erfahrung ? bases of our lives  in a hermeneutic way where we are related to others culturally especially by dialogue of questions and answers not a residue of moments  but an ongoing integrative process in which what we encounter widens our horizon by overturning an existing perspective which we may now see are erroneous or at least narrow (something one undergoes ? gives us a broad sense of perspectives Gadamer, 2004, p. xiiii). 22  2.1.2 Phenomenology Phenomenology is a dynamic inquiry, i.e.,  it is an evolving methodology guided by the ideas of founding philosophers such as Husserl, Heideggar and Gadamer. It is also described as a way of considering phenomena as opposed to a set of doctrines. Notably the language used by these philosophers ?resists hardening in to terminology [it is not] a technical language with stipulated univocal meanings? but is flexible and responsive to the movement of thinking about particular issues (Gadamer, 2004, p. xii). My thinking was informed by the classic texts written by these primary phenomenologists. It was also guided by van Manen?s (1990) lifeworld essentials and recognized occupational theoretical perspectives of doing, being, belonging and becoming  (Hammell, 2004; Rebeiro et al., 2001; Wilcock, 1998, 2006) described in the previous chapter. Below I offer a brief outline of the ideas of the philosophers most relevant to this research as a means to situate the study methodology and methods and eventually the findings and discussion chapters. This research approach encourages an ?attentive awareness to the details and seemingly trivial dimensions of our everyday,? highlighting the significant in the taken for granted of daily life (van Manen, 1990, p. 8).  As described by Husserl, phenomenology seeks ?pre-reflective? insightful non-theoretical descriptions in order to seek plausible insights that may bring us closer to the things themselves (van Manen, 1990, p. 7).  In this way the goal of phenomenology is not just to present the ?general structure of self-interpreting being; it claims to force into view a substantive truth about human beings? (p. 37). 2.1.3 Edmund Husserl and the origins of phenomenology  The tradition of phenomenology emerged at the end of the 19th century beginning with Edmund Husserl (1859-1939) (Giorgi & Giorgi, 2003). For two years he was a student of the influential philosopher and psychologist Franz Brentano (whose was intent on revising Aristotelian logic). Husserl was critical of the prevailing positivist sciences and proposed an alternative i.e, one that attempted to go back to the things themselves and re-integrate the world of science and the ?lifeworld.? His significant contribution was in attempting to describe rather than explain phenomena through lived experience (Moran, 2000). 2.1.4 Core contributions  A controversial aspect of Husserl?s work was the concept of the epoch? meaning cessation or bracketing of world-positioning character (positioning of being) of the researcher. He noted that it is 23  impossible to ignore one?s world-positioning character but one could choose to bracket it ? by first acknowledging it and isolating it in order to grasp the pure phenomenon. In his later years he ?came to realize that the ego played a crucial role not only in generating these acts and in stamping its unifying synthesis upon them, but in structuring the meaning-constituting functions of the acts themselves? (Moran 2000, p. 77).  Husserl asks the phenomenologist to engage in imaginative free variation in order to establish the essence of an experience (Moran, 2000). The idea is to vary specific dimensions of an object or experience (and sometimes removing parts of them) in order to determine the invariant aspects of the experience or object (Giorgi & Giorgi, 2003). He hoped that by using the variation that the edios or the essence of a phenomenon could show itself or be reduced to ?a structure of its essential possibilities? (Moran, 2000, p. 154). Husserl struggled to adequately describe this process (Giorgi & Giorgi, 2003). Imaginative free variation is connected to phenomenological reduction (insights are reduced and clarified with others involved in the research process, described more fully in the analysis section) by retaining the mode of imagination and thus staying away from the traditional naturalistic positioning. He posited that humans are connected to the world where they encounter an event and are conscious of something. Husserl described ?intentionality? as being a psychic act or a structure of consciousness (Giorgi & Giorgi, 2003). By contrast Heidegger for the most part considered intentionality as a practical embodied act. During his last teaching position Husserl became a mentor to Martin Heidegger; a relationship steeped in strife and intellectual challenge. 2.1.5 Martin Heidegger Martin Heidegger (1889-1976) was a philosopher of the 20th century who concerned himself with the nature of Being. Heidegger was born in Germany, and was raised a Roman Catholic. His political ideology has been passionately debated in the literature. It seems clear that Heidegger was in some ways at least complicit in the work of the Nazi party in the 1930?s; a deeply troubling fact that adds complexity to his legacy and is challenging to reconcile. It also inspired me to consider the impact of this belief system on his work and leaves me curious about how he would view this work. As I become more familiar with his text I see no explicit or implicit reference evidence of Nazi ideology but I am drawn to his ideas of considering what it is to be essentially human. What is clear is that he resigned from the party early in 1934. He also inspired his own students (i.e., Hans-George Gadamer and Hannah Arendt) and also philosophers in France and Germany such as J?rgen Habermas, Herbert 24  Marcuse, Emmanuel Levinas and Jean-Paul Sartre. While some of these authors took an essentially critical stance on Heidegger?s work, he nonetheless remains one of the most ?important critical thinkers of the twentieth century? (Moran, 2000, p. 247). This leads me to believe that despite his Nazi affiliation his philosophical work remains an important source in developing human understanding. 2.1.6 Core contributions Heidegger?s seminal work Being and Time was first published in 1927 and translated into English in 1962. I primarily refer to this text and commentaries on this text to help me gain a deeper understanding of phenomenology.  Heidegger sought to understand the meaning of our everyday existence and Being is the essential element of being human according to Heidegger (1962/2008). Being was the central focus of his work and he studied being in order to ?make sense of our ability to make sense of things ? and to reawaken in people a feeling for the importance of this very obscure question? (Dreyfus, 1991, p. 10). It is only through the lens of being that he considered doing but it is clear that doing is important in order for us to reach our potential for being.  Being-in-the-world is more than just occupying space according to Heidegger; it is more akin to being-in a world of engaging in things and encompasses a sense of totality of being-with-the-world or being-in-the-world. This latter term will be used to articulate the sense of being connected to the world at hand while engaging in activity. The sense of being-in-the-world in totality infers a sense of belonging or geh?ren may involve a dialogic process and or comportment and is linked to Heidegger?s notion that being-in-the-world as a to-and-fro process of actively shaping as well as being shaped by other entities in the world. Dasein, is another key concept for Heidegger and in colloquial German can mean ?every day human existence? (Drefus, 1991, p. 13) or being there, being opened or being-in-the-world. Husserl?s notion of intentionality is replaced by the conception of Dasein?s transcendence.  Dreyfus cautions that we should not think of Dasein as a conscious subject in Cartesian or Husslerain terms but rather that humans have an embodied understanding of what it is to be in the world. Heidegger (1962/2008) calls Dasein?s self-interpreting way of being, existence and asserts that cultures as well as beings exist in this way. He is most concerned with analyzing existence and comes to learn more about it through the notion of care.  Heidegger (1962/2008) offers that by ?working out the phenomenon of care, we have given ourselves an insight into the concrete constitution of existence? (p. 231/ 274). In other words, it 25  matters to us who we are (Blattner, 2012). Through the call to care for one?s own being or for something in the world we become our own most unique self. The ultimate responsibility to answer this call rests with each of us individually and we must choose our own course of action to this call.  Dasein?s way of being in the world is of being thrown into history while at the same time becoming. However, Dasein also has a sense of resoluteness or ownness as a way of being and can take a stand on itself by relating to its public nature and its possibilities. We begin to ?tamper with and manipulate things as determined by our interest and our goals,? those things that are ready-to-hand (Moran, 2000, p. 233). Only through intentional or theoretical doing do we manipulate equipment or objects such as a hammer for the sake of inspecting it and these things are simply there or present-at-hand. Being engaged practically with the world is referred to as comportment or Verhalten. Park Lala (2011) posits that ?[w]hile Being is not unfamiliar to the occupation-based literature, the notion of Being from a phenomenological perspective has not been deeply considered in the occupational science literature? (p. 125). I am particularly taken with the following aspect of Dasein as described by Blattner (2012) ?Dasein?s being is a matter of its motion into the future;? it ?is what it becomes (or alternatively, does not become)? (p. 91). In other words I am interested in knowing the how of experience (van Manen, 1990) as it relates to possibilities for the future as experienced by participants.  Heidegger challenges us to consider that we are what we engage in (what we do) and are influenced by our doing and the way in which we do things in the world. The latter position is congruent with constructionism (Berger & Luckmann, 1966) not in terms of building a system for understanding but in the context that both taken for granted knowledge and meanings that are present in the world come to constitute a public reality and influence individuals? behaviour. This public knowledge is intersubjective and socially constructed and allows for the possibility of absorption in the world in a way that is fallen (Dreyfus, 1991).  An assertion regarding publicity by Heidegger is particularly relevant to the findings. Heidegger asserts that human understanding is a result of engaging in the everyday publicity; the world that has successfully absorbed new learning into tradition. Man (sic) lives in this unaware space as Das Man in inauthentic doing as he/she cannot live in the truth all the time. This structural feature of everydayness is called fallen or Verfallen where in some respects we run away from things as a result of being thrown in the world. Heidegger asserts that this is an essential mode of being and one that must be experienced before one can find the possibility of becoming 26  authentic. Our modes of being are connected to state of mind, mood or Stimmung and describe the way the world appears to us i.e., as a way we attune ourselves to the world as opposed to a subjective feeling (such as fear or understanding; an existential way of being). Our everyday fundamental disposition is one of a neutral mood i.e., one of not getting involved in things. Heidegger was interested in how things both appear and are covered up. For this reason he asserted that phenomenology cannot involve description alone and, in order to seek a better understating or interpretation, he links phenomenology with hermeneutics; he asserts that truth comes into the open via dialogue. Heidegger was also drawn to the etymology of words and became an inspiration for others such as Hans-George Gadamer. 2.1.7 Hans-George Gadamer and the contribution of hermeneutics  Much of my understanding of hermeneutics comes from Gadamer?s seminal work Truth and Method, (2004). According to Gadamer (2004) hermeneutics is the time-honored name for the art of interpretation; of helping us understand what happens in our experience beyond the realm of our intentions and our goals. He believes that language not only shows humans who they are, but also lets humans come into existence? including developing self-understanding and as existing communally. Language is imbued with historical and cultural influences and therefore is in some way resistant to being fully understood; language is an essential mode of understanding but not a direct window to understanding experience. Gadamer maintains that the researcher does not ?remain trapped within our own subjective viewpoint? and that that we can transcend our own point of view in seeking to be understood by the others as we open ourselves and take the risk sharing our assumptions (Moran, 2000, p. 270). He calls this experience Erfahrung and proposes that this is the core of our lives where we relate to others especially by dialogue of questions and answers in an ongoing integrative process. As we undergo this experience it widens our horizon by overturning an existing perspective. These enduring residues of moments lived in their full intimacy he names Erlebnisse (Gadamer, 2004, p. xiiii). Gadamer asserts that understanding is fundamental to Dasein and this understanding will provide insight on truth itself. He agrees with Heidegger in saying that truth is a process of ?unconcealment, as a simultaneous revealing and concealment;? realizing that truth is both in the unspoken and the spoken (Moran, 2000, p. 281). The compelling task of trying to find common agreement on language Einverst?ndnis the German term, (infers this is a process of two minds becoming one) opens new 27  possibility of understanding which can be prompted in the first place by misunderstanding between people. 16 17  Gadamer?s (2004) and Heidegger?s (1962/2008) notion of play is also helpful in considering the data as it extends thinking beyond the subject and the object nature of a game or an activity and is helpful in considering how people become and stay engaged with activities. Gadamer believes that, in general, play ?fulfills its purpose only if the player loses himself? in the experience and he describes play as a to-and-fro movement (2005, p. 102-103). Thus, play is a natural process that involves the freedom to choose, is without strain, and is experienced as relaxation; as a pure self-presentation. Play absorbs the person such that the effort of initiating is relieved but one?s play is determined by the context and rules of each game.  He shows that play is not a subjective attitude but that the player is caught up in and shaped by the game. Heidegger (1962/2008) introduces the idea of movement or freedom as he speaks of the lived space that Dasein makes for itself in its existence. He calls this space Spielraum or leeway (p. 368). Sutton (2008) writing from an occupational science perspective links the idea of play to the spaces we inhabit that allow us to connect the self and the world-at-hand. He cites Inwood (2004) and names this space a ?play-space? because it is here that human beings play out their lives with the diversity and variability of a game? (Sutton, 2008, p. 71-72). He also reminds us that play, conceptualized in this way, may be imbued with a certain mood. Central to this idea is that a positive play space draws one in and the activity holds the player?s attention whereas a negative space can result in a closing of space.  Fundamental to Heidegger?s work is the hermeneutic principle of understanding the particular in the light of the whole. The idea being that one must consider context when discerning meaning or that meaning is presented by a part but understood within the light of the whole ?horizon of meaning.?  Gadamer also refers to the hermeneutical circle and acknowledges that an interpreter is constantly shifting from the specific part to the greater whole in order to let new and sometimes taken for granted meanings show themselves. It is then possible for the researcher to move from the particular meaning                                                  16 Dr Marvin McDonald patiently and explicitly demonstrated this way of understanding during four extended conversations between 2010 and 2012 with two fellow PhD students. I employed this technique during interviews and in particular to help research participants and I to reach a common understanding of my interpretations of the data.  17Through a misunderstanding I came to appreciate the important role that his church group (rather than his spirituality practices) played in Painters road to recovery. I learned how the ties that existed between the church and his father called him to become re-engaged in the church and being open to the advice of following his doctor, which he sees as a pivotal strategy for managing his illness and engendering his well-being. 28  of a phenomena offered by an individual to the collective meanings of all participants. This approach is particularly helpful in that it helps the researcher to hold the particular while at the same time describing a shared understating of phenomena.  2.1.8 Max van Manen and the four existentials  Van Manen?s (1990) four Lifeworld existentials are used as a guide to reflection.  These interconnected but not separable essentials are said to be basic modes of human existence and include: lived time or temporality, lived space or spatiality, lived other i.e., relationality or communality, and the lived body or corporeality and are seen to belong to the lifeworld (1990, p. 101). Lived space is seldom reflected on, is non-verbal and helps us to understand the way in which we feel about space we occupy. Lived body refers to the fact that we are always in the world in a bodily sense and that we both reveal and hide something of ourselves through our body, perhaps deliberately and unconsciously. It also suggests that our lived body brings with it a sense of living inter-subjectively and dynamically. For example, we may be aware of someone?s gaze upon us and that may in turn cause us some discomfort. In this way the lived body can act as a portal to the lived world; as such the body is a skillful and practical entity that helps us navigate our world intelligently. Lived time refers to subjective sense of time passing as opposed to time that is measured mechanically; the idea that time passes instantly when we are absorbed in doing something we love and slowly when, for instance, we wait for a kettle to boil. Van Manen (1990) writes that the ?temporal dimensions of past, present, and future [are dynamic and] constitute the horizons of a person?s temporal landscape? (p. 104). Van Manen (1990) asserts that understanding one?s sense of time can provide a deeper sense of mood as one engages in an activity i.e., it can provide a glimpse of how one may be imbued with a sense of possibility or gloom for the future.  Finally, lived other speaks to the relationships we hold to others in the space we share with them (p. 104). In the existential sense we become more fully human (Deegan, 1988) in this space. Considering these existentials allows us to perceive a more rich sense of meaning in human experience.  2.1.9 Making the case for hermeneutic phenomenology  The literature review identified gaps in current understandings within the occupational therapy and occupational science literature regarding meaning in activity for people who live with schizophrenia. Hermeneutic phenomenology is seen as a good fit for the focus of this study as it helps to describe the meanings that participants experience in their daily activity. This study aims to refocus research that 29  attends to participants? lived and embodied experiences. It also aims to uncover deeper individual meanings that exist in the stories of people who live with mental illness that may otherwise be covered over by the public meaning of these phenomena. In summary, this section laid the ground for the study by outlining the methodological and theoretical perspectives that informed this work. This included a constructivist paradigm (Guba & Lincoln, 2005) with an interpretative epistemological underpinning. A brief description of phenomenological methodology was offered along with an introduction to three key phenomenological philosophers and an overview of a theoretical perspective offering an embodied approach to phenomenology. It is noted that this approach is one of many approaches and was chosen because it is a powerful means to begin to answer the research question. 2.2 Methods  This methods section demonstrates the particulars of the research journey and the principles that guided action in gathering and analyzing the research data. Van Manen (1990) proposes that phenomenology is an iterative, emergent process with guidelines that may not lead to repeatable results. However, described below are the principles and practices that guided the interviewing and analysis within this study and serve to help the reader understand how the findings were created and represented.  2.2.1 Ethical considerations  Protecting participants was an important aspect of this study as people who live with mental health issues have often experienced a reduction in their freedoms both within and outside of the mental health system. Consistent with the application that was approved by the UBC Behavioural Research Ethics Board, verbal consent was obtained from each prospective participant prior to the first study visit. Further, prospective participants were given written and verbal information about: (1) the purpose of the research; (2) what is required of them; and (3) their freedom to refuse to participate or to withdraw from the study at any time without negative consequences. Each participant was reminded as necessary throughout the research process of the purpose of the research, the procedures, and that they could always refuse to take part. This is an inclusionary approach that views consent as an ongoing process occurring in a relational context (Dewing, 2002).  30  As a researcher I needed to ensure that my research honored my scientific and ethical obligations to protect participants and to balance the risks and benefits with participants. The anticipated benefits for participants in this study included an opportunity to help develop valuable and useful knowledge for the rehabilitation field. Participants were given a $20 coupon to a store of their choice, as a small token of appreciation for their contribution at the beginning of each interview. One of the real risks involved in this research was the possibility of additional stress for some participants, which could have prompted the need to provide additional support. Previously identified additional supports (in addition to the researcher) were available to participants. Data were checked and adjusted according to the wishes of the participants as a way to equalize power within the research relationship.  2.2.2 Research question and objectives  The main research question was: What kinds of activities are participants involved in and what kinds of meaning do these activities hold for participants who live with schizophrenia? In other words, what is the lived experience of meaning in activity for people who live with schizophrenia? The study objectives were: 1. To uniquely contribute to our understanding of activity participation and personal meaning in the everyday activity or occupation of people who live with a diagnosis of schizophrenia.  2. To utilize a hermeneutic phenomenological approach that would generate a systematized and contextualized approach to understanding meaning in activity for people who live with schizophrenia. 3. To contribute to a person-centered perspective on the experience of meaning in activities for people who live with schizophrenia and add to the body of knowledge about this approach to research. 2.2.3 Recruitment  The study was undertaken within a Canadian urban setting. Ten study participants were recruited through posters distributed via Vancouver Community Mental Health Services (VCMHS), for display on public notice boards within the system. Posters were also circulated to Non-Government Organizations (NGOs) such as Coast Mental Health, Open Door, Canadian Mental Health Association, and Motivation, Power and Achievement Centre. The posters requested that interested potential 31  participants contact the researcher directly. The researcher also visited the seven mental health teams and other adult specialized services (such as Housing,  Early Psychosis Intervention Services (EPI) and  Community Link) and distributed information packages to staff who disseminated the information to prospective participants.  Potential participants were advised to connect with the researcher directly via the telephone number and/ email address provided on the poster (see Appendix B). Staff from Vancouver Community Mental Health Services, now called Vancouver Mental Health and Addictions (VCMHA) was requested to distribute posters to individuals who met the study inclusion criteria.  2.2.4 Inclusion and exclusion criteria  The inclusion criteria were: a psychiatric diagnosis of schizophrenia as defined by the DSM -IV?TR (American Psychiatric Association, 2000) and identified by a psychiatrist, individuals who could read and speak English, were between 19 and 55 years old, who use the services of Vancouver Community Mental Health Services (VCMHS) or agencies such as Coast Foundation or Motivation Power and Achievement (MPA), who had a history of two or more psychiatric hospitalizations but not within the six months prior to their participation in the study and who experienced some degree of positive occupational recovery within the last five to seven years, i.e., they could describe being involved in at least one activity that has some meaning for them. The additional inclusion of two individuals with negative symptoms aimed to ensure maximum variation of the purposive sample. Specifically, these individuals experienced social withdrawal, self-neglect (such as lack of attention to personal hygiene), loss of motivation, emotional blunting and or paucity of speech (Picchioni & Murray, 2007). These negative symptoms were identified by the referring health care professional and the participant.  This criterion was included as it may lend light on how negative symptoms may impact activity participation. A strong rationale for including 10 participants related to the fact that there were four separate data collection points for each participant which resulted in 40 transcripts that were rich with data. Ten participants is within the within the recommended range of between six to 12 participants for a phenomenological study (Thomas & Pollio, 2002) and is in keeping with similar recent qualitative studies (Park Lala, 2011; Reed 2008; Smith 2009; Sutton, 2008). The age group selected allowed the study to focus on adults who were not necessarily managing additional challenges associated with older age; the literature indicates that older adults with schizophrenia have different needs, deriving from factors such as dementia or a change in life goals and roles (Patterson, Mausbach, Kibben, Bucardo & Jeste, 2006; Pentland, Miscio, Eastabrook & Krupa, 2003). Exclusion criteria were people receiving services with a DSM-IV-TR (APA, 2000) diagnosis other than schizophrenia (e.g., 32  schizoaffective disorder), those who have a diagnosis of dementia, those who are unable or unwilling to complete all research interviews, and those who pose a serious suicide risk or who are either actively using substances at the time of interview or have misused substances within the last month. 2.2.5  Pre-interview meeting or screening  Once the ethics application was approved at both UBC and Vancouver Coastal Health Research Institute (VCHRI) the study was advertised and participants were asked to contact the researcher by telephone and or email. An initial meeting occurred at UBC, at VCH mental health administrative offices or at a mental health office of the potential participant?s choice. The participant was offered a study information package which included: a letter of invitation, informed consent letter, and consent for the researcher to consult with the person?s health professional, and the interview questions. In accordance with the UBC?s BREB policy potential participants were given a minimum of 24 hours to review these materials prior to the first interview. The study package of written materials was reviewed as were the aims and procedure regarding study criteria and any questions that the potential participant had were answered (see Appendix C Recruitment Package). Participants signed the Consent Form prior to the first interview.  During the recruitment process participants were also asked for written permission for the researcher to speak to his or her mental health care professional. The purpose of this contact was to confirm that the person met the study diagnostic criteria and he or she was not misusing substances in the past month and, to ascertain whether participation in this research at this time was advisable. Initial contact with participants? professional supports was not an ideal process for a phenomenological project. However, it was necessary in order to ascertain if the participants were well enough to participate in the study. If the professional withheld consent entry to the study would be denied however, this did not occur.     2.2.6 Participants  Through purposive sampling, the researcher selected 10 participants who met the inclusion criteria above. Purposive sampling was intended to provide guidance for the inclusion of participants who provided a variety of experiences in terms of their activity participation across participants (i.e., the variety and the number of activities participants engaged in). It was also intended to consider a variety of age, gender, source of income, marital status, and length of time in recovery and self-appointed level of recovery, negative symptoms, and location of mental health service delivery. Please see Table 2 for 33  maximum variation/demographics table. Two additional men and one woman volunteered for the study and were not included. The woman was of similar age to Rebel Girl and was involved in similar kinds of activities. Both men were in their early 50?s and were engaged in similar activities to Peter and Jonathan. In these instances it was decided in collaboration with my PhD committee to seek alternative participants to maximize variability of the study sample. 2.2.7  Orientations to the phenomena  Gadamer (2004) articulates the need to ? distance oneself from oneself and from one?s private purposes? in order to look at things in the way that others see them and thus keeping oneself open to the other more universal points of view (p. 15). Similarly, Wilding and Whiteford, (2005) recommend identifying the social, historical and political contexts that makes the researcher who she is. This horizon is the position from which one sees the world, its possibilities and seeks interpretations. Van Manen (1990) recommends reflecting on one?s experiences as a starting point for any study. To that end the next section will provide an overview of my horizon through the means of a brief biography and reflections on speaking to a colleague who lives with schizophrenia.  My introduction to mental health began as a child growing up in the rural town of Monaghan, home to one of Ireland?s largest long-term psychiatric hospitals, St Davnet?s. Built in the late 1800s, it was the largest asylum in the country at the time.  The patients, staff and well-kept expansive hospital grounds were a significant feature of life for local people, and on occasion a source for social narrative, almost on the mythic level. As a child on my way to and from school, I encountered and greeted ?patients? who were deemed well enough to be in the community. I fondly remember having unlimited access to the hospital?s swimming pool, where my friends and I spent many entertaining hours. Sometimes we would attend mass on Sunday at the hospital, go for long walks, and almost always find some mischief to get into. In fact, my first teenage kiss occurred on the site. This community oriented introduction to mental health produced in me an ease with people who lived with mental illness. However, it may have also have made me so familiar with their conditions that I did not question (as much as I might have) the quality of life that residents had in this institution, or how our community may have better supported these individuals in general and also during de-institutionalization in the 1970s (Farragher, Fahy, Carey, & Owens, 1999). 34  A recent and sad newspaper article (The Irish Times, 2010) demonstrates how our community was oblivious to at least one long-term resident Charlie ?The Hare? Maguire, who spent almost two thirds of his life in this institution. He was born as a result of an arranged second marriage to a father of 72 years. Displaced from his original home at the age of six upon the death of his father and engaged in some mischief, Charlie subsequently became a ward of the state at age eleven and was institutionalized in a workhouse. Troubled after his release at 16, he was convicted of stealing five hens. By the year I was born he was admitted to St. Davnet?s Hospital and diagnosed with schizophrenia. Ten years later the state purchased his home but the money was never distributed to him; despite his own advocacy and that of his psychiatrist he died at the age of seventy-seven as an involuntary patient with no income. ?The fact that there is no photograph to accompany this obituary of Charlie Maguire tells its own story? (The Irish Times, 2010, last para.).  I have worked as an occupational therapist in mental health for 20 years. As a result of this prolonged engagement, I need to carefully clarify meanings that I may otherwise take for granted (Kvale, 1996). For example, one of my committee members recently brought to my attention that I may hold an assumption that it is through positive meaningful activity that people recover from mental illness. This perspective may not leave room for an appreciation of the power of negative experiences, which may in fact be equally meaningful to people?s recovery. I am grateful for this feedback and needed to be mindful of this possible bias during the research.  A significant personal reason for pursuing this study is that in my role as an occupational therapist, I occasionally find myself at a loss to know how to best support people in maintaining, restoring, or developing their involvement in meaningful activities (a frequent goal in occupational therapy intervention). Some people I have worked with have also expressed sentiments such as, ?I lost 20 years of my life to this illness? (Anonymous). Meaning, these individuals felt they could not do the things they wanted or needed to do for a long period of time, decades even, due to their illness. Fundamentally, much of what I have learned in my career as an occupational therapist has come from people who live with schizophrenia. It is therefore apparent to me that people who live with schizophrenia have a great deal of genuine expertise to share in terms of their experiences (Borg, 2007; Davidson, 2003; Schneider, 2006) with meaningful activities (Sutton, 2008). 35  2.2.8 Pre-proposal collaboration As part of a pre-proposal collaboration, I interviewed a colleague called Renea Mohamed (name used with permission) who lives with schizophrenia. Renea edited the ensuing passage in March 2013. This interview experience helped to distill my own pre-understanding of meaning as it relates to activity participation. This interview provided an exemplar of someone who engages in activities she perceives as being deeply personally meaningful. She actively made choices regarding her employment so she could make use of her experiences with schizophrenia to help others. I respect this person and am in awe of how she speaks about her illness and how she includes a loved one in her wellness plan. From her perspective she has a good quality of life. At the time of the interview I had only met a handful of people who said this while living with schizophrenia. I also gained a deeper understanding of how Renea is required to manage symptoms from time to time that impact her ability to do the things she loves. I remain impressed with her ability to articulate how her experience with schizophrenia has shaped her choice of volunteer activities, how she chooses to engage with her community and her work life.   Renea said ?what was once my chosen work [as a librarian] no longer is my chosen work and I no longer have an interest in working in the area I originally studied for. I am doing my chosen work now, work that means a lot more to me than what I set out to do originally? (Renea Mohammed, personal communication, March 1, 2013).  In her current role as consumer leader, educator, and key change agent within a large community mental health organization, she uses her experience and expertise to provide instrumental support and hope to others who live with significant mental health issues including schizophrenia. Renea adds ?my struggles with mental illness have been a transformative experience, and I have no desire to go back to the way I was prior to those experiences nor do I have the same wishes in terms of work.? (Renea Mohammed, personal communication, March 1, 2013). The next section returns to the interview procedure.   2.2.9  Interview procedure Once the health care professional had been consulted to ensure that an individual met study inclusion criteria, an initial 60-minute interview was offered to the participant. At interview one, the researcher ensured that the informed consent was signed and provided a copy to the participant before proceeding 36  with the interview questions.  The first interview consisted of informally ascertaining demographic information such as: age, gender, living situation, level of education, gross income, marital status and their self-identified level of recovery, establishing the kinds of activities that participants are involved in and the meanings those activities hold for participants. The researcher also briefly asked about the experience of schizophrenia and recovery. A significant aim of this initial interview was to seek maximum variation of the phenomena being studied. For example, the study sought variation in the kinds of activities being done, the frequency of participation, the reasons people participated in those activities, and the meaning the activities held for participants. In order to obtain variation, the researcher offered follow-up interviews to individuals who demonstrated a range in these characteristics. Interview one was carried out at an appointed location (UBC or VCMHS administrative office), and subsequent interviews occurred at a location of the participant?s choice. 2.2.10 Narrative interviewing  Interviews should be approached with a sense of wonder or ?openness? (Kvale & Brinkmann, 2009) towards the fundamental everyday lived experience. This ?conversational interview? as described by van Manen (1990) has two purposes: a) to gather experiential data and b) to ?serve as an occasion to reflect with? the participant on the topic at hand (p. 63). These purposes are often representative of different phases of the interview process. In this study the interviews occurred over a two year period which afforded the gathering of rich experiential stories from the participants. All participants were interviewed four times. Field notes recording my observations and reflections were also a rich source of data. Interviews took place in mutually agreeable locations that had some significance for participants such as a clubhouse, a favourite place and a familiar coffee shop. Participants chose their own pseudonyms for the study. The resulting data were subsequently analyzed for understanding of meaning in activity for participants.  Upon completion of each interview, a transcriptionist who had signed a confidentiality agreement transcribed the data verbatim from the audio file. All pauses and repetitions were left unedited in the transcripts. I checked each transcript for accuracy and discovered that occasionally the transcriptionist made an error in word selection. In addition, missing data were added where possible (a word may have been unintelligible). These gaps were corrected where possible after a careful review of the audio file and appropriate corrections were added.  37  Interview questions focused on activity without seeking causal explanations. Questions were also asked about mood, feelings, emotions and bodily sensations such as smell or touch. These lifeworld existentials were used as guides for reflection during the analysis phase. The factual accuracy of the account was less important than ?plausibility? of the rendered experience (van Manen, 1990, p. 65). In other words, it was more important that the description presents as something that could reasonably be experienced rather than its accuracy. Questions encouraged participants to describe specific situations or experiences in greater detail such as ?And so then what happens after you come home?? Questions such as; ?how did you feel when you were doing that?? or ?can you tell me more about that??  Or prompts such as ?In what way?,? ?how, what?s different?,? ?Would you say you have more energy?? were used to encourage the participant to render a deeper description of the phenomena and to stay focused on the topic at hand (examples of questions from Lisa, interview 4).  The idea of prolonged engagement is typical of a hermeneutic interview in the ongoing development of the transcripts. During this study I consulted with participants on four occasions and each subsequent interview built on previous conversations, which served to validate and deepen my understanding of the phenomena. As noted by van Manen (1990), gathering and interpreting data are seldom separate or discrete phases. During these subsequent interviews, additional time and space was offered to respond to specific topics that arose for each individual during the interview. Additional interviews also provided an opportunity to address issues that arose during the preliminary analysis with committee members. For example, during the analysis phase, a committee member suggested additional questions regarding the phenomena of boredom in order to better understand this experience. The final interviews allowed for space to consider how participants experienced a sense of possibility in their activity participation. Through an iterative process and with the use of a word table all participants offered verbal feedback on my descriptions of their activities and my interpretations of meaning regarding those activities. These collaborative experiences offered a powerful opportunity to deepen understandings. In addition, some participants also gave written feedback and this data was also folded into the data. For example, Peter offered a letter that a friend sent in appreciation of their friendship and this document contributed to the understanding of belonging for this participant. Others asked for a copy of my notes and adjusted my descriptions and interpretations as they saw fit.   38  Some participants were keen to provide information they thought I was seeking. For example, Rebel Girl (self-identified pseudonym) began listing all the activities she was engaged with and seemed to provide this information in a rather remote fashion. However, over time the speed at which she provided the information decreased and her accounts seemed more complete in terms of the experience rendered. After 40 interviews, an adequate depth and breadth of experience was obtained and this showed as many of the new interviews provided similar information to that collected in previous interviews.  The final interviews allowed an opportunity to consider the notion of possibilities as experienced by participants through their activity participation. I asked participants to consider their hopes and dreams in terms of activities and I also asked if they had advice for other people who live with schizophrenia. A summary of findings will be provided to them in recognition of their participation.  2.3 Analysis Gadamer (2004) advises that ?interpretation is necessary where the meaning of a text cannot be immediately understood? (p. 332). The following section outlines the phases of analysis that brought me to articulate the findings. I divided the analysis into two phases. The first phase began with a descriptive analysis and moved into a second phase, an interpretive analysis. The first phase essentially answered the initial part of the question by identifying the activities that people engaged in. The second phase was an interpretative analysis that rendered findings regarding the meanings of activities. During the early descriptive phase I primarily drew from the work of Husserl. I was also guided by the work of Giorgi and Giorgi (2003) and Willig?s (2001) descriptive phenomenological analysis process in order to answer the research question. Giorgi and Giorgi (2003) and Willig (2001) provided a helpful step-by-step approach to analysis that considered the ?content as well form? (Giorgi & Giorgi, 2003, p. 250) of activity and meaning for participants. In other words, this approach to analysis allowed me to consider context. In the second phase I drew mainly from the work of Martin Heidegger, Max van Manen and Hans-George Gadamer. This approach to analysis offers one interpretation of the data and it is acknowledged ?no single interpretation of human experience will ever exhaust the possibility of yet another complimentary, or even potentially richer or deeper description? (van Manen, 1990, p. 31).   39  2.3.1 Analysis phase one  The first step in the analytic process began by reading the transcripts several times in order gain a greater sense of the whole data set and subsequently develop meaning units (Mus) (Giorgi & Giorgi 2003, p. 251-252). These Mus are contextual units that contain one aspect of the phenomena. The intention was to provide a more rich understanding of activity participation that could also inform the context in which these activities took place. Every time I perceived a change in meaning a new meaning unit was established. These Mus were formatted into a table using Microsoft Word (Please see Appendix D  Each transcript rendered approximately 50 Mus and the study rendered approximately 2,000 Mus in total. In this thesis, participant quotations are identified by participant initials followed by interview number, followed by a period and number indicating a specific Mu. Step two involved a phenomenological reduction intended to describe the phenomenon that presented itself by seeking pre-reflective experiences as much as possible while acknowledging that this can be a challenge. The goal of this reduction is to identify the constituents of experience of the phenomenon and the intent is to make clear a person's feelings and thinking that are unique to the experience of the phenomenon under study (Giorgi & Giorgi, 2003; Willig, 2001). The first action is to identify the physical (P) features of the experience such as shape, size, color and texture, as well as experiential features of the experience such as the thoughts or cognitions (C) and feelings (E) that appear in our consciousness as we attend to the phenomenon (Willig, 2001).  Husserl?s Imaginative variation involves an attempt to access the structural components of the phenomenon. That is, while phenomenological reduction is concerned with 'what' is experienced (i.e. its texture), imaginative variation asks 'how' this experience is made possible (i.e., its structure). The aim of imaginative variation is to identify the conditions associated with the phenomenon and without which it would not be what it is; the context. This could involve time, space or social relationships (Willig, 2001). I added a final constituent of experience i.e., that of meaning within each Mu.  As noted meaning here was consistently defined as what was intended or signified by the participant with regard to their activity participation. Lastly, I added a separate column for my own reflections and note taking that was helpful for the analytic process. This phase of analysis was used to develop chapter 3 and also influenced the findings reported in chapters 4, 5 and 6. (Please see Appendix D for an example of this step). 40  This analysis process was guided by the central question, what activities do participants engage in and what are the meanings of these activities for participants? In step three of the first phase of analysis textual and structural descriptions were integrated to arrive at an understanding of the essence of the phenomenon. This was accomplished through writing selected individual experiential structures and by applying a hermeneutic lens and staying as close to the participants? language as possible. This phase of analysis was guided by the work of Giorgi and Giorgi, (2003). The rewriting process required at this step considered context, language, and participants? descriptions of the significance of the activity. The goal was to render explicit the implicit meanings and describe the intentions that are within each meaning unit while at the same time preserving the language used by participants. (Please see Appendix E  the Structure of the Experience of Driving Her Car: Athena). As a result of this phase of analysis, I categorized activity participation for all participants. These findings are presented in chapter 3.  This phase also involved cross-participant comparison to facilitate understanding the shared experience of meaning in activity and meaning in life for three participants. This allowed me to gain a deeper and more nuanced understanding of activity participation and their meanings within the context of participants? daily lives and across these three participants. Chapter 3 provides a novel approach to mapping activities within context for people who live with schizophrenia over time.  2.3.2 Analysis phase two  This phase of the analysis followed van Manen?s (1990) principles for seeking meaning in thematic analysis and constitutes extended periods of overlapping, reflecting and writing activities. Van Manen (1990) advises that the theme is the way in which the researcher can grasp the phenomena; it provides structure and description to the experience and is a reduction of the entire meaning of experience. This second phase of analysis required me to re-immerse myself in the data; to sit with it and mull over the transcripts once more. As before the question asked of the data was what activities do participants engage in and what are the meanings of these activities for them? This phase of the analysis also considered the experience of moving forward into possibilities.  Phase two of the analysis provided a more nuanced understanding of data and a hermeneutical interpretation. I read through the interviews again and tried to create a ?clearing space? in which the data could announce itself. In the words of Heidegger (1962/2008) it is in this way ?that which is 41  present-at-hand become accessible in the light or hidden in the dark? (133/171). The next phase began by isolating thematic statements. For example, some passages were immediately compelling such as when Jonathan described how he felt after watching pornographic movies, how Painter talked about creating art and how Athena experienced being stuck on weekends. These passages were particularly compelling because of the emotion attached to their delivery. Some passages drew me in because they were surprising such as when Hammy announced he likened himself to a broken machine. I was also drawn to Robert?s experience of wanting to give back and become a peer support worker while receiving the same services.  2.3.3 Deepening understanding through anecdotal narrative Next I turned to van Manen?s (1990) recommendation of ?being attentive to the etymological origins of words? (p. 59). He asserts that by retracing the original meaning it may enliven the original meaning of every day words and convey a deeper understanding of the phenomenon. For example, van Manen (1990) traces the original meaning of care to sorrow, worries, anxiety and also, a sense of ?charitableness, love, attentiveness and benefice? (p. 58). He offers that in the case of caring for a child one tactfully18 both relieves them of worry and yet empowers them to be and become. In this instance, tactful concern or care therefore requires both a relief of burden and a sense of empowerment. In a similar way he recommends searching for idiomatic phrases as ordinary language is a ?huge reservoir in which the incredible variety of richness of human experience is deposited? (p. 61). For example, Jonathan who was working as a waiter says, ?but I got through the night and I wasn?t fired? (J 1. 47).  This phrasing captures a sense of anticipation; he could be fired at any moment. The phrase carries a sense that Jonathan has little control over his situation and that he is trying to carry on without being singled out or seen. It also reveals that he is unsure what to do if something goes wrong, that being fired is a constant threat and being watched makes him anxious. Van Manen asserts that these latter techniques of attending to language are often neglected but are valuable sources for understanding the nature of phenomena. At this point I considered five interrelated themes regarding meaning in activity including; 1) citizenship for belonging, 2) building skills and capacities, 3) managing illness and striving for well-being, 4) existential meanings and finally, 5) values-based activities. (Over time the first two and the final two themes each merged into one more connected theme).  I began drawing                                                  18 By ?tact? we understand a special sensitivity and sensitiveness to situations and how to behave in them, for which knowledge from general principles does not suffice? (Gadamer, 2004, p. 14). According to Gadamer tact is said to be tacit and unformulable (2004, p. 15).  42  visual representation of these themes and considered how they related to possibilities for each individual. I extracted passages from the data that spoke to these themes into new documents and placed them in ways that made sense under the themes for all participants, using a flipchart.  Several passages needed editing in terms of punctuation in preparation for the findings chapters and this was done while maintaining both the essence and words of the original account. These actions allowed me to reflect in and be able to see the data in different ways and allowed me to uncover meanings that may have otherwise remained hidden. During this process, parts of the data were separated and brought back to the whole and presented in thematic form. Van Manen?s (1990) lifeworld essentials (of time body and space) were helpful in the description of the themes as they provided a more textual rendering of the meanings of being-in-the-world for participants. For example, Peter compared his building experience to that of his father who built his childhood home. Peter says: ?it staggers me because all I?ve built is a magazine rack? (P1. 17). The notion of being staggered or the sense of being bodily pushed or ?bewildered? (Harper, 2001/2012) adds a deeper understanding to Peter?s account of being in awe of his father?s accomplishments in general.  The final step in the second analysis process was determining essential themes. In this study these themes are presented in findings chapters 4, 5 and 6 and each chapter builds on the content of the previous chapter. Three interrelated themes are identified and discussed and the parts are related to the whole and the significant question for the study is related to specific findings. Van Manen (1990) attests to the value of consulting other phenomenological sources to ?allow us to see and limits and to transcend the limits of our interpretative sensibilities? (van Manen, 1990, p. 76).  During this phase I also consulted numerous phenomenological texts to further appreciate how other researchers approached the analysis and writing process. I am grateful to other scholars for encouraging me to stretch my descriptive analysis and helping me define my own style as I wrote and rewrote text as part of the interpretive process.  2.3.4 Additional considerations for phase one and two of the analysis  During both analysis phases, I had the benefit of coming to interpretations thorough conversations with others. Throughout the analysis phases I continued to dialogue with research participants, my PhD committee members, several clinicians, fellow graduate students, and individuals who live with schizophrenia though face-to-face conversations and reading individual accounts. My PhD committee members offered timely and frequent feedback with regard to my analysis and my attempts to represent 43  the findings. For example, at one point a committee member advised that I ask about the experience of boredom and I invited some participants to share such experiences; this new question enriched the data analysis. Another committee member questioned the need to retain two separate themes i.e., of managing illness and developing skills. Throughout the interviews and during the analysis and writing of findings I continued to engage in the task of reflexivity, making visible positions of power that may have influenced the co-construction of the data and findings ( please see next section for further reflection). As mentioned, participants were invited to provide comments regarding the initial descriptions either verbally (in person during each interview) or in writing (by mail). I compiled an individualized sheet of activity participation and meaning statements summarizing each participant?s description of his/her experience of activity participation. The feedback served as an opportunity to deepen my interpretations and or extend accounts. During both phases of the analysis and in keeping with critical advice gleaned from van Manen?s (1990) text, I wrote and rewrote the interpretation attending closely to my own context. In summary, during the analysis phase I attempted to demonstrate different experiences of meaning in activity for participants as they engaged in their daily activities. 2.3.5 Reflection of how I shaped the data analysis process I wanted to know more about activity participation for people who live with schizophrenia i.e., the way people considered their activities, what was compelling about activities and what was challenging about activity participation. I have been described as being positive or optimistic and this worldview may have lead me to illuminate the more positive aspects of activity participation. However, as participants shared their stories and these were analyzed it became clear that participants' experiences of activity participation were greyer. In other words, many participants experienced angst, exclusion and boredom while at the same time experiencing passion, a sense of desired risk and commitment to their activities. The kaleidoscope of possibilities regarding methodological approaches that draw from phenomenology as a philosophy is both exciting and overwhelming. Because it is a road less traveled, establishing rigorous analytic methods remains a challenge (Park Lala, 2011). I found that bringing together different theoretical lenses that provided foci to deepen the analysis also provided a challenge to represent the data as a coherent whole. Some of these foci included privileging the experience of living 44  with schizophrenia and engaging in activities, considering occupational dimensions of doing, being, belonging and becoming and van Manen?s (1990) lifeworld essentials (lived time, lived space, lived relations, lived body). Integrating these lenses during the analysis took time and will likely engage my thinking for years to come. As I reflect on this process there may have been a way to do this more expediently. Yet, I believe that phenomenology can contribute much to scholarship and practice for people who receive services and their loved ones. 2.3.6 Trustworthiness  Rigor in qualitative research has been widely discussed however; as yet universal guidelines remain elusive. Researchers often do not commit themselves ?to a particular set of criteria? as they assert that no one set of criteria can adequately serve to evaluate all approaches to qualitative research (Cohen, 2006, n.p., para two). In effect, establishing trustworthiness for qualitative research is similar in intent but differs in both the approach and the criteria  used in comparison to those used traditionally for quantitative research (i.e., traditional criteria used in quantitative approaches include validity, objectivity, replicability and reliability). To add to the complexity of establishing criteria for trustworthiness each research tradition (and often each author within a particular tradition) favours their own specific approach (Lieblich, Tuval-Mashiach & Zilber, 1998). For example, Lieblich et al. (1998) who are narrative researchers, propose four relevant criteria that include: the width or comprehensiveness of the information collected, interpreted and presented; internal and external coherence of parts of the research as it relates to the study, literature and existing theories; a sense of innovation and originality; and finally, parsimony which relates to an analysis based on a small number of concepts (p. 173). This study had the benefit of a series of mini-audits carried out in detail with two PhD committee members and more generally with all four committee members.   On the advice of van Manen (1999) (who recommends researchers consult with other phenomenological works) and in an effort to establish criteria for this study, I turned to the recent work of other scholars who focus specifically on meaning in activity (e.g., Park Lala, 2011; Reed, 2008; Smith, 2009, & Sutton, 2008). These scholars confirmed similar challenges with regard to adapting existing criteria to establish rigor for phenomenological research. To that end, I have chosen to use the five criteria suggested by Park Lala (2011) designed for used in phenomenology. Criteria include: comprehensiveness of the data; transparency of the research process; the phenomenological nod; a critically reflexive lens; and the fruitfulness of the findings (p. 219). (Please see Table 1). 45  TABLE 1: FIVE CRITERIA ? ADAPTED FROM PARK LALA (2011) Criteria (Park Lala, 2011) Examples from this study Comprehensiveness of the data The aim is to gather rich and in-depth data that include actions and behaviors and, the contexts in which these occur (p. 219). ? Included four successive interviews with 10 participants over a period of two years. ? Interviews occurred in various locations ? i.e., coffee shops, community events/locations, local neighborhoods, a record store, a favorite town with participant?s husband,  ? Each successive interview built on data from previous interviews ? could ask new questions- gain clarification ? Lapsed time between interviews provided time to accommodate for new horizons of understanding.  Transparency of the research process Allows readers to judge if interpretive findings are appropriate given the context in which the research occurred (p. 221). ? Participants were invited to provide comments regarding the initial descriptions of activity participation. ? I documented the research setting and how, where and with whom activities took place in field notes.  ? I also situated myself in the research and laid open the study?s methodological positions and particular study methods such as two approaches to analysis.  ? Rich descriptions demonstrated how phenomena of interest were analyzed and interpreted.  ? Study benefited from guidance from my PhD committee Phenomenological nod is ?a way of indicating that a good phenomenological description is something that [the reader] can nod to, recognizing it as an experience that we have had or could have had? (van Manen 1997 in Park Lala, 2011, p. 223). ? Allowing the participant to continue a conversation uninterrupted and summarizing their accounts using shared language prompted even deeper descriptions  ? One committee member who read these findings said ?I can see myself in the findings? (February 28, 2013).  Another committee member acknowledged that the findings are also relevant to people who may not live with schizophrenia (March 25, 2013). One study participant noted that showing that people who live with schizophrenia can have a good life ?is important ? and very much needed? (April 20, 2013).  It remains to be seen if that is the case for participants and readers.  ? I made every effort to accomplish this sense of resonance with the findings in how I represented them by using participants intentions as I understood them and own words.    46  Criteria (Park Lala, 2011) Examples from this study A critically reflexive lens ?Adopting a critical perspective within phenomenology involves illuminating and critically reflecting on ? culturally ascribed assumptions.? (p. 226).   This inquiry was not intended to be exclusively emancipatory however the following points demonstrate ways in which a critical perspective was taken up.  ? This study added to the person-centered perspective on meaning in activity for people who live with schizophrenia which is a perspective often excluded from research (Smith, 2009). This study challenges the assumption is that people who live with schizophrenia may not be in a position to contribute to research findings in meaningful ways.  ?  I adopted a critical reflective lens as I reflected on my pre-understandings, my situatedness in the world and my actions and was keenly aware of positions of power in particular during the interviews and when representing accounts and findings (please see reflexivity section for particulars). ? Through accounts I became more acutely aware of participants experiences of poverty and they ways in which government policy is not responsive to the episodic nature of schizophrenia.  This finding highlights assumptions implied in policy regulations that further financially marginalize people who live with schizophrenia.  As noted by Park Lala Applying this critical lens will continue as others read this account and consider if the research has been a rigorous endeavor. Fruitfulness of the findings: Are the interpretive insights useful? ?The fact that phenomenological findings may not be generalizable however does not mean that they may not have fruitful, transferable or practical implications? ( p 228) ? The implications for practice as identified in this thesis are based specifically on the data i.e., the experience of 10 participants who live with schizophrenia. These implications may be transferable to other contexts such as the need for disability benefits systems in general to be more responsive to the needs of people who live with episodic illnesses (i.e., supporting people to work when well and facilitating access to financial support when unwell)  ? Research participants provided insights into the importance of considering meaningful activity in mental health practice. This finding is directly applicable to practice and relates to a recommendation to help people receiving services map their activity participation and the meaning of their activities. This practical application may help people receiving services to more actively consider both the meaning they experience with regard to activity participation and possibilities for their future activity participation to enhance their well-being.   47  2.3.7 How do these criteria relate to others cited in other phenomenological research? Early phenomenologists were critical of the way in which knowledge was generated and wanted to see phenomena in a new light i.e. wanted to describe as they appeared without ?misconstruction and imposition?  religious or cultural traditions, from common sense or science (Moran, 2000, p. 4). Park Lala?s (2011) criteria call for a critical perspective and in that way brings us back to the things themselves. One of several new insights for me was how deeply suicide touched so many participants either directly or indirectly. This allows the study findings to move from an emic19 perspective to an etic perspective.  Notably, van Manen, (1990) indicates that the ultimate aim of phenomenological research is, ?the fulfillment of our human nature: to become more fully who we are? (p. 12). It may be a challenge to set criteria for this lofty aim however, perhaps in the phenomenological nod one can begin to connect with the humanity of the other in ways that affirm there is no us and them when it comes to living with a mental health issue (Krupa, 2008).  In summary, a review of recent criteria used to evaluate trustworthiness in phenomenological studies was presented. Five new criteria offered by Park Lala (2011) for assessing quality in phenomenological research were applied to this study and a critique was offered. Criteria include the comprehensiveness of the data, transparency of the research process, the phenomenological nod, a critically reflexive lens, and the fruitfulness of the findings. These criteria proved to be helpful in considering the rigor of this study. In conclusion, this chapter outlined the methodological and theoretical perspectives that informed this work. This was followed by a brief description of phenomenological methodology and three key phenomenological philosophers were introduced along with a theoretical perspective offering an embodied approach to phenomenology. A description of the study methods followed outlining the design of the study, including recruiting, interviewing and analyzing procedures. Ethical considerations were reviewed and trustworthiness of the study was discussed using five new criteria offered by Park Lala (2011). In the following findings chapters the discussion is centered on activities and their meanings for participants as they engage in their daily activities.                                                   19 Emic research considers concepts that are meaningful to the members of a particular group in contrast to complementary etic research that looks to extrinsic ideas, concepts or theories and categories that hold meaning for the larger community or scientific researchers. 48  Chapter  3: Meaning and Daily Activities in Context20  ?The meaning of life-events is intensely personal and idiosyncratic, understandable only in terms life-course and the context of each individual? (Scharff & Fairbairn-Birtles in Fairbairn, 2001, ix).  Introduction This chapter has three sections. It begins with a brief introduction to the 10 study participants and their key activities followed by a detailed review of activity participation for participants using activity codes published by Statistics Canada (1998, cited in Statistics Canada, 2002). See Appendix E  for a table of categorization of activity participation for all participants. The aim is to show how productive activities (defined in section 3.2.1) are situated in the stream of activities a person may take up within their daily life. The third and final section of this chapter presents activity patterns and meanings for three individuals during the two years of data collection (also see Appendix G for activity maps). Using Frankl?s (1959/2006)  three strategies associated with the possibility of finding  meaning, conclusions are drawn regarding activity participation and meaning over time. Each section in this chapter moves from a descriptive stance to a more interpretative approach to data analysis. The aim of this chapter is to provide a foundation for understanding the meaning of activities from the perspective of people who live with schizophrenia. 3.1 Section 1: A brief introduction to participants  The following section begins by providing a table of participant demographics that may be a helpful reference for the reader. In summary, four women and six men ranging in age from 31 years to 55 years of age participated in the study. Most participants were single, three were divorced and one was married. All but one graduated high school, six attended some college and two participants had university degrees. Table 2 is followed by individual profiles that are intended to provide a brief introduction to each participant in order for the reader to get a sense of who each participant is, and the kinds of activities that each participant engages in, and are important to them. Of note, in congruence with a Husserlain descriptive approach I chose the accompanying pictures to help to visually represent a key activity for each participant.                                                     20 Please see Table 2 overleaf for maximum variation sheet for specifics on demographics. 49  TABLE 2: MAXIMUM VARIATION ? DEMOGRAPHICS Name Gender Age  Education and  Training  Income Living situation Time diagnosed  and self- identified  level of recovery (1-10)  Key Activities Dream Activities/ social needs   Mental Health Service location Presence of Negative  Symptoms  Athena Female   43 (Born in Europe)   Diploma From Overseas Recently BA Sc Single.   Income from  Persons with  Disability (PWD)  benefit $360 per month   and Canadian Pension Plan (CPP) $493 per month Now employed  20 years since first  diagnosed Relapsed  6 months ago      Self-appointed level of recovery  8-9-10 Volunteering Working Applying for jobs (initially) Driving Likes to learn   MBA Partner Be debt free Travel Move up in work  Private. Was at team No negative symptoms   Hammy  Male  52  Grade 12  No  formal training   Lots of experience as farm hand, janitorial worker and helper Single but has girl- friend Disability  Income $906 per month   Lives in hotel  20 years Alcohol  and Drug  35yrs ago   Diagnosed with schizophrenia   Self-appointed level of recovery 6 Works Volunteers  Drug use  Food lineups Caring for health  Truck To be Married Trade Be sober To be recognized by others  Mental Health  Team No negative  Symptoms  Jonathan  Male  44 years  Finished grade 12  Food safe  Single  Supportive housing  Disability  Income $906 per month   Diagnosed at 18/19 years    Self-appointed level of recovery  7-9  Works Volunteers  Computer Adult movies  attends team  Health appointments  Visits family  Helped mum  Would like a partner  Better job Mental Health  Team YES Negative symptoms  50  Name Gender Age  Education and  Training  Income Living situation Time diagnosed  and self- identified  level of recovery (1-10)  Key Activities Dream Activities/ social needs   Mental Health Service location Presence of Negative  Symptoms  Lisa Female   41 years   Grade 12  Almost Diploma fine arts Cert  Child edu 3 1st years college courses  CPP $1,740 Married Husband not working Renting Diagnosed at  37years approximately    Self-appointed level of recovery  8 Drawing Narcotics and Debtors Anonymous  Visiting local  Town  Shopping Recently has homestay student  Return to school To finish arts Have friends   Do more things  Private Psychiatrist YES  negative symptoms    apathy hygiene Concentration Painter  Male  52 years  Attended college ?almost finished degree in Art   Divorced when young  Disability  Income $906 per month  Lives in apartment  Diagnosed in 20?s     Self-appointed level of recovery  7-8 Paints ?  Cooks  Shops for groceries Attends art center Church  Friends  Cares for illness Walks  Tai-chi Manage illness better  Be in eye of critic   See parents  Mental Health Team   No negative symptoms  Peter  Male  51 years Grade 11  Many college courses on health and alternative approaches  Many correspondence courses on health  Single   Satellite housing   (PWD) support $906 Diagnosed early 20?s    Self-appointed level of recovery  7 Exercise, tai-chi Writing, driving Caring for mum Attending church activities  Guitar  Reading  Mediation Caring for his own health Finish his book   Course on relaxation  Mental Health Team  No negative Symptoms  51  Name Gender Age  Education and  Training  Income Living situation Time diagnosed  and self- identified  level of recovery (1-10)  Key Activities Dream Activities/ social needs   Mental Health Service location Presence of Negative  Symptoms  Rebel Girl  Female  31 years  (Born in Asia) Grade 12 ? 2 subjects and  2 first  year college courses  Training for work in mental health system Single  Lives in family home with parents Receives Persons With Disabilities (PWD) support $906  Diagnosed  First year at college     Self-appointed level of recovery  7-8 Cleaning home  Collecting coupons Mental health team activities  Music  Eating out with family  Finding free community activities  Works for dad   TV, Church   would like a new current partner   more live music events  own music   own money Mental Health  Team        No negative symptoms Robert  Male  26 years  Grade 12 Some first years college courses  PSW training Single Lives in semi-independent housing Receives Persons With Disabilities (PWD) support $906  Diagnosed at 22   Self-appointed level of recovery  6.5-7 Computer Games, fixing them and shopping Driving to see people Cooking and eating with people in his home Attending services at team Travelling Would like to  Go back to school  Partner EPI services   No  Negative symptoms identified Sam  Male  38 years  (Born in Asia) Professional degree in China  PSW training Divorced  Supports 6 year old daughter Supported housing  Receives  Persons With Disabilities (PWD) support $906  Ill at 14 in China  Diagnosed  at 28years  Self-appointed level of recovery  8  Clubhouse 5 days per week Cooks  Radio, reads  Internet nightly Likes talking with others/mum Walks   Better job  Attend school (?BCIT)  New family Mental Health  Team  Clubhouse  No negative symptoms identified 52  Name Gender Age  Education and  Training  Income Living situation Time diagnosed  and self- identified  level of recovery (1-10)  Key Activities Dream Activities/ social needs   Mental Health Service location Presence of Negative  Symptoms  Sylvie  Female  48 years   (Born in Asia) Diploma in computers after high school  Employment training through mental health services    Night classes   Divorced Rents  apartment  Support from ex-husband and income from work  Approx. $1, 800 per month  Diagnosed 28 years   Self-appointed level of recovery  10 Work Cooking Visiting daughter  Shopping  Exercise  Yoga  Night classes Computers Likes to learn    Travel  Have money to retire   Like to have friends and things to do   Wants useful experiences  Mental Health  Team   No identified negative symptoms                 53  3.1.1.1 Athena loves to learn Athena graduated from a local university about a year and a half prior to study commencement. Her brother also studied the same course and they were the first of their family to attend university. (I will refer to her field as surgery as the procedures involved require a high level of precision, commitment and intellect. Athena points out that one aspect unique to her chosen profession is that the majority of graduates are men). Athena longed for adventure and came to Canada in her twenties and was diagnosed soon afterward. Her father also lives with schizophrenia and she worried about her increased risk of developing schizophrenia as a young person.   When we first met, Athena was recovering from a recent episode of illness (at least six months prior to engaging in the study). In addition, about one year prior to the study she had separated from a long-term relationship. I began to get to know this person as someone who was busy and accustomed to a high level of activity engagement.  At the beginning of the study she was seeking employment in her chosen profession and in the meantime was working several odd jobs and feeling somewhat ?stuck.? Weekends were particularly difficult for her and she identified that this was partly because her well-established routines or schedule disintegrated over these two days. Athena described that when she has no structure or goal she would retire to bed.  During the study Athena discontinued her monthly disability benefits from the Canada Pension Plan (CPP) and is now self-supporting.  Athena engaged in a range of activities throughout the study and was passionate about school and her volunteer contribution in developing a women?s group associated with her profession. She also liked driving.  Athena?s workdays are busy with structured morning and afternoon routines. She rises at five thirty am, washes, eats, goes to work, returning home by eight p.m. the evening. She will prepare some food for the evening and the next day. She may watch a pre-recorded educational TV show while eating and retires by ten p.m. Weekends are not a problem anymore. She describes, ?Oh, now I have things to do?? ?I have a mission? now. FIGURE 1: ATHENA LOVES TO LEARN 54  3.1.1.2 Hammy feels like a broken machine  Hammy lives in an inner city hotel in the downtown east side. Born one of five children on Vancouver Island he came to the city in his late teens. Up to that point he had worked on local farms while in high school and he particularly liked machines.   Hammy described his most fun and satisfying experience as rebuilding a car in high school with his friend. He also was a keen athlete and was invited to ?try out? for a national hockey team. He declined this offer, as he wanted to get married and have children.  Hammy made some friends on the university campus where he was being treated for his first break. At that time he also became more attracted to drugs and alcohol. He subsequently travelled within central Canada and was incarcerated for three years. He then lived in a regional psychiatric hospital for about the same time span. Hammy has a girlfriend (of 11 years), takes a harm reduction approach to his drug use and attends programs for his mental and physical health. Hammy also lives with a diagnosis of AIDS and recalls experiencing several head injuries. He describes himself as ?a broken machine,? indicating that he often feels mixed up and broken.   Hammy enjoys the social aspect of volunteering, walking in his neighborhood and attending health appointments. He especially looks forward to spending time with his girlfriend. He is keen to reduce the frequency with which he uses drugs and spends time counting his days clean.  He wakes at nine a.m., walks to his AIDS support program for a ?few bowls of cereal? and medications.  He may walk around collecting cans, earning up to two dollars per day though will not go ?binning.? In the afternoon he returns to program for medications, then he visits to the mental health team, returning home afterward. He will line up for supper which may take up to two hours but he usually figures out how to make this a 20-minute activity. With food in hand ne makes his way home to eat and may retire to bed at about nine pm.     FIGURE 2: HAMMY FEELS LIKE A BROKEN MACHINE 55  3.1.1.3 Jonathan likes to walk around the stores or ?scuff around?  Jonathan has been living in the same government subsidized apartment for over 20 years and likes how neighborhood is familiar to him. He grew up in the greater Vancouver area in a blended family with parents who were of European decent and two stepsiblings. He has a large extended family and a new but good connection with one stepbrother and one aunt whom he sees occasionally.   Jonathan finished high school and worked in the service industry for a short time. He then began drinking briefly. He attends a mental health team regularly and describes spending much of his day in his apartment ?with nothing to do? and feeling bored.  Some of his neighbors are loud and intrusive and he feels he is ?picked on? by two of the men in particular. Approximately two years before the study commenced he began to work and volunteer (it was 20 years since he worked) leading him forward to what he calls a more ?normal life.?  Jonathan?s dad wakes him at eight am; he showers, has yogurt and coffee and may watch TV. He may then attend a health appointment or may look around the shops. In the afternoon he will talk with his mum and may watch a DVD and eat leftovers. In the evening he will go on the internet, watch TV and or listen to music. He usually talks to mum again before cleaning his lenses, and then goes to bed around eleven pm. He remarks that he has a lot of time on his hands  and spends most his day at home or watching television, on his computer, listening to music, getting ready for work or dealing with his neighbors.  When he is out of the house he attends appointments or goes window shopping or, something he calls ?scuffing around ? I feel like I?m missing out on life, you know? I just haven?t had as much experience with things as other people have had? (J 3. 30). He describes that his disability pension and subsequent lack of money may have contributed to him not being able to meet people and make friends.   Unfortunately, his mum?s recent passing signaled a big change in his activity participation.    FIGURE 3: JONATHAN "SCUFFS AROUND" 56  3.1.1.4 Lisa the artist Lisa enjoys being married to her husband of six years.  Despite wanting to she feels she cannot work as she does not want to lose her pension benefits. She misses not being able to work in her chosen profession in special education.  Lisa grew up in the countryside of British Columbia and met her husband at narcotics anonymous (NA). Lisa is proud about being clean for nine years. Lisa remains committed to her participation in narcotics anonymous and debtors anonymous (DA) and feels that these self-help groups offer her a spiritual connection to others and to herself. She was diagnosed with schizophrenia seven years ago which resulted in her being less able to engage in the social aspects of NA and DA. Her private psychiatrist worked with her to find the right medication, an arduous process that took two years.  Lisa describes herself as an artist, makes her own greeting cards and spends time at least once monthly with her husband visiting a local artist community. She likes being in this community as the pace of life appeals to her and there are always some new artistic things on offer to engage with. Here she spends time with her husband  Lisa feels ?financially deprived? (L 2. 29), and finds her negative symptoms are a big barrier for activity participation which ?gets her down.? Lisa?s 100Lb weight gain since starting medication is frustrating. She wants to buy good quality, stylish clothing so she is not always reminded of her schizophrenia.  Lisa rises at three am, has breakfast and speaks to a Narcotics Anonymous (NA) colleague. She may return to bed at seven am till midday or one pm, then showers and gets something to eat. She might leave the house but is rarely ready to do so until three or four in the afternoon when most people are generally busy.  In the evening she naps and rises again in the late evening. When not sleeping, she makes artistic cards for friends and her husband, cooks, perhaps goes shopping and generally spends time with her husband. FIGURE 4: LISA THE ARTIST 57   3.1.1.5 Painter  Painter has lived in the same apartment building for 20 years and has attended the same mental health team (for 15 years). He also attended the same church for several years. He values his long-term relationship with both his psychiatrist and his mental health team who he continues to see bi-monthly. He is deeply grateful to his psychiatrist who frequently consults with him about his medication and listens to his need for ongoing changes.   Painter?s parents emigrated from Europe and he grew up in Eastern Canada. Painter was diagnosed with schizophrenia while attending university and ended up in the forensic system for a short time. He is the second of seven children and stays in contact with his parents and some of his siblings weekly. He describes having a ?nice net? of friends (Pa 3. 26).  He discovered painting when he was young, quit for almost 20 years as he found it too competitive. However, he returned to this activity almost seven years ago and now paints for five to seven hours almost daily.  Painter believes artists see everyday things a little differently and values this ?mindset of an artist.? He describes that good art has capacity to help one grow, as it is dynamic. As a spiritual person he describes that he is happy about where he is at in his life. He believes that life is not long and that we should simplify it (Pa 1. 35).  He likes his structured routine that allows him to accomplish his daily goals. Being busy is also a distraction from the illness (Pa 3. 37). Painter has recently enjoyed some acclaim with writing.  Generally, he structures his days and weeks. He rises at 7:30 a.m., does laundry and checks his blood sugar level as he has diabetes, has breakfast and reads his bible (PA 3. 6). He may visit a friend and do tai-chi and may phone a family member. He usually cooks for himself in the evening and retires to bed by 10 pm.  Monday he draws, attends tai-chi on Tuesday afternoon and attends a walking group on Wednesday (P 1. 32). Thursday he volunteers with the animals, Friday is with a spiritual group.  On Sunday, he focuses on tai-chi again which he believes keeps him active.  FIGURE 5: PAINTER 58  3.1.1.6 Peter the spiritual seeker  Peter spent decades educating himself about spirituality and religion and practicing a variety of spiritual techniques. He has been living in the west end of the city in the same home for about fifteen years and he enjoys the location though he is sad to see the changes in recent years (established businesses are closing in favor of new more modern ones). He misses his two favourite local restaurants that closed recently where he used to write daily. Peter?s parents were of European decent. His dad was a ?brilliant man? and a prisoner of the War in Germany who returned to his young family to become a teacher. Tragically, Peter lost his dad at the age of eleven.  Peter?s mum was the sole supporter of the family from that time and had several careers such as nursing, administration and spiritual leader. A big part of Peter?s life is spent caring for his elderly mum in a nearby town and he is grateful to be able to help her.  A self-described spiritual seeker, who is deeply committed to gaining positive mental and physical health he wants to live a long life. Peter is keen not to fit into the category of people who die fifteen years earlier as a result of having schizophrenia. He offers with humor ?I plan to live forever or die in the attempt? (P2. 30). Peter lives in a way that is congruent with his values i.e., he invests in leading a healthy lifestyle, he supports others and tries to give back to his community. He is interested in developing his intellectual and spiritual self and cares about how he spends his time. In other words, he does activities that have meaning for him as opposed to doing activities that just simply keep him busy.  Twice weekly he cares for his mum and spends one night a week in her home. On other days he is seated at a local coffee shop by 7:30 a.m. in order to write.  He may have some breakfast there and may stay for two hours. Much of his day is spent in coffee shops writing and socializing. He exercises five times per week. In the evening he may read. He retires to bed by nine or 10:00 p.m. Although he cooked often in the past he is not interested in cooking now. He eats prepared food at the restaurant, or at home he keeps staples that are raw and easily prepared. He relies on nutritional supplements to support his diet although they are prohibitively expensive.  FIGURE 6: PETER THE SPIRITUAL SEEKER 59  3.1.1.7 Rebel Girl loves music Rebel Girl lives with her parents and brother. She receives a weekly allowance of five dollars from her parents in payment for doing chores. She also works occasionally in the family business and recently started working a half day per week in a grocery store.  Rebel Girl came to Canada with her parents in her teens and is the youngest of three children. She was identified as having a lower IQ when a teen in China and was diagnosed in Canada with schizophrenia after high school. She enrolled in two college courses and subsequently became ill.  Rebel Girl does not have a bank account but would like to have money for leisure activities. She has a passion for heavy metal music. She enjoys collecting coupons and will often have several in her pocket ready to provide them to friends who may be interested. She makes friends through attending many groups at the mental health team and other non-profit organizations for mental health. Rebel girl was the name she used in college and she associates it with a rock song. She sees herself as a heavy metal fan and would like to go to more concerts. She is attuned to music playing in the background when in public spaces and immediately lights up when she hears a heavy metal band. She is knowledgeable re the lyrics and is familiar with many of the heavy metal characters that inspire and entertain her. She considers heavy metal enthusiasts as a tribe and is proud to belong to it. She attends the mental health team at least once weekly and at one point in the study she was working work twice to three times per week. She often has a day of rest during the week when she does not do any activities outside the home. She also had a boyfriend at the beginning of the study and would like to meet someone new. Rebel Girl would also like to cook more. She wakes at 10 am, attends to hygiene and has breakfast. She usually has a health appointment in the afternoon and returns home to set the table for dinner prepare the rice and do the dishes. She enjoys going for a walk and watching the Chinese news with her parents. She retires to bed at 10 pm (RG 2. 16). She is clear that she needs at least 10 hours sleep (RG 2. 18).  FIGURE 7: REBEL GIRL LOVES MUSIC 60  3.1.1.8 Robert the computer guy Robert grew up in the city and his family is from the Philippines. He was diagnosed with schizophrenia four years ago while his mum was dying of cancer. He regrets he was not able to be with her at that time. Robert does not see his sister often and has a guardian to help him make life style choices and financial decisions and he is grateful for this support. Robert also lives with multiple chronic health issues such as diabetes, multiple sclerosis and a 70lb weight gain. He recently stopped smoking and attends the gym when he can. He likes food and in particular some specialty foods from his home country. He also enjoys joining friends for traditional karaoke sessions. Robert values the support of peer support workers and attends his mental health team once or twice weekly. He describes being ?really into computers?, enjoys his car and travelling overseas with long-term family friends. Robert has three friends whom he sees often. He enjoys reading and watching sports.  Robert sees himself as a ?big computer guy.? He takes his recovery seriously. He had a medication change recently, and was subsequently unable to participate in his usual activities. He is beginning to feel stronger and finds he is sleeping less. He tries to pace himself and tries to see someone in the day. Some days are ?great? as he can do what he wants to do however; at other times he describes it being difficult to accomplish anything. He graduated from peer support training and is hoping to find a job. Robert would like to be more active, manage his schizophrenia and diabetes well, and have a job with computers, more friends and a girlfriend. Robert attended college for a short period and would like to return.   He has breakfast, takes medications and works at his computer. He eats microwave pasta for lunch and may see a friend or watch TV and then he will work on the computer playing strategy games with people. He may visit someone in the complex, may watch some TV or get on the internet and then go to bed about 10 or 11 pm. He either attends appointments, or meets friends, or grocery shops daily.  FIGURE 8: ROBERT THE COMPUTER GUY 61  3.1.1.9 Sam the engineer Sam treasures his seven-year-old daughter who lives with his ex-wife. Born in Hong Kong he is one of three children. Sam describes how his parents constantly pressured him to succeed in school. Sam became an engineer, however, is unable to work in this capacity in this country and is not sure he could manage the work at this time.  Sam was diagnosed soon after arriving in Canada and was temporarily connected with the legal system. He described losing his skills and confidence when he became unwell.  He feels that having schizophrenia ?changes your thinking? and ?your ability to apply knowledge? (S 1. 28, 29 & 30). Sam recently moved into supportive housing with roommates and is interested in cooking again. He attends a mental health clubhouse in the community five days per week and describes is as being an important source of activity participation for him (by offering opportunities for working, skill development and socializing). If Sam is not attending the clubhouse he will sleep during the day at home.  Sam mentions that when he first came to Canada that it was very stressful. He remembers that he ?cannot find a job and I cannot support myself and worry a lot about my economic situation? (S 1. 12).  He did try to return to college but found it to be too much. He likes to have something to do and be with people. He is grateful to receive the disability benefits and as a result of having these things in his life he is ?happy and free? (S 1 Mu 9). Giving back is important to him and he enjoys supporting other people at his local clubhouse. Sam remains deeply connected with his mother and his birthplace. Sam saves his BC Person with Disability benefit in order to visit his home every second year. He dreams of having a new family and a ?good life.?   Sam usually rises at about 10 am and has a shower. At the clubhouse he will have lunch, chat, attend a meeting, work as a janitor or peer support worker, or may go out with the walking group. He visits his daughter twice weekly. He usually chats to his mum for an hour in the evening on the computer. He may then read the news and surf the internet for a couple of hours. He goes bed about 10 pm.  FIGURE 9: SAM THE ENGINEER 62  3.1.1.10 Sylvie loves clothes Sylvie lives alone in a rented suite on the east side of the city. Her parents are Chinese and she grew up as the oldest of five children in Vietnam. She came to Canada in her early teens and graduated with a Diploma in Computers in central Canada. Sylvie moved to Vancouver with her husband and was diagnosed with schizophrenia after one year of marriage. Sylvie?s daughter is now 20 years old and attending university. Sylvie would like to spend time with her daughter but is aware that her daughter needs to build her own life with her own friends. Sylvie is hopeful that as her daughter matures that they will grow closer and spend more time together. Sylvie works four days per week. She continues to negotiate with her husband about spousal support and this remains a significant stressor in her life as she did declare bankruptcy in the last five years. Sylvie loves clothes and always likes to look her best.    Sylvie likes to be occupied and likes to learn useful things. She is very happy to be working, as she really did not think she could accomplish this challenge. Routine and schedules are important aspects of her life in particular with regard to cooking and cleaning. She remarks ?I always need to put something in my schedule? (S 2. 13). If she does not have anything scheduled she may retire to bed for the day. She generally cooks one or two times weekly and will bring her main meal to work each day. She says she does not mind eating the same food several days in succession. However, when in out in the community Sylvie demonstrates an adventurous spirit and likes to try new foods and go to new places. She has just discovered the desire to travel and has started to visit the casino with her friend. She would like more activities to participate in and more friends to do those activities with.   Sylvie usually rises between seven and 8:00 a.m. After dressing and doing her make-up she catches the bus. She will have lunch at two and go for a walk at for the later part of lunchtime. After work she usually attends night school and is home about nine pm.  She generally has dinner, listens to music and does homework at the same time, and goes to bed about 10:30 p.m. (S 2. 6).  FIGURE 10: SYLVIE LOVES CLOTHES 63  3.2 Section 2: What participants do The previous section briefly introduced the participants in the hope that the reader could begin to situate the activities and meanings for participants. This section of the chapter first outlines the kinds of activities participants described during our interviews and subsequently maps these activities using activity codes published by Statistics Canada developed in 1988 (Statistics Canada, 2002). These codes were originally used in developing time use criteria called Total Work Accounts System ([TWAS]. The original purpose of the TWAS was to provide a means to better understand time spent by Canadians in both paid and unpaid work i.e., time composed of paid, unpaid and personal investment (or learning) (Statistics Canada, 2002).  Krupa et al., (2010) adapted these activity categories when considering activity health for people who live with significant mental health issues21.  Thus, this method of categorization was chosen because of the link to Statistics Canada and the connection with occupational therapy literature.22  There is no assertion that the final categorization (see Appendix E) is representative of all the activities that people engaged in over the two year data collection period. However, the categorization offers a ?horizon of understanding? or a general sense of activity participation for participants that will be extended on in the following chapters. In addition, no attempt has been made to look at time use in this study (see study limitations). Consistent with Krupa et al. (2010) self-care activities in this instance are defined as those that include both personal care such as dressing or attending spiritual or religious gatherings and health related care that may include attending appointments and filling prescriptions (p. 43). Productive activities include paid and unpaid work, education, parenting, volunteering and civic work and any day program activities such as a social club, an employment center, a mental health team or having a meal in a mental health agency (Krupa et al., 2010, p. 46) such as Coast Clubhouse. Home management includes looking after one?s home regarding repairs, food preparation, chores and pet care. Leisure activities include both passive and active activities and also include socializing and rest activities include sleep and naps (Krupa et al., 2010, p. 44).                                                    21   Adapted with permission from Daily Activity Codes cited by Krupa et al., 2010 (personal communication, T. Krupa, October 1, 2012).  22 Similarly, the Canadian occupational therapy model categorizes activities into self-care, productivity and leisure a practice critiqued by some scholars for its reductionist approach and cultural insensitivity (Hammell, 2004). 64  3.2.1 Philosophical tensions present in categorization.  The study draws on both Husserlian (i.e., drawn more from an epistemological focus on the essential essence or attributes or necessary features of the phenomenon that are to be understood as described by Moran, 2000) and Heideggerian phenomenology (i.e., a more ontological perspective i.e., focus on being-in-the-world more about what it is to be in the world as described by Moran, 2000). Placing data within the given activity categories may be more in keeping with early Husserlian phenomenology that aims to categorize and describe entities, in this instance, the activity participation of participants. Interpretation is required in order to select specific categorization. Thus, it is acknowledged that the categorization is hegemonically organized whereby activities are named and selectively applied based on my interpretation of the data. While not ideal. prolonged engagement with participants helped to offset some of the challenges of making these decisions and helped me to understand that several activities may represent both work and leisure categories of activities for participants.  3.2.2 Beginning to understand the horizon of activity  3.2.2.1 Self-care Using a categorical approach to activity participation provides a helpful, albeit rudimentary, understanding of the kinds of activities those participants engage in. Further, it can provide some generalizations that are helpful in synthesizing data for all participants.  In examining findings in more detail it is observed that generally participants engage in a range of self-care activities and that being socially connected may play a positive role in their activity participation. For example, six participants attend church (categorized by the TWAS as a personal care activity). However, three participants attend only with friends and family and not if alone. Thus, it may be that attending church could be considered as social activity (in addition to or rather than a personal care activity). In addition, going to church may have particular cultural meanings for those who attend only with their families. Some differences are noted in how participants engage in self-care activities. For example, some participants participate in selecting and taking care of clothing while others habitually apply make-up.   Findings suggest that participation in activities regarding health is shaped in part by the presence of additional conditions such as AIDs (one participant), significant weight gain (five participants), high blood pressure (two participants), multiple sclerosis (one participant), and diabetes (two participants). 65  In addition, specific activities are also required to manage both positive and negative symptoms of schizophrenia as well as activities that serve to help with addiction such as withdrawal, harm reduction, maintaining sobriety and managing money. Although cognition was an issue for two participants (one with head injury and one with lower IQ) participants did not identify receiving services to support these issues. Resting and relaxing is an interesting category, as for some participation in that this activity may pose challenges. One participant who is more interested in ?doing activities? and less interested in ?relaxation? or just simply ?being? was keen to discuss her belief that relaxation in our culture may be socially constructed and may be experienced differently by different people. At least one other participant expressed ambivalence about his desire to participate in relaxation activities. In summary, it is apparent that people in this study are involved in all categories of activities as conceptualized by occupational therapy scholars i.e., self-care, productivity, leisure and sleep. This finding is somewhat at odds with literature that indicates that people who live with schizophrenia are minimally involved with activities and engage mostly in passive leisure (see, for example, Leufstadius, et al., 2006). In addition, findings here suggest that relaxation may actually be challenging for some participants.  3.2.2.2 Productivity In the area of productivity, beginning with volunteering and civic duty, six people regularly volunteer in a formal way.  In addition, one participant volunteered for two years and then secured a job and no longer volunteers.23  Three participants informally volunteer to help others such as friends or neighbors. Robert is in the process of looking for a volunteer job for which he has specific criteria (wants to actually help customers not just move goods in and out of the store). Some participants voluntarily help others in the community both formally and informally. For example, Athena is involved in several formal mentorship programs and also informally makes herself available to upcoming professionals in her field. We conclude here that about 7 out of 10 participants regularly engage in a variety of volunteer activities seemingly silently adding to the social capital of Canadian society.                                                   23 The issue of volunteering will be taken up in the discussion chapter 7.9.1 considerations for future research.  66  In the area of paid work, eight out of 10 participants currently work (thus, there is significant overlap between participants who volunteer and are involved in paid work24). Five participants are employed at minimum wage or slightly above and most participants work few hours (often approximately 4 hours a week). In addition, Robert (who is also in the process of establishing a volunteer position) completed peer support training (PSW) and plans to find a job there. Others find creative ways to earn money. For example, one participant sells a small number of his paintings annually and wishes to increase sales through his work with a local studio. Two participants do odd jobs for family members. They also engage in the Community Volunteer Program supported by the British Columbia Ministry of Social Development and receive an honorarium of $100 per month for these activities. Only one participant (who recently stopped receiving the Canada Pension Plan Disability Benefits25), currently earns a salary of more than $60,000 per year. She is undertaking further schooling and has the potential to double these earnings. In addition, two participants have found creative ways to increase their total monthly earnings to $2,500 and $3,800 a month respectively. One participant particularly appreciates being more independent as a result i.e., is happy and relieved she does not have to ask for financial support from the government. Breaks at work are important times and participants engage in a variety of activities at this time.  One person often works through lunch so she can ?bank? time.  The same person will often engage others in the office in work related projects. Two participants bring food for break time and will frequently go for a walk alone at that time.  One participant working in the service industry talks about the flow of work being erratic and stressful.  Jonathan remarks:  the work itself, and you'll be, you'll be doing nothing for two and a half hours, you'll be wondering what to do, then you'll be busy for 3 hours, and you'll be freaking out, kind of thing. All the bumping into people, and arguing, trying to get the stuff done, and then you're back to slowing down again, and your nights over. (J 2. 11)  The same participant spends hours waiting by the telephone for confirmation that has been granted his two shifts each month. He experiences this ?waiting? as a stressful activity. Three participants own cars (only one person uses it for work) however, most participants use a bus pass to get to work. Two people like to walk when they can and one walks to work.                                                   24 See discussion chapter regarding information on the percentage of people who live with schizophrenia work and the percentage of people who wish to work. 25 See findings for specific recommendations re Canada Pension Plan Disability Benefits 67  In conclusion, most participants engaged in paid work and or volunteering either formally or informally. However, on further investigation it became apparent that while at least two people were content with their jobs at least three participants wished for better, more lucrative and less stressful jobs. Some participants also wished for more suitable volunteer positions. 3.2.2.3 Education All participants have a high school diploma and several others have higher education thus it seems that educational activities are important to participants. Two participants have a Bachelor of Science degree (BSc); two other participants became ill while at school and had difficulty finishing their Bachelor of Arts degrees (BA). One participant has a diploma in computers, one participant has completed up to 40 college courses in psychology and massage and two people have completed 2-4 college courses.  By contrast, one participant worked on several farms as a young man, at that time this activity was considered much like doing an apprenticeship in a trade.  One participant has a certification indicating that he knows how to safely handle food and one person has a certification in community mental health. Importantly, six participants expressed a desire for additional education to improve their employment opportunities and or status. Lisa for example, feels additional schooling would offset the stigma she encounters.  Lisa describes how ?professionals particularly in the hospital [infer] that somehow I am especially stupid because I have schizophrenia, that somehow I am like dumb? (L 2. 46). Lisa would like to finish her BA to improve her status and credibility as someone who lives with a mental illness. Two people continue to make use of educational opportunities at work to ensure they have marketable skills and two women express a need for learning to plan for themselves financially as they grow older. At least three participants have participated in formal programs to learn how to manage their life challenges (such as learning to be more assertive or be more sociable). Interestingly, Athena notes that ?schizophrenia gave me an education [it has] made me demand more of life.? In summary, educational activities are associated with both enhancing opportunities to engage in productive activities and for self-improvement.  3.2.2.4 Day program activities  Eight people frequently participate in mental health ?day program activities? (defined by Krupa, 2010) as working for pay, attending for a meal or coffee or for a social activity). Specific examples of such programs include clubhouse programs, work and leisure programs and non-profit drop-in centres. One person uses services for basic support such as food, medicine and for some connection with others. Most other participants use these services to help give them structure in their day, 68  generate opportunities for work, help with making friends, attend social outings, learn about recovery, make personal  recovery plans  and have a place to go instead of retreating to bed. While these programs vary greatly in their purpose up to five people attend such a day program 2-3 times weekly. Two people clearly say they are advancing in terms of personal growth. For example, Rebel Girl ?learns to talk about things? in her closed recovery group (RG 2.29).  Sam notes of this clubhouse that ?they give me a lot of activities? (S1.11). He adds ? ?I drink coffee, drink pop and read the newspaper ?surf the internet and hang out ? you can just relax and sit there and read the newspaper?  (S 2. 10). Sam also describes how his day program offers him a place to reengage in work. ?When I first come here I don?t do any jobs here ? [when] I feel happy here I want to do more jobs, more opportunities ? paying jobs to build your life? (S 2. 29). Two people are not interested in attending day programs but one would like some sort of program that could support people who live with mental health issues and are further along in their recovery journey (i.e., people who may have ?graduated? from the system). In conclusion, day programs are essential sources of support for most participants and some participants such as Rebel Girl and Sam note they may not do anything if these programs were not available.  Sam shares that when ?there is nothing to do it is bad for you. You stay at home and sleep all day and they you cannot sleep at night (S 3. 41)?.  3.2.2.5 Parenting Sam does not live with his six year old daughter and is saddened by this. He does see her twice weekly mostly in the home of his ex-wife. He is comforted by her presence and describes engaging mostly in play activities with her. Sam indicates that his wife is responsible for school and extracurricular activities such as playing the piano and attending Chinese school.  Sam says that being with his daughter is ?a very important thing in my life? (S 1.31). Being a father is a grounding role for him, ?I do not feel alone because I have a daughter? (S 1.31). He is also comforted by the fact that his daughter would like Sam to live with her ?unfortunately [he says] I have to live alone? (S 3.16).  He dreams of a better life for his daughter and would like a new family and to have more children. Sylvie connects with her busy 20 year old daughter monthly for a shopping outing. She would like to see more of her but in the meantime she carries a picture of her in her wallet. Sylive trusts her daughter will ?assume her responsibility? as a daughter when she matures (S4.16). When lonely, Sylvie takes great ?comfort? in watching old videos of her daughter as toddler.  Robert would like children in the future but is not sure due to his schizophrenia. Lisa has decided children are not a good idea for her based on her genetic heritage. Thus, being able to fulfill the role of parent may be a 69  challenging due to schizophrenia. For two participants who do have children being a parent is deeply meaningful to them.  3.2.2.6 Home management Some people have distinct home management routines: for example, Peter likes to sing as he is cleaning his washroom as it positively influences his mood and Sylvie cleans only when she feels like it and cleans only one portion of a room at any time. While folding laundry, Athena likes to talk with her mother long distance. Athena describes that it is ?an investment into doing the dishes? to call her mum long distance in Europe (A 2. 29). She describes her home as a ?disaster zone? and describes this as being ?isolating? for her as she cannot invite people into her home. Instead, she asks people to wait outside for her (A 2. 30). In essence, she does not like housework and would like to have a housekeeper as she has no interest in doing chores for herself (A 4. 31). Two participants would like to improve their cooking skills but they are demotivated by lack of skill, finances, companionship and experience. Eight participants have a bank account. At least three participants feel they have insufficient money and find it difficult to budget. Jonathan for example, notes that he is not good with money and that it is ?a problem? and ?embarrassing? that he cannot afford basic hygiene products (J 1.8, J2.15). Jonathan also indicates that he ?spends money for something to do? as he simply has nothing else to do (J 2.17).  One person gets help with this task. Shopping for food is something 9 out of 10 people do regularly. Three participants make menus and plan their shopping based on this, while others buy things as needed or desired. One participant likes to cook for other people but finds it more challenging to cook for himself. At least five participants go outside their neighborhood (to other familiar neighborhoods) to shop for food and clothes. No participant owns their home therefore repairs are done mostly by landlords. Participants need to begin this process by calling the landlord. For similar reasons with regard to home ownership nobody has a pet (pet ownership is generally not allowed). Jonathan had a cat at one time but ?got rid of it? as the fire drills ?disturbed? it (J 1. 4) and Lisa considered getting a dog in the future.  3.2.2.7 Active Leisure  There is great variation in dimensions of participation in active leisure such as the diversity of activities, the intensity of participation, and the circumstances under which participants participate. As a cohort, these participants engage in approximately thirty different kinds of active leisure pursuits such as going to the symphony or attending tai-chi. Frequency of participation in specific 70  activities varies i.e., two people do tai chi twice weekly and another individual attends the symphony once annually.  In terms of intensity of participation, Robert speaks to the challenges of sustained participation when he remarks that he will attend the gym several times a week for a couple of weeks, that it helps if  someone accompanies him, and he loses motivation and then is not able to participate for another few weeks. Robert comments that his peer support worker helps him stay engaged in his chosen activities.  I like it because I find it hard to, um, find inspiration and also ? I don?t know what the word is but to get myself to go to the gym. The fact that I have a peer support worker that I meet every week keeps me honest about going to the gym. (R 3. 11)  Thus, his participation is sporadic and influenced (at least in part) by his voices, medication efficacy and repeated injuries. Athena will engage sporadically in a familiar activity if the conditions are right i.e., she will hike if she has someone to go with ? perhaps for an entire summer season and may not do this again for another couple of years. While needing the right conditions may be an issue for everybody my sense is that for participants there may be less options to do other things. In other words if a chosen activity is not available to people they may not engage in any activity at all. Robert describes that, some days I feel like it is really hard just to achieve what I want to do for the day or just to be active, accomplish something for that day?I mean some days I don?t even want to go out, you know it is hard. (R 1.12) Robert poignantly describes that ?the world of schizophrenia ? does not have time for leisure activities? (R 3. 34). Driving is considered as a leisure activity for three participants who used a car for going on trips or visiting friends. Some participants engaged in a wide range of activities for short periods of time for example; Rebel Girl does crafts with the support of various day programs (defined above). Some participants spend time on specific or a smaller number of activities and do them more frequently (such as Painter who does tai-chi several times a week, Peter who writes almost daily, Sam who uses his computer daily to connect with family overseas, and Lisa who makes cards and has done so for years). During the study some participants engaged in new activities such as Sylvie who had just discovered casino life and visited the casino with her friend every two weeks. For the first time in her life she is also planning a sun holiday with some friends. Similarly, Painter recently tried to engage with both photography and computers but after gaining some basic skills decided these activities are not for him. Peter discovered the joy of relaxing chair massages. Two 71  participants did not have had the opportunity to try new activities (in general) in a two year period. The notion of lack of commitment to meaningful activity patterns is characteristic of occupational disengagement as is a poorly defined identity through occupation (Krupa et al., 2010). However the notion of trying new things may be a novel approach to considering activity health26. In essence, if ?variety is the spice of life,? the concept of variety as it relates to activity participation may have implications for recovery.  3.2.2.8 Passive leisure Passive leisure is categorized as including; listening to music, sitting smoking and essentially passing time without apparent physical activity (considering the definition this category seems to also imply diminished engagement emotionally and/or intellectually which may add confusion to the categorization process). All participants were involved in at least one passive activity. For example, Jonathan describes that he is ?sitting around [the apartment] all day for weeks with nothing to do? (J 2.16). He watches television through the night for something to do and also listens to music. Rebel Girl watches the news in Chinese with her family and listens to the radio. Robert watches sports with his roommates if they are available and may stay in bed to relax. Sam listens to music and stays in bed if his day program is closed. Hammy smokes and would like to read more. Lisa reads and relaxes in bed and Painter enjoys a scotch at the end of the day occasionally and rests in bed at times. Peter listens to tapes on meditation and is both emotionally connected to the authors of these tapes and is engaged with the psychological aspects of the material that he listens to. He adds ?they?re just fabulous ? I?m empathetic with it or I?m, what?s the word, I connect with it, yeah? (R 4. 28). Thus, listening to the tapes may appear to be a passive activity however for Peter it seems more active in nature. Similarly, Athena watches a previously taped educational program (whereby she selects the program and is interested in learning the material). Many participants choose to stay in bed when not engaging in activities for a variety of reasons. Two participants say that weekends are difficult when there is nothing to do ? or perhaps more accurately when the things they can participate in are not of interest to them.  For Lisa, time with nothing to do is often as a result of dealing with her negative symptoms. Participants cite reading, smoking, watching television, listening to the radio and staying in bed as being the less active things they engage in most often.                                                  26 Trying new things may be similar to a life course perspective looking at how activities or occupations are and transformed over months and years (Humphry & Womack, 2014, p. 70). 72  3.2.2.9 Socializing  Two participants frequent restaurants in order to meet their need for socialization. Engaging in activities such as church, visiting family on holidays, attending funerals and marriages helps people to connect with their loved ones. Peter remarks that attending church is the only place that affords people the opportunity for physical contact with others and that he believes in the power of therapeutic touch. He remarks, ?so I plan to do more reflexology? implying that one way he will help others (and may help himself to be more connected to others) is through therapeutic touch. Few participants socialize at home. Lisa mentioned having a couple over for dinner once but that her schizophrenia markedly impacted her ability to socialize. She describes ?that, you know? unfortunately [I have] become less social and, you know, it takes a lot more effort to go out especially in a busy environment right (L 3. 21). Robert has meals with his roommates but has decided to terminate this activity as it did not have a good outcome for his health. Sam mentioned that some acquaintances would come to his home for help with their computer. Three people visited other people in their homes regularly (Robert, Peter & Painter).  Two people traveled with family and some met acquaintances during a hospital stay. Two participants return to old neighborhoods to connect with people. One person likes to accompany her husband to a familiar seaside town once a month to hang out and shop in the local art stores. Five participants would like more opportunities to socialize, four participants expressed an interest in having more friendships, and three and possibly five people would like to have a partner in their lives.  Robert simply says ?I would like to have someone to do stuff with? (R 2. 36). The need for socialization opportunities, more friendships and partners suggests that almost half of the participants have a need to be more connected with others. 3.2.2.10 Sleep  Many participants expressed needing approximately 14 hours sleep in a 24 hour cycle. Considering the average amount of rest that each Canadian has per day is approximately eight hours (Statistics Canada as cited in Krupa et al., 2010), this finding may require further examination. Some participants (Sam, Jonathan, Robert, Lisa and Sylvie) liked to sleep during the day. This was particularly the case for Sam, Jonathan, Robert and Sylvie when not working or attending a program. Sam notes if ?I stay at home all the time, it?s boring (S 2. 19). I sleep all day? when this place is closed [day program]? I sleep all day at home, yea, it is very negative ? I feel not happy? (S 2. 11).  How much a participant sleeps seems at least in part to be influenced by how well they feel psychiatrically and what other activity demands they are experiencing. For example, thanks to a new 73  medication, Lisa sleeps at more regular times, with fewer naps and for fewer hours in total (a reduction from approximately 12- 14 hours to approximately 10). She observes that earlier she ?wasn?t responding well to medication and it was really hard to find medication that would work (L4. 21) ? [but now] ?Yes, I um have way more energy ? I?m doing really well? (L 4. 20).    She notes that her napping in the day significantly interfered with her ability to engage in activities with other people. Lisa responds that she is ?really grateful I made the change? and proudly describes that among other things that she was recently able to ?take the singing lessons? (L 4 22) that she was previously interested in but could not as she would normally be sleeping at that time. 3.2.3 Some tensions in charting such a horizon for activity participation  As mentioned, it is difficult to categorize activities without having a good sense of the meaning and perhaps the purpose that those activities hold for individuals. In a similar way to the TWAS (Statistics Canada, 2002) mentioned above the Canadian Model Occupational Performance categorizes occupation according to ?purpose? i.e., self-care, productivity and leisure (Polatajko, Townsend, & Craik, 2007, p. 23). For example, Sylvie thinks of her fitness routine as work and not as a leisure activity as one may assume. She affirms that fitness helps with her health i.e., high blood pressure and helps her do things or not be ?lazy.?  Sylvie adds ?like um, yesterday, I went to a step classes, fitness class. And I work, I work struggle little bit ? it?s good for you? (S 3.21). Similarly, one activity may fit in more than one category. For example, going for coffee is a means of socializing for Painter and Peter however, it provides these men with a way to engage in painting and writing respectively which participants consider as both leisure and productive activities. Therefore, categorizing activities is common in OT practice and has both strengths (such as, helps to measure needs and outcomes) and limitations (such as, is an imperfect process). Krupa et al. (2010) recommend reviewing activity health outcomes for a systems perspective to inform service development. They also suggest collecting qualitative and quantitative data regarding changes in activity patterns from program participants. Interestingly, however, is the absence of categories of activity present in data from this study but not within the categorization used here or by Krupa et al., 2010. For example, there is no mention of intimate or sexual activities, activities relating to drug use or misuse or activities such as dealing with a separation requiring significant changes in routine. Identifying activities involved in dealing with suicide, angry neighbors, stigmatization, managing stress, boredom or disclosure of mental illness also do not fit easily into this categorization.  74  In addition, the categorization does not allow for the fact that meanings may change over time (i.e., as Heidegger (1962/2008) asserts meanings can be lost, forgotten and retrieved (Moran, 2010). For example, initially, Athena?s accomplishments at work were important milestones in her career, however, over the past five months work was more of a distraction from the pain of losing someone, providing her a ?mindless routine? that allowed her to be out of her home and earning a living. Athena now describes feeling stronger and is developing steps to help her move forward with her career in new directions (such as doing an MBA). Thus, the meaning of work has shifted significantly for her over a one year time span and this change is not reflected by using occupational categories such as self-care, productivity and leisure. 3.2.4 What the categorization achieves It is acknowledged that only 10 people participated in this study and generalizability is not possible. However, findings of this study (that were identified through a categorization process used in occupational therapy and occupational science) seem to offer an alternative perspective on the activity participation of people who live with schizophrenia. Literature suggests that that people who live with schizophrenia are mostly engaged in passive activities and are not engaged in a wide variety of activities (Leufstadius & Eklund 2008; Leufstadius, Erlandsson et al., 2008; Minato & Zemke, 2004; Shimitras, Fossey & Harvey, 2003).  Findings from this study suggest that that approximately 7 out of 10 participants volunteer and about 8 out of 10 participants work at least part-time, and that all participants engage in a wide variety of leisure activities. These findings may be particularly helpful to people who live with schizophrenia, their loved ones and service providers to as they consider activity participation with and for people who live with schizophrenia.  Findings from the activity code categorization based on Krupa et al.?s (2010) work may indicate broader issues regarding activity participation, citizenship (i.e., civil, political and social rights) and social inclusion. 27 During the analysis phase the notion of social inclusion seemed to be an important and relevant concept and is used to further illustrate themes in the following finding chapters.  Social exclusion (Boardman, 2010a, 2010b) is described using several and sometimes competing discourses. Drawing on the work of Levitas (1998), Boardman (2010b) identifies three of those discourses to include: a) the redistributive discourse with a focus on the debilitating aspects of poverty and the need for redistribution of economic resources, b) the moral underclass discourse that                                                  27 These topics will be taken up in chapters four and five and also in the discussion chapter. 75  consider the moral and cultural causes of poverty i.e., the reliance on state benefits and finally c) the social integrationist discourse with a focus on integrating individuals by means of paid employment (p. 10). Boardman offers an often-cited description of social exclusion as being ?the extent to which individuals are unable to participate in key areas of the economic, social and cultural life of society? (2010b, p, 10). For example, although 8 out of 10 participants did engage in work, for some the work was erratic, low paying, and stress inducing. Thus the categorization may provide evidence that some people who live with schizophrenia may be marginalized with regard to their ability to move past entry level jobs and may, as the Disability Without Poverty Network (2012) points out, consequently experience poverty. This, despite 11 randomized controlled studies indicating that a best practice called Individual Placement and Support (IPS) helps people with significant mental health issues return to, and stay engaged with work (Bond, Drake & Becker, 2008 cited in Areberg & Berjerholm, 2013). Moreover, Areberg and Berjerholm, (2013) also assert that IPS improved quality of life, empowerment, improved time use patterns and level of engagement in community life. Athena astutely questions   ?my question is why are so few people working? ? ? people need money, they could be working?. 3.2.5 The challenges of such a categorical horizon We have established that the meanings that participants experience in activities are not made explicit through this categorization process and thus we are left with several questions about dimensions of activity participation that are not illuminated.  For example, how do these activities fit together for each participant? And how do they relate to participants? hopes and dreams or to the possibilities participants may identify for themselves? Are participants experiencing a sense of satisfaction, challenge, choice, growth, pain, rejection or inclusion as a result of their activity participation? Do they receive recognition for their skills and knowledge? Are participants freely able to share their capabilities and find support for their needs?  How much or in what ways do people value the occupations they engage in?  Therefore, the categorization used in this study offers a momentary view of how participants engaged in their activities which can be a useful tool when considering quality improvements for service delivery. However, the process of meaning making in activities is more reflective of a dynamic ongoing process (Frankl, 1959/2006). 76  3.2.6 Reflection and next steps  The final section of this chapter presents activity patterns and meanings for three individuals during the two years of data collection (also see Appendix G  for activity maps). As noted, information regarding Athena?s occupation and place of origin has been altered in order to maintain confidentiality. Using Frankl?s (1959/2006) three strategies associated with the possibility of finding meaning (such as, creating a work or deed, experiencing another and one?s attitude to suffering, see Table 3 overleaf for more details). Conclusions are drawn regarding activity participation and meaning over time.    77  3.3 Section 3: Three possibilities of finding meaning adapted from Frankl (1959/2006) TABLE 3: THREE POSSIBILITIES OF FINDING MEANING ADAPTED FROM FRANKL (1959/2006)   Pseudonym  Possibility of meaning Creating a work or deed Possibility of meaning Experiencing another Possibility of meaning Attitude to suffering Considering possibilities through hopes and dreams   Athena  Volunteering =contribution, competence, recognition, skill development, advocacy. Working  = intellectual challenge, importance acknowledgement Both = accomplishment, risk, ?mission?.   Gives as a volunteer, gives to mother,  Wants a partner. Wants to help women. Disciplined to work within  ?Windows of opportunity?. Schizophrenia compels her to ask more of the world and perhaps herself. Transcends own sense of loss To help others.  Wants further education. Travel. Financial security.   Jonathan   Work-is a challenge, gives sense of normalcy, responsibility, financial support, connection Internet is engaging, is sometimes lost in survival mode. By absence or loss, feels alone. Death of mother, desire for girlfriend,  Unsure of self. Feels unheard and lonely.  Carries on.  Wants a better life.  Things to do.  More social contact.  Lisa Art ? proud of it. Is recognized for it Homestay- wants to help the family financially. Feels useful. Committed to husband and to marriage. Seeks support from family.   In Narcotics Anonymous / Debtors Anonymous for almost a decade. Commitment to overcome addiction. Wants financial freedom Finish BFA Credibility  Painter  Painting ? talented pushes himself, ever-changing- unique way of painting Wants to make others think- a mission.  Committed to family ? diligently regarding communication. Committed to church.  Schizophrenia gets in the way but is ?happy.? There is something better waiting after death. Would like money to visit family. Wants to be in the eye of the art critic.  Rebel Girl Fulfills role in family- gets recognized for this ? useful. Committed to family. Rebelled against family to keep boyfriend.   Gets on with things.  Wants to make money ?Hang out with different people.?  Sam  PSW, proud dad, son helps others ? feels useful. Spends time with others at clubhouse ? contributes. With his daughter does not feel alone.  Likes to be connected. Is ?happy.?  He lost mathematical capabilities but likes his new interpersonal ones ? gives to others.   Wants a good live, new family. ? Return to engineering. 78  Pseudonym  Possibility of meaning Creating a work or deed Possibility of meaning Experiencing another Possibility of meaning Attitude to suffering Considering possibilities through hopes and dreams   Sylvie Working makes her feel useful. Never thought she could work and is proud of her accomplishment. Work is boring sometimes but makes her feel capable and fills time. Loves her daughter. Waiting for her to mature. Wants friends and feels the absence of friendships.  Feels the worst is over. Looking forward to even brighter times. Beginning to move into a different more relaxed phase of life. Wants more fun, people and activities Wants financial freedom. Peter  Spiritual seeker and healer ? his mission is to help. Always learning and practicing  Is uniquely himself. Cares for elderly mum. Belongs to two communities.   Focuses on others ? when connected describes that he ??meets others? minds.? Draws on his sense of character strengths.   Wants to share his capabilities i.e., more formally. Teach Tai Chi. Robert  Is a ?computer guy? ?  Is committed to gaining trust, kindness, and love from others. Focused toward others  Has guardian, family friend and MH team. Seeks help. Follows through.  Wants to work on computers. Wants to stabilize illness.  Hammy Volunteers: is fulfilling and connects him to the world, gives responsibility, identity Works for financial reward, fills time and to show he is a capable citizen. Survival may be his mission. Lives to be connected to others and be acknowledged Cares for his girlfriend lovingly keeps a watchful eye. Does what he can.  After each drug use he picks himself up again and carries on. ?Want to be a totally upfront person.? Wants to ?break through the door of life.?    79  Introduction  This section of the chapter examines the activity participation of three participants during the two years of data collection. The intention is to consider meaning in activity from Frankl?s (1959/2006) three perspectives: 1) a deed we do, a work we create (i.e., a vital activity or a mission), 2) an experience, a human encounter and love (caring for someone other than ourselves), and 3) when confronted with an unchangeable fate (such as an incurable disease) a subsequent positive change of attitudes i.e., the ability to turn suffering into human triumph (p. 111). This frame shows something of meaning in activity within the broader context of daily life as opposed to looking at a single discrete activity. It also aims to move the analysis from individual participants to considering meaning for three participants (i.e., Athena, Jonathan and Hammy). 28 These participants were chosen as they engaged in similar productive activities (all worked and volunteered) however, their patterns of activity participation were different, their lived space and place was different, as was their social and mental health support systems as well as what they hoped for (i.e., their dreams). 29  Note an additional column was added to note participants? hopes, dreams and possibilities. Similar to Deegan?s (2005 30) work on personal medicine, Frankl (1959/2006) calls individuals to listen carefully to what life requires of us and offers three possibilities by which people find meaning.  3.3.1 Experience of activity participation over time What follows is a brief description of productive activities (i.e., working and volunteering) as described by three participants over time.31  Accounts show that connection with others, living with schizophrenia and ideas of place and space all imbue activity participation with certain and specific personal meaning. Notably, the life circumstances of each participant changed over the duration of the study in various ways and a review of this theme will begin the discussion.  3.3.2 Athena Athena experienced ongoing and significant contextual changes during the study. Her goal was to be able to leave several part-time lower paying jobs (and the financial support of her Canada Pension Plan that she received for 15-16 years) in favour of working in a professional job within her                                                  28 See Table 3 for additional information for all participants.  29 The concept of hope is a central component of the recovery model and is linked to the notion of possibilities for the future (Deegan, 1988). 30 Personal medicine is defined as activities that give life meaning and purpose. 31  More nuanced interpretations of meaning in activity are offered in chapters 4, 5 and 6. 80  professional field. Athena described ?striving for work that has meaning and that?s lucrative enough? for her to be self-sufficient financially (A 4. 45). Her first chosen professional job did not work out as the employer wanted someone more experienced. Soon after she accepted a second full-time job and experienced much success. For example, she described a growing sense of competence and mastery, was awarded a substantial bonus. She was delighted with this additional financial security and marveled that ?because I got the raise?.I can buy myself fresh crisp farmers apples that do not have wax and do not come from Safeway ? I can [also] give back and do some of the things I hoped? (A 4c ) to do. Interestingly, Athena discovered she did not like her career choice as much as she thought and plans to do further education.  During her transition to-full time work she was fearful of disclosing her illness and losing her accommodation ?My company does not know that I have a mental illness? I don?t rock the boat I just keep it quiet? (A4c). Without much warning she was terminated from her Canada Pension Plan (CPP) ?I got a letter in the mail ?. and that is it? I am all by myself? (A 4c). Athena was able to remain in her original home however, now was fully responsible for paying the rent. Because her first job did not work out she was without CPP benefits for six months while selecting a new professional position. Also, important to Athena?s experience of becoming self-supporting was the challenge of navigating several government systems (namely, CPP administered by the Ministry of Health and her housing benefits administered by the Ministry of Housing). Athena described that having two Ministries with two sets of rules further adds to the complexity, confusion, and uncertainty to becoming self-supporting. In addition, as Athena moved into a full-time work she was worried she may become ill again and not be able to pay rent herself. She notes that she asked herself  ?how secure do I feel with myself to get on my feet, to get out of debt and build a [different] safety net? (A 4c).  After being in the job for one year she had saved $12, 000, busily attending workshops to help he plan her financial future ad planning to bring her mother on holiday.   Close to the end of the study, Athena also lost a close friend to suicide. She shared she was grateful to be able to meet his family and help them better understand their son?s experience of major mental illness. Because she was doing well financially and performing well at work she had the freedom to fly to her friend?s funeral and be a support for his family (a marked difference with regard to her freedom to contribute to herself and to society). She reflects when her friend died ?my job was my stability, my safety net, somewhere I go , something to rely on and go to every day? (A 4c) 81  Earlier in the study she worked several jobs, earned approximately $12.00 per hour, was investigated by the Ministry of Health regarding her reporting times. By contrast, she now works full time, earns $60,000 a year, pays taxes. Early in the study Athena expressed her dislike of weekends and described herself as being ?stuck.?  Now she notes that weekends are not an issue ?now I have things to do so, I have a mission (A 4c).? Despite significant changes in her work status and routine Athena continues to volunteer and this activity offers her additional emotional connection at work. At university she created a women?s networking group and she has transferred her ability to bring people to work together to the workforce. Her volunteer activity pattern is similar and her goal of volunteering is similar but the location is different ?I can give back? (A 4c). She is now in line to assume the presidency of her professional organization and aims to further advance women?s issues within her profession. In general, Athena was able to take up new possibilities or opportunities of working, of being-with others and of contributing to others in-the-world. Athena remarks ?it is a relief to be able to take care of myself on my own terms? (A 4c). 3.3.3 Jonathan Jonathan also experienced significant changes over time. In the early stages of the research he was relocated to receive services at a different mental health team. Despite experiencing some anxiety with the move and meeting his new care team members he had just begun swimming again. Jonathan shared ?they?ve been really good at trying to ? I went swimming for a little while but then things started happening with mom and I quit couldn?t swim anymore.  I quit the swimming group? (J 4. 55). He was pleased to be doing this activity, was beginning to meet people and starting to enjoy it. Throughout the study he worked twice a month and notes he has a ?heck of a time making sense of things? (J 1. 8). He started a new volunteer job and describes it as eye opening but that he was not scared. Jonathan reflects ?well I realize I do not have it as hard as some people sometimes people come in there and sometimes people are like really suffering and that? (J 4. 24).  Through his volunteering he also feels more connected with the real world ?And I-I-I just think it?s helped me take a look at the real world, really, A close look at the real world you know I just feel like I have something more to do with it now? (J 4. 24). However, suddenly and close to the time of our final interview his mother, (and most significant source of both financial and emotional support), died. His possibilities closed down significantly. Jonathan adds ?yes I don?t feel like going out? (J 4. 30).  He was left with less money and was lost in terms of 82  how to fill his time. He was distressed as he could not ?phone her to tell her? things nor could he receive her help. Further, his doctor did not respond to his call for support. Jonathan was displaced with regard to his mental health team and did not have access to his supportive relationships. He was also grieving the loss of the instrumental support offered by his mother. Soon after losing his mother he took a week away from work but continued to volunteer in a new position. In summary, Jonathan?s possibilities closed down over time and he experienced a sense of being excluded from care, from family life and became troubled about his financial security. He described feeling very alone. Heidegger (1962/2008) offers that death is a time when we grasp our possibilities in that; it conceals the not-yet actual (Mulhall, 1996/2005). Because of his ?Mum?s? death, the loss of her support, and his sense of displacement he was having trouble seeing his future without her. Paradoxically, in some ways, his need to work became more compelling ?it?s just more I?ve got to do something with myself you know what I mean? ... I just, I have all these hours and I think what should I do? I?m not sure sometimes but-but? (J 4 Mu 58).  Here, it is noted that Jonathan?s habits, routines and roles have been seriously altered which imbued him with a sense of uncertainty about his possible activities; it became hard for him to grasp his possibilities for the future, in particular his possibilities about work. The last time we met was shortly after his mother?s death in December 2012.  3.3.4 Hammy  Hammy?s context changed more subtly. Hammy lives with AIDS and reported having a series of head injuries. He lived, worked, volunteered and received care for more than a decade in what is referred to as the poorest postal code in Canada, the downtown east side of Vancouver (Croll, 2012). He comments that sometimes he sells his belongings on the street and explains ?I do that just so I?m surviving, Yeah ? They?ll give you money, or cigarettes? (H 4 8). It may that Hammy?s mission is survival.   Since he and I first met, he mentioned feeling weaker, the drug use and the weight loss were beginning to take its toll. I observed his need to sit more often and on occasion, he would share that his energy was low. At times his ability to work was compromised. For example, he was sent home a few times by his boss who said he needed to eat more and care for himself. He was less able to do the physical part of the job and he got injured more often. I observed that at times when he was working he seemed more cheerful and dressed with more care (which was also the case 83  for Athena). For example, he was working on the last morning we met and took a break to meet with me. He had work gloves in his jeans pocket, new shoes and a new shirt.  marvels in his new outfit  saying ?they?re brand new ? Yeah it cheered me up? He considers that he ?never has to buy a new shirt? that work clothes are often given to him and that he likes wearing them (H 4. 7). When feeling less energetic, Hammy went to his volunteer placement and explored his possibilities for activity participation and remuneration there (such as getting involved with research). Research gave him a chance to help someone, to connect and to get a little money. All that to say, intuitively, he was able to shift his activity pattern in order to experience some of the same meanings in his volunteer work as he could through his work. Lysack and Adamo, (2014) propose that a higher socioeconomic status is associated with better health and more numerous opportunities for engagement in, and experiencing the benefits of meaningful occupations (p. 188). Undoubtedly, Hammy lives with multiple challenges; however, he does express satisfaction with and appreciation for, his volunteer work and the leaders of this program. It did not seem so, but a question might be to ask if Hammy experienced a sense of being ?ghettoized? in his role as a volunteer as is often the case according to a seminal report by the National Centre for Volunteering (2003). It was clear that work remained limiting for him in terms of income, quality and quantity. Yet he remained adamant that he is ?not going to work for hotels anymore ? I?m happy the way I am right now.  I?m going to go to college; Vancouver College?I?m going to join up? (H 4. 8). However, his ability to engage in education remained challenging and his work opportunities were receding so he looked to volunteering with people he knew in order to fill the void. Lysack and Adamo?s (2014) apt recommendation for occupational therapists to help clients get out of poverty is a compelling one and is discussed in the recommendation section of this thesis. 3.3.5 Reflection: Activities, parts whole and salutatory meanings    This section considers research approaches used to better understand meaning in activity. For example, Watters, Pearce, Backman and Suto (2012) consider personal meaning with regard to engagement in ikebana practice (the Japanese art of flower arranging). Study findings indicate that engagement in ikebana: is a means 1) to a richer life; 2) affords the opportunity for transformation, and 3) supports harmony in life (p. 1). This is an example of a practice within the occupational therapy and occupational science whereby authors choose a discrete activity to gain a better understanding of the meanings of activity and or to learn how activities contribute to well-being (see also, for example, P?ll?nen, 2012). These authors acknowledge that further study of these ideas would help deepen our understanding of meaning in activity. Findings from this study by contrast  84  contend that articulating and mapping the meaning dimensions of participation of discrete activities within the context of a person?s full range of activity participation (looking at the activity parts in the context of the whole) may render helpful understandings of how such activity choice impacts overall health and well-being. (The notion of choosing an activity for specific salutary effects is observed in the scenario with Jonathan above who found that volunteering helped him be more connected with his world-at-hand). Considering meaning in activity in this way may also serve to engage people receiving services to identify how their overall activity participation contributes to, or detracts from, overall meaning in life. Mapping meaning in activity may be accomplished by a) supporting people in recovery to narrate their activity pattern and the meanings they experience in their activities, and b) generating activity maps using this information (please see Appendix G for an example of this idea for Athena, Jonathan and Hammy). Activity maps could help people in recovery to better understand how meaning in their discreet activities may be connected to their overall well-being. Mapping activity participation and meaning in this way may also open dialogue for both goal setting and evaluation.  Conclusion The previous section looked at productive activities for three participants through Frankl?s (1959/2006) work relating to the meaning in life (See Table 2). Athena, Jonathan and Hammy experienced multiple possibilities of meaning in life within their respective productive activities. Shared meanings included a sense of connection, recognition, competence, accomplishment and financial reward (see figure 2 for additional details). For some, meaning centered more on angst, trying to ?get on with things? and loss. Athena was the only participant who described having a ?mission? with regard to her activity participation which is a key aspect of meaning in life according to Frankl (1959/2006).  I then consider meaning in discrete activities as they relate to overall activity participation. A short review of space and place indicates the value of this approach in helping people manage disruptions.  Chapters 4, 5 and 6 will identify participants? experiences of meaning in activities by using Heidegger?s concept of Dasein. According to Mulhall (1996/2005), Dasein necessarily takes a stand on itself and is defined by this stand. Blattner (2012) asserts that Dasein always determines itself as an embodied entity ?in the light of a possibility? (p. 38), i.e., it concerns itself in an embodied and practical way with who it will be or not be.85  Chapter  4: Activities of Citizenship, Recognition and Skill Development for Social Inclusion  ?Autonomy is a resource for action and the principled development of the human spirit, and it is a resource that people with schizophrenia vehemently fight to retain? (Doubt, 1996, p. 89).  Introduction  The aim of chapters 4, 5 and 6 is to synthesize the findings under three overlapping and compelling themes: (1) activities of citizenship, recognition and skill development for social inclusion, (2) activities for health and well-being for justice, and (3) activities that resonate with the call to be more fully human. These themes are helpful in understanding the sometimes hidden nature of meaning in the everyday experiences of participants as they go about their daily activities in the world. In this way, the themes relate to Heidegger?s concept of Dasein (understood as being-in?the-world, existence or way of being) and show how participants move into their futures; i.e., experience their possibilities. Heidegger asserts that ?Dasein?s being is a matter of its motion into the future?; it ?is what it becomes (or alternatively, does not become)? (Blattner, 2012, p. 91). Blattner, (2012), also posits that confronting our possibilities allows us to liberate ourselves and own our futures. Similarly, Dreyfus suggests that one is defined not by one?s ?current projects or goals but by the possibility of being? (1991, p. 188). The notion of possibilities in relation to activity participation also appears in the occupational science and occupational therapy literature for example in Reed, (2008) and Reed, Hocking and Smythe (2011).  This notion of possibility (as linked to a hopeful future) is helpful in that it embodies participants? past, present and future experiences and is aligned with the concept of psychosocial rehabilitation (PSR) and recovery described in the mental health and addiction literature. 32                                                    32 As noted in the literature section PSR is ?based on recovery focused principles and provides accessible and person directed services? (PSR, 2010, p. 2). The Substance Abuse and Mental Health Services Administration (SAMHSA) in the USA defines recovery as a ?process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential? (SAMHSA, 2011, n. p. para. 2). 86  4.1 Citizenship as belonging   Heidegger (1962/2008) proposes that, as people, we are located in a social world with expectations regarding what one can do and how one can do it in our daily life or how we can be-in-the-world. To that end, PSR practices in Canada ?support [the] full integration of people in recovery into their communities, where they can exercise their rights of citizenship, accept their responsibilities and explore the opportunities that come with being a member of a community and larger society? (Psychosocial Rehabilitation (PSR) / R?adaptation Psychosociale (RPS) Canada, 2009, p .2). Hamer (2011) reviews the literature on citizenship and concludes that the concept of citizenship for people who live with mental health issues is the legacy of a bio-medical understanding of disability. Key aspects of citizenship from this perspective  include the legal or formal status of citizenship, the protection of rights and the responsibility to ?participate in the community?s political, civic, economic and social processes in return for this allegiance and solidarity to the state and one?s community? (2011, p. 24). In addition, and of relevance to this study, citizenship from this perspective also includes the persons? social relatedness and connection to members of society (Hamer, 2011, p. 24). Prince (2009) asserts that the obstacles that people who live with a disability face are ?the product of the interplay between impairment or health problems and socio-economic and cultural environments including attitudes? (p. 47). This latter notion of the interconnectedness between the person and the larger social context is in keeping with work by Pelletier, Davidson and Roelandt (2009).  Pelletier et al. (2009) assert that recovery is best achieved through empowering both individuals and larger communities (globally) and this approach is based on the idea that citizenship is fundamental to both recovery and empowerment.  Hamer (2011) makes the case that citizenship has rarely been studied from the perspective of persons who live with a mental health issue. She states that a ?review of the citizenship literature revealed that there were no empirical studies that focused specifically on service users? understanding of citizenship? (Hamer, 2011, p. 2). She concludes that citizenship is crucial to the process of recovery from a serious mental illness and future well-being; a topic for discussion in the closing chapter of this thesis.   Hamer (2011) is interested in understanding how people receiving services understand the notion of citizenship and if the recovery approach helps or hinders in the journey toward full citizenship. To that end, she engaged 17 people receiving services and 12 key stakeholders in her research.  Hamer 87  (2011) applies Isin?s (1999; 2002; 2008)33 conceptual model of citizenship and asserts that people who live with significant mental health issues experience citizenship in a reduced way and she calls this state conditional citizenship. In other words, their sense of belonging or inclusion and therefore their sense of citizenship is often compromised. Based on Isin?s work Hamer describes four interlinking processes that can represent a journey to becoming a citizen for her seventeen study participants who lived with mental health issues. These components include shaping behaviour that enable participants to blend in with society, engaging in practices of inclusion such as education aimed at challenging discrimination within society. She posits that these acts by participants bring about a sense of belonging that is linked to a sense of citizenship. She also acknowledges that some engage in specific acts of citizenship that aim to lay claim to full citizenship.34 Hamer?s (2011) work serves as a useful lens with which to consider the themes, as several participants in this study identified that their activities brought to light and often promoted a sense of belonging and citizenship. Activities that were associated with an experience of citizenship for participants included applying for legal citizenship, receiving a pension, teaching others about illness, holding a job, and doing volunteer activities. The aforementioned process of citizenship as defined by Hamer (2011) also linked to future possibilities and well-being for participants. The next section articulates how participants experienced a sense of citizenship (i.e., both the rights and responsibilities) through their activity participation and then explores how participants experienced being recognized for their successes and contributions. Some participants experienced a diminished sense of belonging and citizenship and this will also be discussed.  4.1.1 Rights and acts of citizenship Engaging in activities pertaining to citizenship allowed participants to consider ?owning who and how one is? (Blattner, 2012, p. 15). Blattner adds that by confronting the notion of ?possibilities,? it allows us to see what kind of  Being we are and this ?in turn opens possibilities of liberation and self-ownership that Heidegger explores? (p. 13). During the study, two participants engaged in specific acts of citizenship requiring them to make some important decisions about who they are and their                                                  33 Isin?s model of citizenship is dynamic and citizenship may be experienced on a continuum ? from being an insider to being an outsider. The assumption is that one?s perception of citizenship is influenced by both contextual and individual factors that can influence one?s sense of inclusion and exclusion.   34 Hamer (2011) describes such acts /narratives of political agency and citizenship agency as ways to counter the ?epistemic injustice within the mental health system? (p. 182). 88  options. Athena for example spent almost two decades finding a way to become a Canadian citizen. This task was complex as she wished to also to maintain her citizenship of origin. With the help of a knowledgeable lawyer she was able to accomplish this dream; having dual citizenship. Although obtaining dual citizenship was a financial burden and took considerable effort, Athena was proud of the outcome. She remarks: ?You have to jump through a lot of hoops and there?s a lot of regulations to keep your [original] passport? (A 1. 55). Athena feels connected to both countries and in a sense now owns this position as a full citizen of both countries.  Sam emigrated from China with his now ex-wife. He is appreciative of what being a Canadian citizen has offered him as he learns how to live with his illness. He believes this support is necessary and allows him to see his possibilities for activity participation: a ?lot of organizations help us, you know, if society doesn?t give this to us we cannot do anything? (S 2. 47). He was also fearful of returning to his country of origin as he felt he would not be treated well there because he lives with schizophrenia Sam applied for temporary residence for his parents and this application was declined on financial grounds. He felt having them close by would be good for his health. Immigration regulations required Sam to be financially responsible for his parents during their six-month stay. He ?was disappointed? by the rejection of the application (S 4. 22).  Heidegger (1962/2008) indicates that we bring together our past, present and future possibilities, thus opening up or closing down possibilities for the future and this idea may help to understand part of the dilemma that arose for Sam. Sam adds he ?gave his family a lot of stress? when he became ill and his father treated him badly as a result (S 2. 45). Sam may have perceived himself unable to meet his expected responsibilities for his Chinese parents. Being able to offer them time in Canada may have been a way for the family to heal. Sam is now torn between returning home to his family in China knowing that life will not be easy there, as he would not be able to work in his profession due to his schizophrenia. His other option is staying in Canada where he is deeply grateful to receive his disability assistance and mental health supports. However, in Canada he must live separated from his parents knowing he is unable to help them come to this country. This account shows the dilemma he is faced with in the context of living with schizophrenia; each of his options offers and restricts aspects of his life, influenced by the fact he lives with schizophrenia. Sam is connected to both countries but neither option offers a full sense of inclusion. For now, he has resolved to stay in Canada despite being separated from his family of origin.  89  4.1.2 Receiving financial support  One of the benefits of citizenship for some participants was receiving financial disability support from the government. Most participants received Persons with Disabilities (PWD) assistance from the Ministry of Social Development and one person received the Canadian Pension Plan (CPP) disability benefits from the Government of Canada. Receiving these benefits had multiple meanings for participants. As noted above, Sam remained immensely grateful for this financial support, which allowed him to support his ex-wife and child when he was unwell and simply could not work. It also supported him in developing new work skills and he is grateful that he can be independent and not have to ask his wife for financial support. Similarity, Peter and Painter appreciated this financial support. However, having a keen interest in their health found it required significant financial planning and organizational skills to be able to eat well on this level of income. Of concern to Peter was the impending threat of yet another rent increase. An additional financial concern for Painter was to have enough money to reunite with his ageing parents after more than a decade. In a similar way, Peter was able to fulfill the call to care giving for his mother only because she provided the necessary financial support. An inability to support others may be seen as compromising one?s sense of citizenship or as Boardman, Currie, Killapsy and Mezey (2010) assert it may be interpreted as an act of social exclusion.  Hammy explained that his disability benefit was not enough for him to live on. Similarly, Jonathan, Athena and Lisa, found receiving assistance a challenging experience. To begin, Jonathan frequently expressed his frustration at his inability to purchase the basics of food so he did not have to survive on cereal and a boiled egg. He wanted ?to cook some more?Whatever it takes to you know, cook something decent. Like, make a salad with it or something ? as long as I can afford to get the stuff? (J 4 .6). He also would like to be able to purchase self-care products such as contact lenses and shampoo so he could be prepared for work. At the beginning of each month he had to choose between these options and once a purchase was made he would find himself planning his next set of essentials for the ensuing three weeks. He says ?I cannot see to afford anything? (J 4 .42). However, these frustrations regarding limited income opened the possibility of volunteering for-the-sake-of earning a small time-limited monthly honorarium of ?100 dollars a month? but he is cautious that ?Well, you have to go off it after a little while too? (J 4.25) as he can only receive this money for two of three years in succession.  90  Lisa described that her CPP disability pension ?does not allow for her reality of schizophrenia? and that the current system does not accommodate the episodic nature of schizophrenia. Lisa states that the system ?Doesn?t really allow for people with disabilities or at least with schizophrenia to work when they can work and then go back on disability when they can?t work? (L 2. 29). She asks: ?What is the point of going off of disability and then in five years having a job and trying to go on disability and having them deny my claim because I have a pre-existing disorder?? (L 4. 23). Lisa does not like receiving benefits. At the same time, she is alienated from the possibility of work and distanced from returning to her role as a competent teacher who can contribute to society and support her husband financially. She describes her experience of receiving benefits as being financially deprived and trapped in poverty with no way out (L 3. 21). The sense of poverty and being trapped is limiting and makes it challenging to find new direction leaving Lisa unsure of how to improve her financial circumstances through occupation. This lack of money and opportunity to improve their life circumstances is anxiety provoking and a constant source of strife between Lisa and her husband, thus further reducing Lisa?s sense of control over her material and social life. As is the case here, and as Boardman, et al. (2010) point out not having a sense of control can be experienced as anxiety which in turn can have a damaging impact on one?s sense of inclusion and health and well-being.  Athena?s disability benefits were audited which triggered her most recent episode. She remarks ?I just want out of this system, I want to be done.  I don't want that watch dog? (A 3. 10).  Once Athena secured a full-time job in her chosen profession she stopped receiving benefits. This process took about a year and was intensely anxiety provoking as Athena explains that the: Disability is not my concern, my housing is my concern. [If] I come off my housing subsidy. That is my biggest concern (A 3. 45). I've been doing my spreadsheet on my budget, I know every month how much I'm making, how much goes out, I know on average about how much I'm spending a month, just on nothing, only necessities.  There's not a lot left over. I want to get my debt down so I can move on and feel free and unstuck.  Because I'm also worried, if anything happens to my car there's another outlet that will impact my well-being and mental health ? my car, is part of my therapy. My own imposed therapy. (A 3. 46)  This account is helpful in understanding the act of negotiating uncertainty and risk when moving into being financially unsupported and terminating benefits. Athena prepared herself by mapping out this calculated financial risk, which required considering competing priorities (driving versus being housed) so she could discern her possibilities. Boardman (2010a) asserts that the extra stress of financial worries can negatively influence mental health and can be a key driver for people 91  experiencing a feeling social exclusion (or a reduced sense of citizenship). However, despite this stress Athena committed to the new possibility of employment and accepted the challenge of being a person who is independent financially. Athena began her new job without disclosing illness, mindful that it could nullify her insurance contract. She remains unsure of her ability to stay well enough to work but is taking a leap of faith and trusting in her own abilities. In summary, receiving benefits (a right accorded to citizens of Canada) opened up possibilities for people in terms of caring for their basic needs. In addition, while receiving benefits Sam was able to take peer support training and started working and Jonathan began receiving a small honorarium for volunteering.  As Sam notes, receiving benefits relieved him of the pressure to immediately find a job so he could feed his family. In that way it gave him time to seek additional sources of income. Receiving benefits also created, in Heideggerian terms, a mood of anxiety and closed possibilities for some participants as they felt they could not feed, clothe, or house themselves adequately on their current income. These participants experienced a diminished sense of citizenship as they felt excluded from being able to do many activities that more affluent citizens take for granted such as caring for their parents adequately, going to the gym or buying fresh fruit. Tragically, Lisa considered leaving a long-term loving relationship, so that she would not be responsible for her husband and they would not be so financially deprived.  These latter experiences of conditional citizenship negatively impacted participants? well- being.  4.1.3 Committing to and influencing citizenship expectations through activities for inclusion  Hammy engages in activities to show himself that he is indeed a citizen and thus belongs to the world however, his descriptions show a sense of ambivalence i.e., he seems to wrestle with knowing if he is deserving of being a citizen. Lightman, Vick, Herd, and Mitchell (2009) articulate this dichotomy (of being deserving and not deserving) as a way to understand ?living in-between? and apply this positioning to considering episodic disability. This work is helpful in that it may help to show Hammy as living in an ?in-between? place between both positions (inside citizenship and outside citizenship). Hammy lays out the argument that he deserves to be a citizen as he has worked and volunteered.  I?ve been known to work in a community I?ve done a lot of work in the community, I?ve been known to work, good work for the community for years now just about eleven years [and] going on fourteen, fifteen years, volunteering and working hard. I?m working for hotels for years. (H 2. 39) 92  Hammy concludes this passage by affirming ?I am a citizen? (H 2 40). Hammy acknowledges his ability to show himself and others that he is responsible by paying his debt to society in completing his prison time: ?I?ve done all my time, for everything I?ve done, a couple of years? (H 1. 4).  However, Hammy?s citizenship is in part contingent on how he is seen by both others and himself. For example, staff at his bank assured him in this respect by describing him as a citizen and reflecting on how he has been employed for many years and done much good work within the local community.  When using drugs at work Hammy experiences a sense of being alienated from himself and others. At these times he describes himself as a ?tin man,? ?empty? or a ?monkey called Charlie? who responds with hostile emotions and immediately withdraws and experiences  a sense of feeling bad generally (H 3. 83). Here Hammy seems to dwell in a place of being empty and unsure of himself. Heidegger (1962/2008) suggests that in order to move forward one needs to discover one?s being by building solid ground in which to become. Although Hammy?s time in prison was also an alienating experience, he chose to return to his native British Columbia after serving his sentence. This move provided him a way to be return to solid and somewhat familiar ground. Hammy explains that if he wants to remain a citizen he has to be vigilant, reduce his drug use and avoid becoming angry.  Hammy?s drug use can put his sense of citizenship in jeopardy such that his hard won assurance of contributing to society seems to evaporate. He then retreats to a familiar ?in-between? place where he ponders if he is worthy of being a citizen or not. However, being a citizen is important to him and explains that if he did not feel like a citizen he would experience this sense of alienation emotionally as a ?bigot or an old grump.? He straddles these past, present and future worlds (of home, work, volunteering, drug use, citizenship and prison). Hammy?s worlds are tied together through addiction and are incongruent for him at times, in terms of his perception of what it is to deserve being considered a citizen.   In summary, Hammy seems to experience being both included and excluded with regard to his citizenship or what Craig (2010) describes as ?the inclusion-exclusion seesaw? (p. 355). Hamer (2011) asserts that ?modeling to others in society that mental illness is not a permanent limitation or a barrier to one?s citizenship, is a practice of inclusion? (p. 94). Lisa, for example, explains to other people what it is like to recover from drug addiction and mental health issues and 93  she sees this as a rewarding part of her responsibility to the Narcotics Anonymous (NA) community and the mental health community.  Lisa says:  I think it?s really helpful in letting loved ones know that even if their family member is extremely ill at the time that recovery is possible.  And that even though I?m not able to work that I still have recovery in my life. And their loved one might have an addiction issue and they might even overcome that? so, I think I do it to give hope to families. (L 4) By this act, Lisa not only enacts a sense of hope for families but she also shows that despite living with mental illness she can contribute to society therefore, she demonstrates that living with mental illness is not as debilitating as society may lead us to believe. Through this teaching she also shows herself to be a contributing citizen. 4.1.4 Disclosure Participants engaged in a range of activities that showed themselves as active participants in society however, this participation was often tempered by shaping their behaviour (Hamer, 2011) or hiding parts of their experience. In this way, participants managed information in such a way that they would not be excluded by society and would be able to have the same privileges and opportunities as others. Athena speaks of her non-disclosure at university ?I didn?t come forward myself, I felt the stigma is so huge even at university I never disclosed to anyone that I had a mental illness? (A1. 20). Goffman (1963/1986), in his seminal work on stigma, proposes the mechanism by which the general population singles out those who are perceived of as having different attributes. He notes that as a society we consider these individuals as being tainted and subsequently labelled as ?not quite human? and our society acts to  ?reduce their life chances? (Goffman, 1963/1986, p. 5). In this account Athena shapes her behaviour to hide her illness so her chances at university are not diminished. Later however, Athena shares that she did disclose to two fellow students with whom she felt safe and from whom she received personal support.  These seemingly contradictory behaviours show the different ways this notion of shaping influenced Athena?s behaviour within one context i.e., the university, and allowed her to be successful.  Peter disclosed his illness while renewing his class four driver?s license. He wanted to have a license (wished for a responsibility) but decided not to drive at the time (gave up the responsibility) and experienced a sense of exclusion and mistrust as a result of his disclosure. 94  I had a class four to drive kids in a van. And they asked me whether I had any uh, health problem and I put schizophrenia. They freaked. Cuz they thought I was the driver of the bus who, who was on medication and, so uh.  I said, I?m not driving, I haven?t driven [a van] in 10 years and don?t intend to. But they arranged for me to be tested every second year. But my doctor, he has to fill out a form to say I can drive. But I had to give up the class four license ? I wasn?t gonna drive kids when I was on medication anyway?But they, ya, they immediately jumped to conclusions. [It is] a little bit scary. Everyone comes down on you. (P 3. 8) This rather poignant account shows how Peter took responsibility and chose not to drive as a commitment to the safety of others while at the same time applying for a driving license. In this way, Peter tried to find his own unique way of demonstrating a sense of citizenship to himself and others.  His disclosure resulted in a restriction in his freedom and thus he chose to formally exclude himself from the privilege of driving any vehicle for a decade. This action limited his capacity of being in the world in his own unique way. He was left feeling more alienated and scared as a result and limited in his possibilities for driving during the ensuing decade which was a deeply and negatively disruptive experience for him.  Lisa feels excluded in society in general and describes a hurtful perspective held by society that  assumes that people who live with schizophrenia as being ?less than? or less valuable than others. She explains: ?You know I think there?s a lot of misconception that people with schizophrenia are under educated and that we?re incapable of educational activities? (L2. 47).  Lisa also feels particularly stigmatized while receiving mental health services.  She remarks that, ?There?s this preconceived notion that I?ve run into when dealing with healthcare professionals, not my psychiatrist but with other healthcare professionals particularly in the hospital that somehow I am especially stupid because I have schizophrenia that somehow I am like dumb?(L2. 47).  These accounts concur with Hamer?s overarching finding ?that service users experience conditional citizenship, which includes barriers and restraints to their participation and to the rights and responsibilities that others in society enjoy? (2011, p. iii). The passages serve to illustrate that some participants were open to and strove to commit to citizenship expectations, and experienced success while others had experiences of being deliberately excluded. Athena?s account of disclosure demonstrates how an individual may experience degrees of citizenship even within this same context i.e., at university she could not disclose her illness however she did share this information with three individuals in that setting over a seven years.  As mentioned, the link between social exclusion and 95  stigmatization is well-established for people in recovery. For example, the Australian government asserts that ?[c]ritical to recovery is [the] right to participate meaningfully in community life without discrimination, stigma or exclusion? (Queensland Government, 2011, p. 5). Participants expressed fear of being stigmatized and took steps to maintain their inclusion such as hiding their illness and increasing their social status through higher education. Having a compromised sense of citizenship reduces possibilities for people to engage in their societies as equal members and thus reduces a sense of belonging. The Mental Health Commission of Canada (2012) proposes that an increased sense of community belonging as an indicator of a transformed mental health system (p. 128). Despite strides being made regarding social inclusion as a result of anti-stigma campaigns, the outcome of disclosure for participants in this study was a stigmatizing experience leaving participants with a decreased sense of belonging to their communities. This finding may be more in keeping with recent studies suggesting that in some instances that community rejection may be increasing for people who live with mental illness (see, for example, Pescosolido et al., 2010)  4.2 Being recognized as belonging  Petherbridge, (2011) drawing on the work of Luk?cs and Honneth, describes recognition as a genuine mode of being much like Heidegger?s call; a form of praxis in which humans are engaged in the world empathetically to themselves and others as a result of the world?s perceived value and significance. Here the stance is of ?affirmative practical engagement? (p. 28) wherein one remains emotionally open and responsive to the world. A normative extension of recognition would be the experience of achievement. Honneth, as cited in Petherbridge (2011), concludes that recognition therefore can be seen as a ?precursor to all other forms of action or interaction? (p. 30). According to Honneth, we essentially move from struggling to be recognized toward mutual recognition and in that process we are reliant on the response of others to develop our sense of ourselves (Meehan, 2011, p. 89). Study participants showed how being open to, and being recognized by others, offered them additional possibilities for recovery and social inclusion. What follows is a series of  accounts of how participants experienced being open to and  recognized by others as they engaged in a range of activities such as volunteering, leisure pursuits, work, school and learning to care and  live with schizophrenia. These experiences of being recognized in turn provided participants a possibility for experiencing a sense of belonging to, and feeling included in, their civic and social communities.  Lisa?s account shows how being recognized for her participation in Narcotics Anonymous (NA) helped her to recover. NA is a peer-lead 12-step program to help people with additions enjoy a drug 96  free lifestyle. Soon after joining Lisa was asked to volunteer as treasurer and manage the finances for her home support group. Lisa described this new possibility for using her time. ?Yeah, it was good and we encourage newcomers to do that sort of thing because there is a vacuum that?s left when drugs leave.? In the spirit of hermeneutic understanding we consider how Lisa?s life without drugs was experienced by her use of the word vacuum suggesting a stark emptiness of space or void. In looking at the Greek root of vacuum or xenon, it means literally "that which is empty? or in more modern terms ?that which is empty of air? (Harper, 2012). Looking at the etymological definition for this word may help render a deeper understanding of how Lisa felt at that time. Her life appearing empty; it may have been difficult to breathe.  By contrast, as she began to volunteer with trusted others, became more confident and began to experience a sense of  belonging with people who understood what she was going through and what she could expect in the future from people who walked the same path; Lisa found ?her people.?  She adds that with her new group: I had somewhere to go, ? people to talk to who knew what I was talking about and ? knew it from an inside sense ? I could talk to somebody with nine years and talk to them about what it meant and, you know, they could say well maybe you should go to more meetings or you could call me ? [she says] I got a sponsor pretty early on I think ?I was about six months clean and ? and I started [volunteering], that so that?s another way we use to fill the vacuum. (L3. 19) A sponsor enters into a mutually trusting relationship and supports others in their spiritual growth by reading text, meditating, or writing with them so they may overcome the challenges that brought them to NA. Lisa describes her experience of mutual trust or in her words ?connectiveness? and belonging that influenced the decision to choose her sponsor: I went to DA and then I finally picked her as a sponsor and, you know, we talked about that and how our lives in a way kind of parallel each other.  And how interesting it is that we didn?t know each other at all and then how we came together. (L3. 25) Here, Lisa remembers this event as if becoming part of the taken-for-granted background of her everyday engaged experience and yet their meeting remains a strong bond for both of them.  Since that time she has been given the opportunity to sponsor others. As Heidegger (1962/2008) offers, it is by our typical and consistent acts in our world that influences how we are to be-in-the-world. Lisa found committing to the responsibility of her new role in NA helped to fill the vacuum left by the drugs. She was called to find a new way of being-in-the-world and being-with-others. The journey began by being acknowledged by her home group which helped her develop ties or bonds with others 97  in NA; she experienced a sense of belonging within the shared world of NA. She continues to be recognized for her drug abstinence for the last seven years; this includes an annual cake-cutting ceremony to publically honor her ongoing accomplishment. While her role within this group has changed (in part because it became more difficult to connect with large groups of people due to her symptoms of schizophrenia), Lisa remains bound to specific people such as her sponsor and her mentor and with their support and guidance she wishes to further embody the NA teachings for her daily life. When Peter was a young boy he played guitar frequently but in later years became less interested. Peter?s mother, recognizing her son?s dormant strength, expressed her desire for him to share his guitar playing with her church group thus, offering him an opportunity to at least glimpse at his past musical being. He was ready to accept the call and practiced diligently. As a result, he received much positive feedback and appreciation from church members when he played and sang with and for them. Peter describes that his mother?s shared concern and invitation offered him the ?impetus? he needed to play again. A similar experience occurred some years ago. Peter was also asked by a friend to play for children. He was drawn by the nature of the invitation which encouraged him to play badly as the children would love it: ?So I said, ?Ok I?ll give it a try? ? a year and a half later I had a 300-song repertoire ? [It really got me going], ya, it really did ya? (P 3. 35). Through being acknowledged and invited to participate Peter became reconnected with a past pleasurable activity that was essential to his being as a young boy; i.e., his own most whole way of being. Peter would like to build on these musical skills in order to experience the possibility of providing entertainment for elderly people in residential facilities as he ages. He says, ?I?m thinking when I?m in an old age home, [that] I?ll be playing guitar and piano for people? (P 3. 32).  For Athena, working in her chosen profession affords her an opportunity to be recognized by her employer for her superior intellect and skills and earn a handsome financial incentive after her first year of work. This recognition confirms for her that she is performing well at work; a source of both outward and inward affirmation. The recognition at work is important to her, as is the recognition she received from the dean of faculties in her university for her volunteer work.  Painter receives much positive feedback from his psychiatrist regarding his increased ability to manage his psychiatric episodes. Painter hopes he will become even more proficient at managing these troubling episodes by applying the sophisticated ever-evolving coping techniques that he and 98  his psychiatrist continue to develop and refine. An example of one such technique occurs in the wintertime when he: ?can get nice clean sheets and get into my pyjamas and just kind of cocoon. And ? it?ll eventually calm down? (P 2. 59). To Painter?s surprise he was approached to write about his experience with schizophrenia which he did with enthusiasm and using his own name.  His story was published in a book recently and a secondary popular magazine has since re-published his eloquent and compelling story. This is an example of public recognition that resulted in unforeseen possibilities and an unplanned success. One way Painter measured his success was that his writing adventure came with some ?decent? financial reward and some comfortable new shoes. Buying new shoes may hold particular meaning for Painter as when ill he did not have proper footwear and thus his feet were severely injured due to exposure to snow and rain for prolonged periods of time.   The recognition that Sam and Robert received from their respective health care facilities (as being people who could help others recover) resulted in both additional training to become peer support workers and future employment possibilities. Some participants acknowledged that recognition from specific activities and from specific people was particularly meaningful. Painter, for example, would like to gain recognition for his work from the art critic world, as he would like the possibility of being able to earn a living from his painting. Peter looked to experts in his field (such as the president of his college) for meaningful recognition and appreciated acknowledgement from dear friends.  The findings above are in keeping with Reed et al. (2011) who link Being-with others and possibilities. However, these findings extend this conversation and provide a deeper understanding of the situated nature of the how of being with (namely through recognition) specifically for people who live with schizophrenia. Thus, it is noted from the accounts above that recognition was often offered to participants from people they knew and cared about and that participants themselves needed to be open to receiving this recognition.  It is also noted that participants gained possibilities for future participation and of being more fully included in society by responding positively to the opportunities offered to them and that at times it was difficult for participants to act on that call.  4.2.1 Being recognized quietly by doing  Sutton (2008) offers that ?[t]he discourse of being and world is not necessarily verbal; rather meaning is first made explicit through engagement with things or people for some purpose. The manner, content and outcome of one?s activity can be seen as part of the discourse between being and world? (p. 193). Lisa underwent a medication change and described having more ?emotional 99  availability and freedom? as a result. She reflects that even when people who live with schizophrenia seem not to be communicating a great deal or with emotion, the dialogue between ?being? and ?world? is present. She says: ?I think people may know it but they don?t know how to say it actually.  It may look like they don?t know what?s going on but they do know what?s going on, they just don?t have the words? (L4 . 26). Above, Lisa describes a different time when she was less able to verbalize her experiences, offering that others may also experience this more quiet way of being. She cautions that even when people are less verbal that it is important to acknowledge that this behavior should not be interpreted as if the person is not aware of their experiences; rather she shows that communicating and verbalizing may not be available to them. This is a helpful consideration when creating a space in which people can get involved in activities. Specifically, acknowledging that this quieter mode of existence may require people to engage in more practical activities that show them their own accomplishments. It may also require that recognition is offered in a practical non-verbal way so people can experience the possibility of what is ready-at-hand for them. Lisa?s insight may provide a way forward for people who live with schizophrenia and those who wish to help.  4.2.2 Recognizing the self and being authentic In addition to having external recognition participants also recognized their own success and accomplishments. According to Heidegger (1927/1962) authentic being-in-the-world (or to be our own most selves) is more closely related to its own ways-of-being rather than what it is in relation to others. For example, Jonathan began working again and found a way of being-in-the world that was important to him. He found that working in a regular job (i.e., not a job designated for someone with a disability) was an important way of being for himself and a means for him to recognize his own abilities. He sees himself as someone who is learning to become competent within the work world. He interprets the normative aspect of the work (i.e., the fact that this job is not specifically for people with a disability) as a great accomplishment as he was not sure he could achieve this goal. Similarly, Sylvie is proud that she can work as it shows her that she is doing well. She says:   Before I wasn't working at all, the- the days just passing by like that. You just sit on there, your bed, and then the whole day you don't do anything and you don't have energy to even cook for yourself. (S 2. 14) 100  Sylvie was not sure she would ever be able to work; this sentiment was shared by Rebel Girl and Jonathan. This idea of being open to, recognizing one?s own accomplishments and being acknowledged by others seems to be linked with having opportunities for being included and valued by self and others from participants? perspective. To illustrate this point, during visits to Hammy?s volunteer work site and his mental health team I observed him becoming more animated when people acknowledged his presence and described him as being well-liked in the neighborhood and making a contribution via his volunteer work. In a similar way, Peter describes how his chiropractor is appreciative of his skillful massages; the ensuing accolades were welcomed from his respected health-care professional and a letter of recommendation helped him to accomplish his goal i.e., to teach in an elderly centre. He says of his volunteer mentor ?It took a lot of convincing to get her to let me teach. ? [he explains], I uh, taught in my apartment for 10 years. And I taught my chiropractor in his home and when [the volunteer mentor] heard that, I think something twigged. It?s nice when people recognize, right? (P 3. 30). This experience revealed to Peter the possibility becoming a massage therapist. Both aforementioned accounts speak to the positive emotion experienced by both participants as a result of considering themselves as contributing members of their respective communities. 4.2.3 Freedom to belong inside and/or outside mental health communities Some participants received services at a mental health team and some through a private psychiatrist. In addition, some participants chose to be involved in rehabilitation or supportive communities for people with mental health issues while others choose not to. Participants choose these various settings generally for practical reasons.  Heidegger asserts that people engage with things for practical reasons rather than as a result of specific planning (Dreyfus, 1991). Participants became involved in different aspects of the mental health system for a variety of practical reasons and for some these decisions changed over time. For example, Athena discovered she had to leave the formal mental health community if she was to succeed at her goal and states ?the mental health field was holding me back; I really had to step out?.I felt I was always sheltered? (A 1.13).  She wanted to grow past what was being communicated as being her possibilities within the mental health system. She therefore elected to leave. While attending university she found a new psychiatrist (rather than a mental health team) to help her manage her illness. However, within her new university community she could not disclose her mental illness. Athena adds, ?I achieved a lot of awards and recognition at university and in the 101  community for the work that I?ve done but I could never say? I?m limited by certain illness right?? (A 1. 13).  Interestingly, once Athena left the mental health system and became unwell after approximately 15 years she felt a deep separation and felt in need of additional support from the mental health team but felt unable to return. In essence, she chose not to return as she anticipated that she would be criticized for taking such a risk of stress related to the intense nature of her degree and leaving herself vulnerable.  ?I could not go back to the mental health system for support because I felt they don?t even understand it they would just say, you know, get out of it or why are you doing it? (A1. 14). This account shows how the mental health system was closed to her and that it did not offer her the flexibility regarding the help she needed.  Although Painter receives services within the formal mental health system he chose not to disclose his diagnosis to peers there as he was not sure that he had much in common with other people who live with schizophrenia. It seems his position changed over time since becoming a published author he suggests that this is less important to him now.   Lisa and Athena do not wish to socialize with people who have schizophrenia as they feel they are at a different stage of recovery from other people and find it is hard to connect. Lisa describes a friendship that she ended with someone as she found it difficult to connect with her. It may be that being an insider in the mental health community can be a painful experience; perhaps a reminder of a more challenging time.  As Lisa states, ?I don?t like the word ?lower functioning? because I find it very derogatory. But they are not functioning at the level that I am [and are] more in need of more care? (L 4. 33). Both Lisa and Athena have obtained the services of a private psychiatrist. They say that team mental health services are inaccessible, do not convey a sense of hopeful possibility and do not provide relevant services to people who are doing well. Interestingly, contrary to her earlier choice, Athena attended a series of peer-led sessions about developing a personal wellness plan (called Wellness Recovery Action Planning by Mary Ellen Copeland, 1997). She recommends that this program be available to others who may not access formal mental health services.  This series was offered by the mental health system in a community centre and she discovered it was very helpful. She also met a man during these sessions who lived with a major mental illness and he became her partner for two years.  102  In summary, these accounts demonstrate the push and pull of belonging to different communities that can both open and close possibilities for people.  4.2.4 Getting recognition, to belong and be included  The experience of being recognized (or ignored) can be a motivating force for pushing forth with possibility. Sutton (2008) quotes Heidegger (1987/2001 p. 274) as saying that ?no one wills except when he sees? (p. 135) meaning that we can only be motivated by what is proximal to us. At least two participants spoke of wanting to gain further education so they may increase their level of power and be better recognized as credible within the mental health system should they become ill again. Athena wanted (and accomplished) a good education to elevate her status in the world and to be more credible. If you get a university degree you?re respected, you make money; you get, you get a certain status in society, it lifts you automatically to a different level? [it gave me] this instant lift out of where I came from, you know, which is nowhere. (A 1. 23) Heidegger asserts that when things are disrupted, such as your ability to do things, it becomes apparent (1962/2008). Lisa shares an experience in hospital that motivated her to consider going back to school. She found it demeaning when asked by the occupational therapist to do some beadwork. Lisa describes this activity as something she would do when she was a teacher working with children who lived with a developmental delay, the inference being it was not a suitable activity for her and  made her feel less than an artist. In addition, she described the occupational therapist as not interacting with others. Lisa felt that this professional should have known better on both accounts and was angry. I have a degree in Fine Arts like I?m going to use beads, I?m going to string beads together, that?s going to bring a lot of meaning in my life like I?m stuck on this ward 24/7 ? It was very demeaning ? [the staff were] just drinking coffee and they were letting the people play with beads. (L 2. 48) In conclusion, being recognized by others is an important and meaningful aspect of activity participation. Where, when, how and with whom are all important contextual factors that seem to impact on how meaningful the recognition is to participants. For instance, Athena received a welcome public recognition from her university for innovative volunteer work with peers in developing the first educational support group within her faculty and for raising funds. By contrast, 103  both Sam and Robert?s recognition was less public (but provided by service providers) and allowed them a new opportunity to further their training. Less public still was a beautifully written letter of recognition of kindness received by Peter from a long-standing friend that meant a great deal to him. Peter described a renewed sense of self-appreciation from the thoughtful words of his friend. For some recognition was desired and not offered. In most instances not being recognized closed down possibilities for people and on occasion (when not being recognized) but when opportunities were present other possibilities could revel themselves. For example, when Athena was told not to attend university as it was too stressful for her she moved out of the system and made the most of her educational opportunities. In sum, recognition that resonates with the recipient can lead to future possibilities. 4.3 Developing skills  Developing general skills and abilities (regarding daily life activities including skills for managing illness and flourishing) was a key theme and is explored below. It is noted that various bodies of literature support the importance of developing and practicing one?s skills and abilities. One such approach stems from a social rights perspective and is called the Capabilities Approach by Sen (1999/2000; 2009/2011) and Nussbaum (2006/2007) who assert that people should have the right and opportunity to achieve all they can do or be (such as have a healthy life of normal length, be employed on an equal basis to others and participate as an equal citizen). The belief is that if people do not have access or opportunities to use their basic capabilities they may become socially and economically excluded.  From a recovery perspective, Davidson and Roe (2007) assert that mental health services should be concerned with ?enhancing the person?s capacities for living with, managing, and pursuing his or her own life in the presence of disability, as well as on removing barriers to the person?s exercising of these same capacities? (p. 466). Similarly, psychosocial rehabilitation best practices focus on optimism and recovery and recommend that people who live with schizophrenia engage in skill development to improve social interactions, living independently, and other relevant skills that positively enhance to community functioning (Dixon et al., 2010). Participants engaged in developing various skills and competencies (and know-how) as a foundation for opening new possibilities and many experienced success with these endeavors. In an attempt to set the stage for 104  the ensuing discussion, I offer an overview of how participants developed their skills and then turn to discussion of the specific activities in which participants engaged.  Participants had a desire to develop skills and this desire was applied to a wide variety of leisure, work, educational and self-improvement activities that influenced their identities. A number of participants expressed the desire to develop interpersonal skills. Athena finished her professional degree, Rebel Girl attended a mental health employment program and found a job, Sam and Robert took peer support training, Peter and Painter continued to advance with regard to their health and artistic activities, Sylvie remained committed to attending her evening classes to improve her English skills and computer skills so she remains employable. Lisa developed new know-how to be able to host a student in her home. Peter and Painter committed to their own self-improvement. Hammy was open to extra training so he does not have to work his minimum wage job however, those possibilities were not present for him. Jonathan began to look for financial support so he could return to school but later changed his mind as he felt it would not advance his career. In that instance, he remarked that the staff person did not object to this change (nor did they ask questions regarding more suitable training opportunities). 4.3.1 Developing skills for work and inclusion Rebel Girl attended a mental health vocation skills program which proved challenging due to its frequency and duration. Initially, Rebel Girl worried she may not be able to commit to such an intense program. Soon she began to use her new skills and volunteered and subsequently began to work as a junior grocery clerk. Initially, she described the job as ?something else to do? (RG. 12). She maintains it is ??a start because I no longer have any job experience ? and the money is good at nine dollars fifty per hour? (RG 3. 12). This was her first job outside her home in approximately 20 years and she was excited, proud and grateful for the experience and the financial reward. Slowly, the job provided the opportunity for her to show herself as a professional by wearing a uniform and by developing skills to work with customers, her co-workers and her boss. Working helped her show herself and others that she is competent in locating products in the store, instilling in her a feeling of competence and confidence Heidegger (1962/2008) calls this mode of skillfully managing actions in the world ?circumspection.? Through this job she was able to experience and understand the world through practical embodied action.  105  By wearing a hockey jersey on game nights Rebel Girl showed herself to be a fun person. ?When there-there?s a game-game night I get to wear a Canucks jersey? That?s a funny rule? (RG 3.27). Getting involved in wearing the jersey allowed her to connect with the broader community while at work and opened her world as she participated in a shared activity. Rebel Girl also shows her resourcefulness and became more included with fellow staff. However, despite her obvious success she discovered some challenges such as using the cash register. The most complicated part of her job was remembering specific codes for products. Rebel Girls shares ?many people thought I?d do cashier but no, I just do um, grocery? (RG 3. 29). Heidegger (1962/2008) speaks of incompleteness, the idea that our beings are not fully complete which allows a sense of striving toward completeness. By engaging in such striving we experience our possibilities for being who we want to be. In a similar way, Rebel Girl continues to hope that she will be able to use this machine competently and strives toward this goal.  Sam and Robert found that learning to become peer support workers (PSWs) provided them new opportunities for employment and to help or do-for and do-with others. Robert described how it was difficult to finish his course as he was absorbed with his illness during a medication change; he was pleased that he could finish the exam and meet his expectations. He had to manage the challenge of attending classes and concentrating while having trouble engaging in the world. During exam time Robert also asked for support from PSW services to be-with him which increased his confidence in his abilities to find a way to be-in-the-world. Robert and his PSW would: Work out at the community center and sometimes if it?s a nice day, we go for walk. I was struggling like going to the grocery store when I was sick. Like, I-I was really afraid to go so they helped me just to be there. Just to kind of center myself. (R 4. 8) Robert is struggling to stay connected with the world of everyday doing, while at the same time holding a place for his own possibilities to be a PSW. Receiving PSW services provided a way for him to find concern for, and act on, what has become important to him as he engages with these services. Heidegger (1962/2008) offers that we concern ourselves with what becomes apparent to us, in going about our daily lives. Robert was able to see what was visible partly because of his experience receiving PSW services. Developing new work skills and abilities allowed participants to move into new possibilities of being. Being open to these possibilities allowed participants to engage more fully with their world 106  and experience themselves in a new ways. Participants turned to what was available to them in their world and began doing-for and doing-with others in new ways.  4.3.2 Developing skills through further education  Athena was called to do one specific university degree, the same one that her brother took. She was compelled to learn and she ?pushed herself? as she wanted to take both the academic and personal risk (people warned her against the additional effort). She remarks she needed to ?solve things, tackle things? (A 3. 17) and socialize with smart people. It seems in this instance that Athena was ready to take up further education when it presented itself.  Heidegger (1962/2008) explains. Being-in-the-world is proximally absorbed in the world of concern. This concern is guided by circumspection, which discovers the ready-to-hand and preserves it as thus discovered. Whenever we have something to contribute or perform, circumspection gives us the route for proceeding with it, the means of carrying it out, the right opportunity, the appropriate moment. (p. 216) Athena?s university degree was challenging, expensive and took a long time to accomplish (seven years at university and several years in preparation at college level). Athena says, ?I wanted to get the best education that I can get into. I wanted to invest in myself and I didn?t want to spend my money on something that in the end I would not get a decent job? (A 1. 24). When complete, she experienced a sense of freedom in being able to care for herself financially as a result of her education. She shared that if she is not learning she does not have a good sense of where she is going in the world and that she needs this feeling (A 3. 19). Learning was an activity that was ready-at-hand or simply there, something she pursued all her life and brought toward to her own unique being-in the world. Here we get the sense that Athena is driven to excel at her chosen profession and that she will not compromise with regard to being able to use her capabilities (mental health staff warned her against it). Athena now saw herself as useful. She remarked that her profession is important that in fact it can ?save lives? (A 1. 50). In other words, as a result of her learning Athena experienced being accomplished and useful in the world. She felt she could contribute something significant and important. Heidegger (1993, p. 217), as cited in Sutton (2008), explains ?[w]e view action as only causing an effect. The actuality of the effect is valued according to its utility. But the essence of action is accomplishment. To accomplish, means to unfold something into the fullness of its essence, to lead it forth into its fullness - producere? (p. 153). 107  By contrast, Hammy would like further education and has not been able to access this possibility for himself. He would like to improve his English, and do janitorial training at a community college in order to get a steady well-paying job.  I want to go back to school, learn how to spell again, and write so my mind remembers the alphabet, how to spell ? [have] better reading.  Better printing, writing and sign my name?better just to be smarter ? [the employer doesn?t] pay the right amount?it?s not a real job, it?s just part time.  You can?t even save the money ? so, I want a regular job. (H 4. 18)  For Hammy, educational opportunities that he thinks would help him get a better job are not ready-to-hand, and therefore it is difficult for him to unfold this possibility for himself. This may in part be due to the fact that the opportunities that are available to him are not suitable for his needs for education or that he does not see the utility of the opportunities that are present for him. Either way, it is challenging for Hammy to bring his hopes to the fullness of their essence. It may be that not having this opportunity leaves him in a place with less firm sense of grounding in the world in which to become.  As a result of committing to university education Athena became a skilled professional who felt she had something important to offer the world. Though the road was long and had numerous challenges through discipline and focus Athena moved forward into a more fullness of being. She describes university as thrilling, energizing, compelling, risk taking, an activity that she has to tackle and knows that she needs a specific focus. She describes an experience of attending university. if I have something new ? exciting, it just pumps up my energy ? keeps me going ..., lessens the day to day routine and makes it actually an ease to go through the day, because you're focused on something that you really enjoy, and that really drives you forward. (A 3.15) Specifically for Athena this growth occurred in part through developing her skills. Unfortunately, by contrast Hammy found it difficult to access educational opportunities and thus his possibilities with regard to work were less open to him.    4.3.3 Developing skills through painting In a similar way to Athena, Painter pushed himself and developed his skills through his participation in painting. Painter usually works alone in his home, or in coffee shops. He is also attending classes at an art studio and describes his growth or evolution as a painter as ?constantly learning, searching and evolving as a painter? (Pa 1. 24; Pa 3. 31). This moving forward, learning and constant growth is 108  an essential aspect of his being. Recently, a fellow artist commented ?you make me think? and Painter described this comment as a ?quite a compliment.? He says, ?If I can make people think ? it?s worked? (Pa 3. 31). Making people think is the measure of his success for Painter and shows his depth of concern for and commitment to his painting and to the impact it has on others.  While painting or talking about it he is in his element. Heidegger proposes that being in one?s element allows one to genuinely and fully ?be? oneself and in order to be in one?s element one needs to be ?resolute? or open to what shows itself so that the call for authentic care can be heard (1962/2008,  p. 297). Along with constantly learning Painter claims that to be able to create new things he must keep his own mind open and free.  He describes the experience of growing. He cites three famous contemporary artists, whose techniques also evolved during their career, suggesting that this evolution is part of being a successful artist for him also. During this study three distinct approaches to painting were observed in Painter?s work. Painter takes various art classes with people he admires and respects intellectually, technically and interpersonally. In this way he experiences being his own self -in-the-shared-world with fellow artists while developing skills and abilities. Curiously Painter describes a time when he did not paint. He remarks, ?I quit painting in 1987 and then I started again exactly, almost 20 years later just started in ?07 seriously painting again for galleries. I?ve had a number of shows? (P 1. 13). Painter was ill in 1987 and destroyed all his work. However, since re-engaging in this activity it now holds his interest for four hours daily. Some days he will paint for a significant portion of his day and simply feels he must engage in this activity for his sense of self.  With much consideration he says ?When I?m painting generally and then my music? when I am painting I am doing that? (Pa 3. 27). Painter says this in such a way that one considers this is where he needs and wants to be. He is content and completely given over to this activity.  Painter also engages in other creative activities such as poetry and writing which is his newest endeavor. He remarks:    I just uh, wrote a little story. And it?s gonna be published ? I get a royalty. I just signed the contract. I met [the editor at a caf? and] she found out I had schizophrenia, I don?t know how I don?t usually tell people, so I wrote my first psychotic episode, you should read it. (P 4. 61)   Painter is successfully expanding his repertoire of creative activities. However, painting remains his passion. He describes his artistic work as being a serious yet a seemingly effortless hobby that engages him (he loses time), pleases him, and intellectually stimulates him. In this way painting 109  seems to affirm to Painter that he is a proficient skillful artist. Painting enables him to be and become by providing a safe, predictable world apart from his illness (painting is sometimes a distraction from the illness) and yet connected to it (he must work around his episodes, eat and do other things besides paint) while offering him possibilities for growing and learning. Painter engages in this activity in many locations in the community and shares his artistic skills with people at his local art studio. He also generously shares his finished work with friends. He is prolific and may have two painting sessions in a day. He is always working on something and has several pieces in development at the same time. As with Athena, in Heideggerian terms, Painter took a stand on himself and moved into his own fullness of being with the world through painting.  Part of his way of being as a painter is to push himself to learn and grow and hone his skills as an artist. In this way, he is connected with himself and his unique way of being in a shared world. 4.3.4 Developing spiritual and wellness skills for being and doing self and others  Peter also discovered his element through spiritual and wellness practices. He sees engaging in his spirituality as part of developing his intellect. He remembers  I started when I was fourteen. Mom bought ? an illustrated book of yoga. So, I said okay, I'll learn ... So I learned ... I took 2, 000 hours of meditation. I have 300 hundred books on health and wellness. I am [also] thinking of school again. (P 2. 26-29)  His spirituality is his way of life, a means to stay healthy, and a way to give back to the world. He remains committed to researching, participating in, and drawing on the teachings of seventeen distinct exercise gurus or masters and has done so for the last 20 years. Peter completed several college courses in alternative health and committed to learning a variety of spiritual practices demonstrating a serious commitment to his education and health. Peter?s unique way of being-in-the-world engages him in constantly adding new techniques, challenges, and shaping his daily exercise routine where necessary while meticulously recording and analyzing his daily actions and reactions.  Being aware of the research on schizophrenia regarding longevity he is concerned that others have a significantly reduced lifespan and wants to share his learning. To that end, he is busily writing a book to share his techniques. He shows me how his book will be meticulously laid out ?This is what I?m writing my book on is how uh, exercises helped me in the mental health system? (P 4. 5). He hopes this book will be a powerful tool for others. He writes in coffee shops, and can sometimes write 110  up to two pages at a time liking his writing experience to being on single current: ?I feel like my consciousness is [on single current] if I?m on output for a long time, I can write pages and pages and pages. But if I get a block I can?t go back very easily and remember what I did before? (P 3. 23). Here we get the distinct impression that he experiences a sense of flow while writing. He remembers a time when he was ?pushed to his limits as he learned to meditate? (P 3. 29). Peter reflects that he may have been unwell at that time however, currently, he experiences a sense of congruence with his activities and describes being in very good physical health. He playfully displays a sense of humor when he announces that his ?plan [is to] to live forever or die in the attempt? (P2. 30).  Peter?s day is comprised of a series of healthy physical, spiritual and wellness activities (eating well, seeing other people, playing music). In preparation for his book he tirelessly records his daily physical activities and shows me his daily log. He shares that over the previous few days he walked in the am, did aikido basic exercises, listened to a tape for forty-five minutes of meditation, and did exercises for seventy-five minutes. His routine also included a ?warm-up, cool down, coordination, and then did yoga and basic fitness for fifteen minutes? (P 4. 5).  He has spent his life deeply committed to learning about and engaging in spiritual and wellness practices. Peter describes a time when he needed to become less engaged with his spirituality and more on his physical health. ?I was always into the uh, radical kind, [but now] I stick to ?Feldenkrias? and ?Masters? [approaches], you get the same energy, but it?s safer? (P 4. 33). Content with this new way of being he wishes to help others by sharing his wealth of information as he moves forward to a new possibility of writing.   4.3.5 Developing relationship skills Robert spends a good deal of time alone or in the company of mental health professionals. He shares, I?d like more [friends.  I?m] kind of looking for a girlfriend. I always wanted to like get out and do stuff in the city.  But a lot of people don?t want to do stuff, they just want to stay home you know. (R 2. 36; 27)  Robert would like a girlfriend and adds that he is concerned that he may not be a good parent should he become a father. He would like children but is not sure this is a possibility for him given his illness. Having more friends is an important goal. He wants to learn how to manage his anxiety so he can be more connected with others and the world at hand. Popular psychology books help him learn 111  to manage his anxiety and have a deeper understanding of people. He adds ?I like self-help books? and in particular books about ?conquering fears and ? gaining confidence? (R 1. 42). Some days anxiety holds Robert back from doing things or reduces the opportunity for him to be more active in the world. Like Athena, self-help books help him to see he is not alone and serve to open the space again for him to be more connected with the world. He believes books help him ?grow as a person? (R 2. 27) and open possibilities for his future. Being mindful that knowledge of how to be and do is bound by his relationships with others, Robert takes a risk and tries to engage his friends in a dialogue by sharing key messages he learned from reading books. However, his friends remain uninterested in this and so they close this space of understanding and learning for him. Interestingly, Robert describes the world opening up as a result of living with mental illness that before it was just him and his friends now he is learning different things and doing different things.  Sam found that his schizophrenia changed how he thinks. Since his schizophrenia he thinks less like a scientist and instead connects better with people. He now wants to be able to capitalize on these new skills. The paradox here is that one may need to lose something (Sam?s ability to compute in this case) in order to gain something else (a deeper connection with others). As Sam turns away from a very successful and lucrative engineering profession he begins to get an appreciation of a new way-of-being-with-others i.e., as a sociable interactive person.  He remarks before: [Before] I think aggressively. But now [I] think passionately [and I am] more relaxed ? before the illness [there was] more tension ? [because of a] voice. But now [the] voice is gone. I can think, I can think more clearly. Before, I had bad, relationship[s] with people, you know. I cannot [connect with] people, but now I, I can. (S4. 55) Sam, above perhaps offers a summary by describing how it difficult to socialize with the illness and recalls losing many of his communication skills while unwell. Robert adds: ?I still feel like I?m lagging behind cause a lot of my friends have like full time jobs and they have girlfriends and ? girlfriends or boyfriends and ? or they?re going to school? (R 4. 45). MacKay, (2010) a local author and artist who lives with schizophrenia, offers that it is possible to become ?frozen in time? (p. 131) perhaps implying a reduction in the opportunities to develop skills and abilities. Several participants expressed an unmet need to develop their communication skills so they could become more connected with the world-at-hand and some wished to develop more intimate relationships.  112  4.3.6 Developing skills to manage money Lisa tried to learn to manage her money with Debtors Anonymous (DA) and discovered she and her husband simply do not have a large enough income to maintain current lifestyle. Recently they quarrelled about money and their ordinary way of coping was not working. Lisa was able to help them ?understand themselves ? to make sense of the world and of their lives? (Dreyfus, 1991, p. 4) by asking her husband to apply the skills she learned in DA. Together they acquired a deeper understanding of their financial situation.  I did what is called I made him do his numbers.  And what that is, is you write down all your expenses and your income and you figure out exactly where you?re at? he figured out he?s got like two hundred dollars extra and that?s it the whole month and that has to include his food.  So, you know, I really made him see that he?s living in deprivation and that we?re living in deprivation as a couple. (L 2. 21)  Lisa and her husband discussed separation however, with her dad?s support they began to consider how they could begin to earn additional income and turned toward having a foreign student in their home. This dilemma forced them to make a decision as a couple. According to Dreyfus (1991) Heidegger interprets that every decision occurs as something is not yet mastered or something is hidden and so the issue comes to light. Otherwise, there would never be a decision. Thus what is most important to us is in part inaccessible to us and cannot be fully articulated. What is not fully articulated here is the fear that Lisa and her husband may lose each other and that they may reach an impasse regarding finances and separate. Having reached a way forward by welcoming a foreign student into their home they now appreciate the income and it has allowed them a better quality of life together. They eat together more often and enjoy sharing their lives with their student who is appreciative of their care. Lisa and her husband engage in more routine family activities such as cleaning and eating together and treasure their new family member. They discovered an agreeable solution and learned new ways of being with each other and skills for managing money. Hammy and Jonathan would also like to be able to manage their money better and currently experience their income as insufficient. Hammy describes often not having money for his basic needs. He would like to save but finds that his earned income is so small that it is very easy to spend it. For example after a day of work he may have $25 ? $30 and he feels it is not worth saving this money. Both Hammy and Jonathan experience spending money when they have it and then going long periods without any.  113  Sylvie and Athena have taken formal financial planning courses to improve their skill level in this area but find that these courses are prohibitively expensive and the information is not easily applied to daily life. Sylvie lays a challenge that actively concerns both these women: I want to learn how to invest money and learn, how to grow ? money but ? I can?t find any [