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A qualitative study on the relationship of future orientation and daily occupations of adolescents in a psychiatric setting

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A qualitative study on the relationship of future orientation and daily occupations of adolescents in a psychiatric setting

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Content A QUALITATIVE STUDY ON THE RELATIONSHIP OF
FUTURE ORIENTATION A N D DAILY OCCUPATIONS OF ADOLESCENTS
IN A PSYCHIATRIC SETTING
by
Laura Evon N elson
A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillm ent of the
R equirem ents for the Degree
MASTER OF ARTS
(Occupational Therapy)
May 1995
Copyright 1995 Laura Evon N elson
UNIVERSITY O F S O U T H E R N CALIFORNIA
THE GRADUATE SCHOO L
U N IV ER SITY RARK
LO S A N Q ELES, CA LIFO R N IA SOOOT
This thesis, written by
Laura Evon Nelson
under the direction of k.9S. Thesis Committee,
and approved by all its members, has been pre
sented to and accepted by the Dean of The
Graduate School, in partial fulfillment of the
requirements for the degree of
MASTER OF ARTS
D m m
D a f f . „ „ A p r i l . 2 6 J.,1 9 9 5 ........
THESIS COMMITTEE
Chtirmmm ,
ACKNOW LEDGEMENTS
I thank m y father, m other, an d sister for their faithful support
and loving encouragpm ent, w hich they have provided th ro u g h o u t my
lifetim e. This thesis was created w ith the constant care of m any
devoted friends, som e of them including Bethel Cooley, R ene’ Bryk,
Elisabeth K nauss-A nderson, and A ndrew W hitelock. I thank the
U niversity of S outhern California s Research C om m ittee, the
D epartm ent of Occupational Therapy, an d m y thesis com m ittee
m em bers Dr. Florence Clark, Dr. R uth Zem ke, and Dr. Gelya Frank. I
also greatly appreciate all of the staff m em bers and rehabilitation
therapists at the U niversity of California, Los A ngeles w ho supported
and guided this venture. Finally m y highest acknow ledgem ent gpes to
the Lord, my God, who is m y strength. He taught m e that n o th in g is
im possible.
TABLE OF CONTENTS
Page
ABSTRACT v
CHAPTER I. Statem ent of the Problem 1
L im itations 7
D efinition of T erm s 9
CHAPTER II. R eview of the Literature 12
Introduction 12
D efinition an d C onstruct of Future O rientation 14
Im portance of F uture O rientation 17
T em poral C oding 18
Personality 19
Delay of G ratification 19
A ch iev em en t 20
Desire to Live 21
D efinition and Im portance of O ccupations 22
A dolescence 24
C onclusion 26
CHAPTER HI. M ethodology 28
Introduction 28
N arrativ e A nalysis 30
N aturalistic Inquiry 32
T ru stw o rth in ess 35
C redibility 35
T ransferability 40
D ependability 41
Confirm ability 42
S etting 43
Sam ple Selection 44
Data Collection 49
Interview One: F uture O rientation 53
Interview Two: Daily Occupations 54
i i i
Page
Interview Three: Future O rientation
and Daily O ccupations 55
Data A nalysis 58
CHAPTER IV. Results 62
Introduction 62
The C ulture 62
The Setting 66
The A dolescents 68
V ince 68
C hristine 72
M elanie 78
Future Defined 82
Goals Defined 84
L ove/A ffiliation Goals 85
Career Goals 87
Independence G oals 89
H ealth Goals 91
F uture O rientation 91
M otivation 92
P lan n in g 93
E valuation 96
Daily O ccupations 101
O ccupational Changes 101
Goals Delayed 110
F uture O ccupations 112
CHAPTER V. Sum m ary, Discussion, and R ecom m endations 116
S u m m ary 116
D iscussion 117
R eco m m en d atio n s 124
REFERENCES 127
i v
Page
APPENDICES
A. Description of Study 137
B. Occupational A ctivity Log 141
C. Letter of A ttestation 143
D. C onsent Form 147
E. N ote from Transcriber 150
v
ABSTRACT
The purpose of th is qualitative investigation was to explore the future
orientation and daily occupations of three adolescents hospitalized for
psychiatric disorders. N aturalistic inquiry (Lincoln & Cuba, 1985) and
narrative analysis (Polkinghom e, 1988) were the m ethods used as the
follow ing questions w ere addressed:
1. How did the adolescents anticipate and evaluate their future
in the areas of m otivation, planning, and evaluation?
2. W h at had been their daily occupations and how h ad those
occupations changed since adm ission to the hospital?
3. W h at was the relationship betw een future orientation and
daily occupations for these hospitalized adolescents?
All three participants rated overcom ing their illness as the nu m b er one
goal they hoped to attain. The teens were highly m otivated to conquer
their disorder, how ever, the degree of p lan n in g and evaluation of their
future orientation v aried as well as the aw areness of changes in their
daily occupations. In contrast to occupations prior to hospitalization,
the daily occupations of the adolescents revolved a ro u n d th eir illness
du rin g their hospital stay as the adolescents focused on the present and
postponed w orking tow ard their future gpals.
CHAPTER ONE
S tatem ent of the Problem
A n increasing n u m b er of studies have been published on
adolescent fu tu re orientation since the 1950's, how ever, review s on
this subject have yielded contradictory results and have revealed
n u m ero u s m ethodological problem s (N u rm i, 1991). Future
orientation has been defined as anticipation or evaluation of the future
(Agarwal & T ripathi, 1984; T rom m sdorff & Lam m , 1980). Researchers
suggest that it is com prised of the follow ing processes: motivation, or
w hat interests people h av e in the future; planning, w hich refers to
how people plan the realization of th eir interests; and evaluation,
w hich addresses the extent to w hich the interests are expected to be
realized (N u rm i, 1989, 1991; N u ttin , 1984). These three elem ents
provided a basic guideline for the in terv iew an d analysis procedure
concerning the future orientation of the three adolescents w ho
participated in this study.
The purpose of this study w as to explore and identify
relationships betw een the fu tu re orientation an d daily occupations of
1
adolescents in a psychiatric setting. "Future tim e perspective is
relevant to occupational therapy because of its presum ed role in goal-
directed activities" (Suto & Frank, 1994). A lthough an array of
em ergent fu tu re goals set by the adolescents w ill be discussed, their
m ost im p o rtan t goal was interpreted in relation to their occupational
fun ctio n in g defined below.
O ccupations refer to "chunks of purposeful activity that m ake up
o u r days” (USC, 1991, p. 1). The adolescents were asked to discuss their
occupations prior to and du rin g hospitalization. T his study disclosed
occupational shifts that seem ed to result from illness and subsequent
hospitalization. Occupational fun ctio n in g then, in this study, referred
to the adjustm ents in occupations m ade by the adolescents after illness
an d hospitalization. How adolescents spend th eir tim e is a question of
interest to occupational therapists an d occupational scientists.
T hree questions outlined the focus for th is study;
1. How did these adolescents anticipate and evaluate their
future in the areas of m otivation, planning, and evaluation?
2. W h at h a d been their daily occupations and ho w h ad those
occupations changed since adm ission to the hospital?
2
3. H ow has th eir future orientation influenced their
participation in daily occupations or vice versa? In other words, w hat
is the relationship between future orientation an d daily occupations for
these hospitalized adolescents?
First, data was gathered in the initial in terv iew w ith each
adolescent regarding their future orientation. T hen, the next step was
to gain a sense of th eir daily occupations prior to and d u rin g
hospitalization in the second interview . Finally, I probed the
adjustm ents they planned to m ake in the fu tu re and the evaluation of
their goals in a com prehensive th ird interview . These findings are
reported in chapter four.
M any researchers support the use of a qualitative
approach (Carlson & Clark, 1991; M cCuaig & Frank, 1991; and Yerxa,
1991) in the developm ent of occupational science, Yerxa (1991)
identified the follow ing advantages of qualitative research: (a) it is
descriptive; (b) it uses the n atural setting as a direct source of data; and
(c) it is concerned w ith the process as well as the outcom e. Data are
analyzed inductively, and the m ean in g gathered from the participant's
perspective is em phasized. A qualitative approach was suitable for this
3
study because orientation to the future is a com plex, m ultistage process
that m u st be understood in relation to the person an d the situational
context (N uttin, 1984). Bogdan and Biklen (1982) support the use of
qualitative research w hen the purpose of the study is to describe
behaviors and u n derstand th eir m eaning. By focusing on the fluid,
intricate interactions of persons w ithin their natural e n v iro n m en t, it is
also possible to establish the genuineness of w hat is studied (Carlson &
Clark, 1991). The influence of hospitalization was taken into
consideration w ith specific in terv iew questions targeted at this
p h e n o m e n o n .
The persons I studied w ere adolescents currently hospitalized
and diagnosed w ith psychiatric disorders such as Obsessive-
C om pulsive Disorder or A norexia N ervosa, both defined in the
definition of term s at the end of this chapter. They were adm itted to a
neuropsychiatric in stitu tio n for a full psychiatric an d developm ental
evaluation. A lthough the literature on adolescent future orientation
has som e applicability for these patients, th eir distinctive m ental status
dem anded that they be studied as a unique group. N u rm i (1991) stated
that "little research has been carried o u t on the relationship between
4
fu tu re orientation and other types of problem behavior" (p. 46). T his
position found support in a recent study by Suto and Frank (1994),
w hich revealed that in d iv id u als w ith chronic schizophrenic illnesses
were lim ited in their future-tim e perspective and perceived aspects of
tim e differently from in d iv id u als w ith o u t such illnesses. The future
orientation of those w ith psychiatric disorders cannot be assum ed equal
to those w ithout.
First, this study provided fu rth er data on future orientation as
applied to hospitalized youth. Second, the adolescents described their
typical daily occupations prior to and d u rin g hospitalization. Third,
the relationship of future orientation to daily occupational behavior
was explored.
T he way in w hich adolescents perceive their future is, in itself,
an im p o rtan t issue and m ay have im plications beyond the realm of
their daily activities. For exam ple, N u rm i (1991) stated, "A dolescents’
future-oriented decisions, such as those related to career, life-style, and
future fam ily, crucially influence th eir later adult life" (p. 1). Future
orientation plays an im portant rote in an adolescent's identity
form ation (Bosma, 1985; Marcia, 1980) as well as being found to
5
influence achievem ent m o tiv atio n (Agarwal & T ripathi, 1980),
socialization (Trom m sdorff, 1983), delay of gratification, and problem
solving abilities (M ischel, 1974, 1981).
M ost interests, m otives, an d goals are future oriented in nature
(N u ttin , 1984) th ro u g h o u t an in d iv id u a l's lifetim e. H ow ever,
p lan n in g for the future is especially significant in adolescence, w hen
em phasis is placed on the approaching adult role (K ielhofner, 1980).
N eville (1980) n o t only believes that future tim e perspective is critical,
but that it links the future to the present. If anticipation of future
events m otivates daily behavior over the lifespan (N u rm i, 1987), an
adolescent’s view of the future w ill m ost likely affect h is/h e r
occupations. Likewise, daily occupational choices m ay shape an
adolescent's future as described in the p rev io u s paragraph by N u rm i
(1991).
T his study was designed to give detailed accounts of the future
orientation of three adolescent patients adm itted to a neuropsychiatric
institute in S outhern California. A lthough all of the teens were
initially received as inpatients to an adolescent u nit, one m ale was
interview ed after he had m ade the transition to an outpatient day
6
program . The relationship of future orientation to daily occupations
prior to an d d u rin g hospitalization was explored w ith the adolescents.
Data regarding ho w these adolescents w ith psychiatric disorders
perceived their future an d depicted their daily lives em erged, and
fu rth er questions for study arose in the areas of future orientation and
daily occupations. Lincoln and G uba's (1985) m eth o d of naturalistic
inquiry provided the fram ew ork for the research and a narrative style
(Polkinghorne, 1988) was incorporated for a detailed look at each of the
adolescents.
L im itations
The sm all n u m b er of participants m ight be considered one
lim itation of this study. A lthough patterns em erged from the data, a
lesser n u m b er of adolescents was chosen than the n o rm for naturalistic
inquiry (Lincoln & Guba, 1985) in order to m ain tain the detailed
n arrativ e picture of each participant. T he approach to collecting data
was largely shaped by the verbal in fo rm atio n shared by the adolescents,
w hich was a com ponent com pletely controlled by the adolescents, and
the gpal of th is study. H ow ever it w as possible th at the adolescents’
7
responses m ight have been influenced by the obvious fact that they
were recorded on audiotape.
Researcher bias was a possible lim itation, because as a participant
observer, I was the m edium through w hich data were collected and
analyzed. It was highly unlikely that any of m y p rio r hypotheses
directed the data, because the m ethodological n atu re of naturalistic
inquiry (Lincoln & Guba, 1985) dem ands that the relationships em erge
during the research process and n o t before. In addition, the findings
surprised m e as I analyzed and presented relationships I was not
expecting.
To offset lim itations and produce valid data, m an y steps of
precaution were taken. The adolescents were asked to check
inform ation they had given and respond to the definitions provided by
other participants, a strategy term ed m em ber checking (Lincoln &
Guba, 1985), in order to arrive at an accurate consensus of the data.
After interview ing an d observing each adolescent in the sam ple, the
data were edited, coded, an d analyzed by m yself and critically review ed
by an external auditor.
I, the researcher, wrote u p detailed personal observations and
8
reflections after each of the n in e interview s to add credibility,
transferability, and confirm ability to the study (See definition of term s)
and provide insight into personal bias. W ritten reports and notes,
m ade by interdisciplinary team m em bers w orking w ith the patients,
provided fu rth er trustw orthiness of the data. In order to create only
theoretical relationships w hich were grounded in the data, I engaged in
recorded reflection, and the m aterial was subjected to the rigor of a
triangulation of m ethods and sources of data (Krefting, 1990). Peer
exam ination, described in this study as peer debriefing (Lincoln &
Guba, 1985), was utilized to provide further credibility and
dependability (Krefting, 1990). The strategies for trustw orthiness will
be defined and discussed in detail in chapter three.
D efinition of Term s
Future orientation -- The anticipation or evaluation of the
future (Agarwal & T ripathi, 1984; T rom m sdorff & Lam m , 1980).
M otivation - W h at interests people have in the fu tu re (N urm i,
1989, 1991).
P lanning - How people plan the realization of their interests
9
(N urm i, 1989, 1991).
E valuation -- The extent to w hich the interests are expected to be
realized (N urm i, 1989, 1991).
Extension -- The length of tim e projected into the future
(N eville, 1980).
Occupations — C hunks of purposeful activity m aking up a
person 's days (USC, 1991).
Occupational Functioning - The adjustm ents, or shifts, in
occupations m ade by the adolescents after illness and hospitalization,
w hich created the current purposeful activities m aking up their days.
O bsessive-Com pulsive D isorder -- "A neurotic disorder
characterized by the presence of recurrent ideas and fantasies
(obsessions) an d repetitive im pulses or actions (com pulsions) that the
patient recognizes as m orbid and tow ard w hich he feels a strong inner
I
resistance" (Berkow & Fletcher, 1987, p. 1505).
System ic Lupus E rythem atosus -- "A n inflam m atory connective
tissue disorder of unknown^ etiology occurring predom inantly in
young w om en, but also in children" (Berkow & Fletcher, 1987, p. 1274).
Lupus Cerebritis w ith psychotic features - Inflam m ation of the
1 0
cerebrum , due to Lupus, characterized by the im paired capacity to
process inform ation (Berkow & Fletcher, 1987).
A norexia N ervosa — A disorder ’characterized by a disturbed
sense of body im age and m orbid fear of obesity, m anifested by
abnorm al patterns of han d lin g food, self-induced m arked w eight loss,
and am enorrhea in w om en" (Berkow & Fletcher, 1987, p. 2124). It is
particularly associated w ith the loss of at least 25 percent of body weight
(Berkow & Fletcher, 1987).
Credibility — The truth value criterion w hich establishes the
degree of confindence the researcher has in the tru th of the findings
based on the study design, inform ants, and context (Krefting, 1991).
Transferability -- The degree to w hich the findings can be applied
to other contexts and settings or w ith other groups, also know n as
applicability (Krefting, 1991).
Dependability -- Also term ed consistency, it is the strategy which
m easures w hether the findings w ould be consistent if the study was
replicated w ith the sam e subjects in a sim ilar context (Krefting, 1991).
Confirm ability - The neutrality factor of the study w hich
m aintains its freedom from bias (Krefting, 1991).
1 1
CHAPTER TW O
R eview of the Literature
Intro d u ctio n
The experience of tim e has captured the attention of
philosophers and scientists for centuries (Cottle & Klineberg, 1974). As
St. A ugustine stated, "There are three times: a present of things past, a
present of things present, an d a present of things future" (A ugustine,
1857). This tim e sense dates back to prim eval cultures, w hen the dead
were buried in belief of som e co ntinued existence (W ilson & Grant,
1980). C urrently, Suto an d Frank (1994) h av e recognized that
sodocultutal tem poral influences begin in early childhood an d that the
fam ily experience and en v iro n m en tal constraints affect a person s
future ability to adapt to the w orld a ro u n d him or her. In 1939, L.K.
Frank term ed the consideration of past, present, and fu tu re as o ne's
tim e perspective. In a recent study, L ennings defined tim e perspective
as "the cognitive representation of either past or future events in the
present" (Lennings, 1993, p. 808) and noted its im portance as a
m otivational concept. The future perception of tim e, or future
orientation, is one aspect of tim e (Trom m sdorff, 1983).
Paul Fraisse incorporated expectations of the future in his
revolutionary theory of "tem poral horizon." T em poral horizon is the
acquisition and perception of o u r past an d future as view ed from the
present (Fraisse, 1963). Fraisse n o t only discussed future as a
com ponent of tim e but pointed o u t that o u r present actions depend on
o u r future expectations (Fraisse, 1963).
M any other people have linked future orientation to present day
activities. K. Linton (1989), in h e r study of Fraisse's w ork on tim e,
stated that "the fact th at o u r life in the present is n o rm ally oriented
tow ard the future gives a purpose to o u r actions" (p. 17). Future tim e
perspective connects the future to the present an d is im portant to
consider w hen assessing patients' organization an d im plem entation of
goals into purposeful activity (N eville, 1980). O rientation to future
events inspires everyday behavior o v er a lifetim e (N u rm i, 1987) an d is
a d eterm in an t of h u m a n m otivation an d action (Raynor & Entin,
1983). As discussed at the en d of this chapter, occupational therapists
an d occupational scientists, concerned w ith people's daily occupations,
are interested in the effects of future orientation on everyday activities.
1 3
D efinition an d C onstruct of F uture O rientation
In order to m ain tain consistency in this study, future orientation
was defined as anticipation and ev alu atio n of the future (Agarwal &
T ripathi, 1984; T rom m sdorff & L am m , 1980). A nticipation refers to
expectation or hope, and ev alu atio n m eans appraisal (Stein, 1980).
Future orientation is com prised of aspirations, plans,
expectations/hopes, and fears (Seginer & Halabi, 1991; Tism er, 1985;
T rom m sdorff & Lam m , 1980). Perceptions of the future are subjective
(Seginer, 1988; Seginer & Halabi, 1991) and unique to each individual
(Fraisse, 1981). There is also a distinction w ithin the individual
betw een private (personal) future o rien tatio n and a m ore global or
public (societal) orientation (Sundberg et al., 1983).
In the review of the literature, the psychological processes of
future orientation were n am ed in a variety of ways. For exam ple,
Lewin (1948), in his early definition of fu tu re orientation, described this
com ponent of tim e perspective as a d eterm in an t of an in d iv id u a l's
action. T rom m sdorff (1983) presented a m u lti-d im en sio n al approach
to future orientation, incorporating cognitive an d m otivational factors.
The cognitive schem ata included the structuring of future events in
1 4
term s of their tem poral sequence an d causal order. The affective
quality of the future, such as goals, hopes, and degree of optim ism , fell
w ithin the category of m otivation. T he latter dim ension became a
priority in this study.
Jari-Erik N u rm i (1991) conducted m ajor research on future
orientation an d applied it directly to adolescents. For sim plicity and
consistency, h is division of future orientation into m otivation,
planning, and evaluation was adopted for this study. N u rm i
conducted a study (1989) providing support for h is theoretical m odel
w ith results suggesting that these m ethods provide a satisfactory
m easure of adolescents' th in k in g of the future.
T he first m ajor process, m o tiv atio n , describes w hat interests
people hav e in the future (N urm i, 1989). M astering skills is irrelevant
w ith o u t the m otivation factor (Leventhal & K eeshan, 1993). Leventhal
and K eeshan w rote, "Efforts m u st be directed tow ard successfully
m otiv atin g adolescents to m ake use of the skills provided" (1993, p.
266). M arcus an d W urf (1987) acknow ledged that future goal-setting is
based on a com parison between m otives and the expectations people
have for the future.
1 5
Included in the category of m o tiv atio n is extension, or length of
tim e projected into the future (N eville, 1980). Extension is closely
related to the content of interests because the expected realization tim e
of a goal is influenced by the type of interest (N u rm i, 1989).
Suto an d Frank (1994) adopted W allace’s 1956 definition of
future tim e perspective. T he com ponents included "extension (the
length of tim e into the future that a person thinks about and acts
upon), coherence (the degree of organization an d logical order of
events conceptualized) and density (the n u m b er of ev en ts
envisioned)" (p. 8). Coherence is the one category w hich parallels the
second process utilized in this study described below.
The second stage of future orientation, term ed planning,
pertains to h o w the interests m en tio n ed above will be realized (N urm i,
1989). P lanning is characterized by the setting of goals, construction of
i
plans, an d realization of these plans (N u ttin , 1984). Sim ply stated, the
p lan n in g process is the problem so lv in g stage resulting in the
execution of a course of action (N u rm i, 1991).
Finally, the evaluation of the fu tu re reveals to w hat extent the
interests w ill be realized (N urm i, 1989). Causal attributions (based on
1 6
cognition) and affects (based on unconscious factors) are both included
in this dom ain. In support, W einer (1985) ascribed the characteristics of
future events to internal an d controllable causes follow ed by feelings of
hopefulness a n d optim ism .
In sum m ary, N u rm i (1989) rem in d s us th at m otivation,
planning, and evaluation are all aspects of the sam e process. The
division is helpful in understanding the concept of future orientation.
H ow ever, the three processes are integrative and overlapping
functions of fu tu re perspective.
Im portance of F uture O rientation
W hy is the process of future orientation im portant? Past studies
have show n future orientation to be an influential factor in m any
areas including the five categories o u tlin ed here: (a) tem poral coding;
(b) personality; (c) delay of gratification; (d) achievem ent; and (e) desire
to live. F uture orientation affects social and personal behaviors and
will continue to be im p o rtan t through the life span into old age
(M acKenzie, 1989).
1 7
T em poral Coding
The first, and m ost superficial, is that future orientation
influences tem poral coding (Tzeng et al., 1979). As defined by Tzeng,
tem poral coding is the storage of inform ation regarding the 'tem poral
date’ of an event. One type of coding m ay be how far into the future a
person plans. H ow ever, this is purely a quantitative m easure w hich
neglects the quality of the goals and the hopes for realization of the
dream s. W hereas other au thors (Lenningp, 1993; M orris, 1992) have
focused on the im portance of tem poral extension into the future, it is
argued here that the quality of that future perspective is ju st as, if not
m ore, significant. T his study looked at the quality of future orientation
versus sim ply the degree of extension.
In 1956, W allace generalized th at a w ell-structured and extended
future orientation leads to a well adapted personality. In contrast, later
studies have pointed o u t that a m ore extended fu tu re outlook does n o t
necessarily indicate a w ell-adapted personality (Trom m sdorff, 1983). In
fact, Bandura and Schunk (1981) fo u n d th at children w ith learning
difficulties are m ore successful if they set goals in the n ear future for
them selves. According to Lewin (1948), a successful in d iv id u al
1 8
typically sets h is next goal only a sm all a m o u n t ahead of his last
achievem ent. Sim ilarly, N u rm i (1989) fo u n d that adolescents believe
they have less influence over th eir fu tu re and less hope for realization
of th eir goals w ith increased extension of future orientation. A lthough
adolescents in th is study co m m ented on extension of their future, the
underlying m otives, planning, and ev alu atio n (N urm i, 1991) were
em phasized to build a contextual and quality picture of the future.
Personality
The structure, or organization, of o n e’s orientation to the future,
n o t the distance into the future an in d iv id u a l projects, m ay well likely
influence o n e’s personality. N u ttin (1984) proposed that a person's
aim s a n d goals are basic structures of personality. Gjesm e conceived of
future tim e orientation as a sem i-stable personality variable in 1981
an d accepted it as a personality characteristic in addition to a
situationally induced variable in 1983. O rientation to the future, an
essential part of people's th in k in g , m ay play an im p o rtan t role in
personality (N u rm i, 1989).
Delay of Gratification
Future orientation is a useful construct in determ in in g lifestyle
1 9
(T rom m sdorff & Lam m , 1980). For exam ple, future orientation is
related to the ability to delay rew ards (Klineberg, 1968; M ischel, 1974).
A person s w illingness to w ork and w ait for future outcom es hinges on
the expectation that the goal w ill actually be attained (Mischel, 1974).
Delay of gratification leads to persistence, w hich depends on the value
of goals an d the outlook for the future (Lewin, 1948). "A s long as there
is hope that difficulties m ay be overcom e for th at price in effort and
pain w hich the individual is ready to pay, he goes on trying. If the
objective is w orthy, indeed, the effort is n o t even felt to be a sacrifice'"
(Lewin, 1948, p. 107). This quality contributes to the ability to reach
long term goals, producing quite a different lifestyle than living for the
m o m e n t.
A ch iev em en t
As m en tio n ed in chapter one, future orientation has also been
fo u n d to contribute to o n e's com petence in the areas of achievem ent,
socialization, an d problem solving (Agarwal & T ripathi, 1980; M ischel,
1974, 1981; T rom m sdorff, 1983). T he influence can be positive or
negative depending on the orientation of the person. For exam ple,
Hirsch (1979) discovered that m edical students w ho sucoeeded in their
20
later career, h ad m ore specific an d realistic plans for th eir future than
those w ith low success. In contrast, a study in 1980 (Trom m sdorff &
Lam m) fo u n d th at delinquent adolescent boys in W est G erm any had
future orientations th at were less structured, less optim istic, and m ore
oriented to private concerns than the n o n -d elin q u en t population.
In a 1992 study, M orris found that students w ith a strong future
focus tended to do well academically, were less disruptive, and had
positive self-concepts. These adolescent leaders sought long-range
rather than short-range goals and were m ost concerned about attending
a univ ersity an d attaining a career. F urtherm ore, Bottorff (1980) found
that un iv ersity students were significantly m ore future conscious than
n o n -u n iv ersity students.
Desire to liv e
An adolescent's evaluation of the future can affect h is or her
desire to live. Suicide is one of the m ost frequent causes of death
am ong adolescents 15 to 19 years of age (Brent & Kolko, 1990).
Hopelessness has been found to be a pow erful predictor of suicidal
behavior (Steer & K um ar, 1993; T ruant, O 'R eilly, & D onaldson, 1991).
Steer and K um ar found pessim ism in 43 percent of th eir adolescents
21
studied, also psychiatric patients as studied here, and determ ined them
at risk for suicide.
In addition, a person can develop m u ltip le orientations tow ard
the future (Frank, 1939).
D efinition and Im portance of Occupations
Occupations were defined in chapter one as "chunks of
purposeful activity th at m ake u p o u r days" (USC, 1991, p. 1).
Occupation is the purposeful use of tim e (K ielhofner, 1980) w hich can
only be understood through a com prehensive analysis of its biological,
psychological, sociological, and sym bolic elem ents (d a rk & Jackson,
190 1 'erxa et al. (1989) w ould add that w hen people are engaged in
occupation, they are m ost true to their hum anity.
The w ord "occupation" com es from the Latin root "occupaio”
m eaning "to seize or take possession"; "to engage in occupation is to
take control" (Yerxa et al., 1989, p. 5). A sense of control o v er o ne's life
can be m ain tain ed by choosing an d shaping daily activities (Q ark &
Jackson, 1990). O ccupations are im p o rtan t because they shape the
quality of one s life (Prim eau, d a r k , & c Pierce, 1990), including the
22
perceived degree of control over o n e ’s existence. A desire for increased
control is developed typically d u rin g the adolescent stage (Sholle-
M artin, 1987).
Even an au th o r in other fields determ ined that the two
d im ensions needed to m aintain positive m ental health in adolescence
are: (a) protection from stress and (b) in v o lv e m en t in personally
m eaningful activities (Compas, 1993). Sim ilarly, in a healthy state,
adolescents are expected to occupy th eir tim e with interests, skills, and
roles (Jaskulski et al., 1994). Participation in ordinary daily occupations,
for exam ple tennis or video games, significantly affects health,
happiness, and life satisfaction (Carlson & Clark, 1991).
The m an n er in w hich people choose to orchestrate their daily
occupations is a central focus of interest for occupational scientists
(TJSC, 1991). Therefore further research in the area of occupation will
add to the foundation of occupational science, defined as the systematic
study of h u m a n s as occupational being? (d a rk et al., 1991).
O ccupational science em phasizes the d ev elo p m en t of occupational
behavior an d choice th roughout the life span (Carlson & d a r k , 1991).
Sim ilarly, this study addressed the occupations of hospitalized youth,
23
ages 16 an d 17, and their relationship to gpals and perceptions
concerning the future. The field of occupational science is concerned
w ith independence, adaptation, an d com petency (Yerxa et al., 1989),
concepts w hich unfold through th is study.
A dolescence
T here are m ore rapid changes in v o lv e d in the stage of
adolescence than in any other developm ental period except infancy
(Sm etana et al., 1991). Changes m ay be taking place w ith peers,
classm ates, and fam ily m em bers. A dolescents are in the process of
transitioning from liv in g w ith fam ily to being in d ep en d en t w ithin
society (A m anat & Beck, 1994). In fact, Sm etana et al. (1991) found
several studies indicating that the adolescent years are m ore stressful to
parents than at any other phase of the fam ily life cycle.
D uring adolescence, puberty begins, form al logic evolves, and
new social-cognitive abilities are established (Sm etana et al., 1991).
Teens attain m atu rity in th eir m oral a n d sexual behaviors (A m anat &
Beck, 1994). It is a tim e to earn respect, self-esteem , and a sense of
belonging (H am burg et al., 1993).
24
As adolescents are gaining the ability to th in k in the abstract, this
translates to the capacity for future oriented th in k in g (Sholle-M artin,
1987). H am burg et al. (1993) stated, "Today o u r children and
adolescents n eed to find ways to develop a positive vision of the
future, to form ulate an image of w hat ad u lth o o d offers and dem ands,
and to w ork out a perception of opportunity and paths tow ard practical
im plem entation of such opportunity" (p- 377).
T he period of adolescence is certainly preparation for the future,
w here vision becom es a m o tiv ato r for carrying o u t plans an d enabling
a w orker role (M illstein, 1993). Typical adolescent goals include
academic plans, m arriage, ho m e, em ploym ent, h ealth , happiness, and
peace, an d m ost teens regard their fu tu re w ith significant optim ism
((M illstein, 1993).
T he three adolescents in this study h ad the opportunity to
discuss th eir future, goals, an d degree of hopefulness as well. They
were hospitalized teens, how ever, an d provided an in-depth look at a
subgroup of adolescents less often studied.
25
Conclusion
In conclusion, future orientation is a com plex process w hich is
determ ined by a person's age, gender, culture, social class, parental
support, personality, and e n v iro n m en ta l situations (N urm i, 1987;
Poole & Cooney, 1987; Seginer & Halabi, 1991; T rom m sdorff, 1983).
Future orientation, defined in this study as anticipation and evaluation
of the future (Agarwal & c T ripathi, 1984; T rom m sdorff & Lam m, 1980),
m ay have effects in the areas of tem poral coding, personality, lifestyle,
achievem ent, and the desire to live. N u rm i's (1991) three constructs of
future orientation applicable to adolescents, including m otivation,
planning, an d evaluation, were chosen for this study.
Tem porality is a universal property of occupation (Kielhofner,
1980), the purposeful activity that shapes the quality of o u r lives
(Prim eau, d a rk , & Pierce, 1990). In v o lv em en t in personally
m eaningful activities is necessary in order to m ain tain positive m ental
health in adolescence (Compas, 1993). O ccupational therapists, who
incorportate purposeful activity into treatm ent (H opkins & Sm ith,
1988) an d occupational scientists, w ho base th eir studies on the h u m an
as an occupational being (Clark et al., 1991), w ill both be interested in
26
the occupational fram ew ork and em phasis of this study.
Adolescence is a dynam ic period full of a variety of changes
prom oting independence (A m anat & Beck, 1994; Sm etana et al., 1991)
and a m ore abstract, future oriented way of th in k in g (H am burg et al.,
1993; Sholle-M artin, 1987). A qualitative study best accounts for the
com plex and overlapping variables as the adolescents described their
view of the future and daily occupations. M any researchers support a
qualitative approach (Carlson & Clark, 1991; M cCuaig & Frank, 1991;
and Yerxa, 1991), and it is the prevailing m ethod w ithin occupational
science (Clark et al., 1991). The purpose of this study was to describe
behaviors an d perceptions, attem p tin g to u n d erstan d their m eaning, a
goal best supported by qualitative research (Bogdan & Bilken, 1982).
The follow ing chapter discusses the blended qualitative m ethods,
naturalistic inquiry (Lincoln & Guba (1985) an d n arrativ e analysis
'(Polkinghorne, 1988), w hich created the m ethodology for this study.
27
CHAPTER THREE
M ethodology
Intro d u ctio n
M illstein (1993) addressed the fact that research on adolescents
has focused prim arily on quantitative research traditions. She
suggested incorporating qualitative m ethods in order to provide rich
and detailed descriptions of the adolescent experience.
A qualitative approach was chosen for this study for the reason
above, and, in addition, because of its com plem entary style w ith
occupational science an d occupational therapy. Clark et al. (1991)
stated, "Existing m ethodologies that allow detailed description and
an a lysis...become those m ost likely to prevail in occupational science
(p. 306). "M any constructs of interest to occupational therapists can
only be studied througjh qualitative m ethods. Such constructs include
m eaning of activity or the illness experience an d the context in w hich
these occur" (Spencer, Krefting, & M attingly, 1993, p. 303).
T his study incorporated two types of qualitative m ethods,
narrative analysis (Polkinghom e, 1988) a n d naturalistic inquiry
2 8
(Lincoln 4c Guba, 1985). Blended approaches hav e been utilized before.
For exam ple, Clark (1993) used the com bined elem ents of life history
ethnography, ethnom ethodology, n atu ralistic m ethods, an d n arrativ e
analysis in h e r in n o v ativ e 1993 Eleanor Clarke Slagle Lecture regarding
occupational science and occupational therapy. Sim ilarly, Schon (1983)
blended m eaningful content w ith an in v estm en t in rigorous
m ethodology and depicted the use of naturalistic inquiry (Carlson &
Clark, 1991).
G rounded theory, such as the m eth o d of Lincoln and Guba
(1985), utilized in this study, is an in d u ctiv e approach to theory
generation (Spencer et al., 1993). It is m ore an approach to analysis and
"m ay be com bined w ith o th er approaches such as ethnography"
(Spencer et al., 1993, p. 305). From a n arrativ e analysis perspective, the
com bination of m ethodological approaches is also valued. "N arrative
analysis, as a new er research m ethod, m ig h t w ell be used in
conjunction w ith other m ethods of...research" (Cortazzi, 1993, p. 138).
T his chapter first characterizes n a rra tiv e analysis (Polkinghom e,
1988) an d naturalistic inquiry (Lincoln 4t Guba, 1985). T hen,
inform ation on the setting, sam ple, an d collection an d analysis process
2 9
involved in the blended methodology are described.
N arrative A nalysis
The object of inquiry for h u m an disciplines is the h u m an being.
Thus, Polkinghorne (1988) w ould argue that we m ust have the tools to
respond to the characteristics of the h u m an . H um an science can no
longer seek only m athem atical and logical certainty but should also
aim for producing believable results (B runer, 1986; Polkinghorne,
1988).
N arrative analysis m ay be used as a research tool with a num ber
of occupational groups and th ro u g h o u t the social sciences (Cortazzi,
1993). Polkinghorne (1988) articulately describes the application of
narrative to daily occupations and future tim e perspective, the two
concepts a ro u n d w hich this study revolves:
N arrative m ean in g functions to give form to the understanding
of a purpose to life and to join everyday actions and events into
episodic units. It provides a fram ew ork for understanding the
past events of o n e's life and for p lan n in g future actions. It is the
prim ary schem e by m eans of w hich h u m an existence is rendered
30
m ean in g fu l (p. 11).
N arrativ e is a m ean s by w hich people represent an d restructure
the w orld (M itchell, 1981). It is the organizing principle by w hich
h u m an beings "organize their experience in , know ledge about, an d
transactions w ith the social w orld” (B runer, 1990, p. 35).
N arrativ e is a form of expressiveness (Polkinghorne, 1988); it
tells a story. "G iven the personal, em otional, social, cognitive, an d
cultural v alu e in...stories, it is hardly su rp risin g th at they sh o u ld be of
interest to researchers” (Cortazzi, 1993, p. 139). As narrative translates
know ing in to telling, th en n arrativ e analysis looks at the telling to get
back to th e k n o w in g (W hite, 1981).
W ith in th e narration of th is study, the first-person voice was
often used to em phasize m y participation in the qualitative process.
A nother researcher, D orinne K ondo, d em onstrated this technique in
h e r book, C rafting Selves, w here she explains, "W h at counts as
experience is itself a discursive production underlain by certain
theoretical assum ptions, an d w h at is conventio nally considered
'theory* is always already a position in w hich a positioned subject has
'personal' stakes" (Kondo, 1990, pp. 303-304).
3 1
N aturalistic Inquiry
T his investigation follow ed the m ethods of naturalistic inquiry
as described by Lincoln an d Guba (1985). The study design em erged
through the research process of data collection an d analysis, w ith the
em ergent theory grounded in the data (Glaser & Strauss, 1967). T his
m ea n t th at theory follow ed after the data rather th an preceding it. In
the w ords of Carlson & Q a rk (1991), "Theoretical concepts are n o t
im posed on the data, but rather, em erge from the particulars of the
specific research context" (p. 236). T his sequence allow s for the
expansion and refin em en t of th e em erging theory.
As a m eth o d grounded in theory, naturalistic in quiry provides
thick description for analysis. T he goal of grounded theory is n o t to
operationalize th e w orld but, rather, to n ote com plexity o v e r prediction
(Ferguson, Ferguson, & Jones, 1988). T his again coincides w ith the
approach of occupational science. "Interpretive occupational science
research speaks to practice, n o t by discovery of general law s or
principles, but by providing thick descriptions of actual cases th at
practitioners can refer to as they subm erge them selves in practice"
(Q ark, 1993, p. 1076).
3 2
The naturalistic paradigm was n o t an arbitrary choice. The focus
of this study was w ell su ited for the fo u n d atio n al axiom s posed by
Lincoln and Guba (1985) described in the five parts below.
First, the naturalistic paradigm asserts th at there are m ultiple
constructed realities th a t can be studied only holistically (Lincoln &
Guba, 1985). As m en tio n ed in chapter one, fu tu re orientation is a
com plex process (N u ttin , 1984) experienced subjectively. T here is n o
single reality of future orientation. T he goal of th is study w as to
provide a greater level of u n d e rstan d in g of a m u ltid im en sio n al
orientation to the fu tu re a n d how it relates to th e daily occupations of
hospitalized adolescents.
Second, cause-effect linkages w ere n o t established. T his shift
from quantitative research expectations w as in accordance w ith the
m eth o d s of Lincoln an d G uba (1985). Factors, such as future
orientation an d daily occupational behavior, w ere identified, defined
from the perspective of th e adolescents, a n d th e ir relationship explored
but direct correlations w ere n o t assum ed. Each in d iv id u al participant
pro v id ed a unique addition to the schem e of m eaning.
T hird, the know er (inquirer) an d th e k n o w n (respondent) w ere
3 3
interrelated (Guba, 1981). As they interacted, each one h ad an influence
on th e other. The prim ary in stru m e n t w as myself, th e researcher. I
used m y listening skills, questioning ability, and perception of the
context an d situation to draw forth rich and p e rtin en t inform ation
from th e dynam ic h u m an resources in v o lv e d in th is study. A s a
h u m a n in stru m en t, I applied m y ta d t know ledge to describe situ atio n s
an d in terp ret findings w ith th e insight an d past experiences available
to m e.
F ourth, the inquiry w as value-bound. The values of the
researcher shaped the focus of the study, the m ethods of data collection
an d analysis, an d the interpretation of th e finding^. For exam ple, I
v alu e personal sacrifice in order to achieve long term goals. I w as
expectant an d encouraging of m eaningful goals expressed by the
hospitalized adolescents. F u rth e r lim itations w ere delineated in
chapter one. M ethods to increase trustw orthiness an d address the
study lim itatio n s w ill be discussed here. Overall, the qualitative
approach itself prom oted the v alu e of in d iv id u al cases by striv in g for a
depth of u n d erstan d in g th ro u g h a com prehensive look at each
teenager.
3 4
Fifth, the aim of this study was to provide a w orking hypothesis
of future orientation an d daily occupations specifically for adolescents
in a psychiatric hospital setting. A n idiographic body of know ledge,
rather than a generalized statem ent of tru th , was the goal.
T ru stw o rth in e ss
I, the researcher, aim ed for trustw orthiness th ro u g h o u t m y
narrative analysis and naturalistic inquiry to in su re credibility,
transferability, dependability, a n d con firm ability (Krefting, 1991;
Lincoln & Guba, 1985). These criteria are eq u iv alen t to th e term s truth
value, applicability, consistency, and n eu trality respectively (Krefting,
1991). Each category is defined below and the strategies incorporated
into this study described. F u rth er exam ples of these criteria are
included th ro u g h o u t the chapter in order to consistently n o te the
em phasis of trustw orthiness.
Credibility
T he credibility, or tru th v alu e, criterion establishes th e degree of
confidence the researcher has in the tru th of the findings based on the
study design, inform ants, an d context (Krefting, 1991). Lincoln and
3 5
Guba (1985) argued th a t in tern al validity is based on the assum ption
that there is a single, tangible reality to be investigated. In order to
dem onstrate credibility, th e researcher m u st accurately represent the
constructions of reality as liv ed and perceived by the inform ants.
Credibility w as en su red through four m ain techniques. These
strategies included: (a) triangulation, (b) m em ber checking, (c) peer
debriefing, an d (d) reflexivity (Krefting, 1991; Lincoln & Guba, 1985) and
are described below. In addition, the variety of tim es and days used to
interview each adolescent, the rapport I bu ilt w ith each p rio r to
collecting data, an d m y experience in terv iew in g and observing
adolescents all add credibility to this study (Krefting, 1991; Lincoln &
Guba, 1985).
T rian filia tio n .
T riangulation allow ed for m u ltip le perspectives on th e
interpretation of in fo rm atio n gathered (Lincoln & Guba, 1985). The
triangulated sources were com pared w ith one another in order to cross
check data an d interpretation. T he data for th is study were collected
from a variety of sources in cluding interview s, observations,
occupational activity log sheets, an d m edical record charts.
3 6
A variety of people w ere also consulted th ro u g h o u t th e entire
m ethodological process to prom ote th e tru th value. Dr. Florence d a r k ,
PhD, OTR, FAOTA, m y thesis advisor, pro v id ed guidance an d
corrections at each phase of m y inquiry. Dr. Clark is Professor and
C hair of the D epartm ent of O ccupational T herapy at th e U niversity of
S outhern California and h as several publications regarding qualitative
research in the field. Two other colleagues, representing m y peer
debriefer and external auditor, w ere consulted frequently. T hey
contributed assistance and insight from th eir objective perspectives an d
are described later on in this section. Finally, a variety of o th er sources
edited w ritten m aterial. T he strategy of triangulation was an essential
factor in guaranteeing this significant aspect of tru stw o rth in ess know n
as confirm ability.
M em ber checking.
T he m eth o d of naturalistic in q u iry (Lincoln & Guba, 1985) itself
required th at data be presented to th e respondents for their
exam ination, w hich is term ed m em ber checking. T herefore th is
m easure of credibility was built directly into the study design. M em ber
checking can be form al and inform al an d oocurs c o n tin u o u sly (Lincoln
37
& Guba, 1985). M em ber checking w as geared to the level of the
in fo rm an ts studied. D efinitions an d statem ents w ere review ed w ith
each adolescent th ro u g h o u t, an d they responded by agreeing, revising,
or adding to the concept presented. By the th ird interview , they were
presented w ith a w ritten list of goals w hich 1 had h e ard them express
th ro u g h prior interview s. T hey revised and prioritized these goals a
final tim e before results w ere concluded. The interview process is
delineated in detail u n d e r the data collection section of th is chapter.
Peer debriefing.
Peer debriefing is the process of "exposing oneself to a
disinterested peer in a m a n n e r paralleling an analytic session an d for
the purpose of exploring aspects of th e inquiry that m ight otherw ise
rem ain only im plicit w ith in th e in q u irer's m ind" (Lincoln & Guba,
1985, p. 308). Peer debriefing is know n as peer exam ination in
K refting’s article on trustw orthiness (1991) a n d serves a variety of
purposes. T h ro u g h th is m eth o d m y biases w ere probed, th e em erging
design was tested, and I w as allow ed a n opportunity for catharsis
(Lincoln & Guba, 1985).
R ene' Bryk, OTR, acted as m y peer debriefer. She was em ployed
38
at Rancho Los Am igos Medical Center in Downey, California at the
tim e of this study, and was a student in the M aster of A rts program for
Occupational Therapy at the U niversity of S outhern California.
A lthough she h ad an understanding of the qualitative research process,
she was an objective, n o n -involved, professional peer w ho m et w ith
m e m ultiple tim es as a soun d in g board for questions, insights, an d
personal catharsis. On April 5, 1994, Ms. Bryk n oted the rapport I had
developed w ith the adolescents, which appeared to enhance th eir
ability to express feelings w ith m e and m y likeliness to sense m ajor
obstacles to their testim ony.
Refiexivitv.
The tru th value was also enhanced by the use of a reflexivity
strategy (Krefting, 1991; Lincoln & Guba, 1985). It includes the effects of
the researcher's personal history, perceptions, and interests on th e
process of qualitative m ethod (Krefting, 1991). A field jo u rn al is
recom m ended to catch researcher bias.
T hroughout this study, narrative style observational h eld notes
were m ade im m ediately follow ing each of the n in e interview s.
W ithin these notes, I expounded on m y thoughts, perceptions, a n d
3 9
possible biases. A t other tim es en tries in a jo u rn al were used to
docum ent m y feelings an d issues w hich m ig h t potentially influence
the data. T his allow ed a record w hich could be exam ined by m yself and
others to prom ote credibility.
Transferability
Transferability , also know n as applicability, "refers to the degree
to w hich the findings can be applied to other contexts and settings or
w ith o th er groups" (Krefting, 1991, p. 216). A lthough the goal of
qualitative research is n o t to generalize th e experiential findings to
others, as lo n g as the researcher presents enough descriptive data to
allow for com parison, the issue of applicability will hav e been
addressed (Lincoln & Guba, 1985).
Transferability was stren g th en ed th rough the use of dense
description w ithin the observational h eld notes m ade im m ediately
after each of the n in e in terv iew sessions. T his m eant th at detailed
descriptions were m ade of th e setting, subjects, and situational factors.
Data collection and analysis procedures h a v e been delineated w ithin
this chapter an d resulted from w ritten transcripts of the audiotaped
sessions. Lincoln an d Guba (1985) argue th a t it is n o t die responsibility
4 0
of the naturalistic inquirer to insure transferability in th e traditional
quantitative sense, but to build a trustw orthy database from w hich to
draw upon.
D ependability
Dependability, or consistency, is the criterion w hich m easures
w h eth er th e findings w ould be consistent if the study w as replicated
w ith the sam e subjects in a sim ilar context (K refting 1991). It tests the
repeatability of th e inquiry, or as Lincoln a n d Guba (1985) described, th e
reliability.
Dependability was increased v ia the m ethods of triangulation,
peer debriefing, a n d a thorough description of data collection, data
analysis, and interpretation of the findings (Krefting, 1991). These
strategies were defined above. H ow ever, one o th er im p o rtan t
dependability m easure, the external audit (Krefting, 1991; Lincoln &
Guba, 1985) is described below.
The role of th e external auditor is to exam ine the process and
product of the inquiry to determ ine if the results are reasonable and
accurate. T his includes follow ing the progression of ev en ts, the
decision m aking process, as w ell the data, findings, interpretations, an d
41
recom m endations (Lincoln & Guba, 1985).
T his role was filled by Elisabeth A nderson, M A, OTR. She
represented a professional peer w ith experience as a naturalistic
inquirer (Lincoln & Guba, 1985). Dependability, as well as
confirm ability, increased as she traced the trail I h ad docum ented
d u rin g the qualitative research process. W ith h e r firm understanding
of naturalistic inquiry, she reinforced an objective perspective to the
em ergent theory process and interpretation of the data. She subm itted
a w ritten letter of attestation (See A ppendix Q in order to docum ent
h e r conclusions.
C onfirm ability
Finally, the neutrality, o r objectivity, of the study m ain tain s its
freedom from bias. The findings sh o u ld be a result of the inform ants
an d conditions of th e research, n o t d u e to o th er biases, m otivations,
i
an d perspectives (Guba, 1981). T his includes th e expected objective
distance betw een the researcher and th e inform ants. H ow ever,
qualitative research attem pts to increase the w orth of the findings by
decreasing th e distance betw een researcher a n d the subjects (KreftLng,
1991). T hus, Lincoln an d Guba (1985) clarified th at the em phasis of
42
n eu trality in qualitative research should shift from the researcher to
the data. The neutrality of the data, versus the neutrality of the
investigator, sh o u ld be the indicator of confirm ability.
T he fourth criterion, confirm ability was m ain tain ed th ro u g h the
use of a triangulation of m ethods, reflexivity, an d the external audit.
These strategies, described above, play o u t th ro u g h o u t the detailed
m ethodology portion of th is presentation. The three techniques
p ro v id ed support in the o th er categories of trustw orthiness as w ell.
In sum m ary, by attending to the four areas of credibility,
transferability, dependability, an d confirm ability, the degree of
trustw orthiness in the process an d outcom e of the study at h a n d was
significantly enhanced (Krefting, 1991).
S etting
T he naturalistic setting in w hich the observation of hospitalized
adolescents took place was the U niversity of C alifornia of Los A ngeles
N europsychiatric Institute an d H ospital [UCLA N PI & H] and is
described fu rth er in chapter four. Linda Florey, Chief of R ehabilitation
Services, M A, OTR, was supportive of this study an d w as the m ain
4 3
contact person regarding logistical conoem s. A w ritten statem ent of
purpose regarding this study (See A ppendix A) w as given to Linda
Florey, as well as other p e rtin e n t staff, before the actual research process
began in January 1993. A fter discussion w ith the C hief of
R ehabilitation Services, it w as decided th a t th e collection of interview
m aterial fell u n der clinical occupational therapy services. T he
adolescents participated in occupational therapy in terv iew s an d data
w as collected H ow ever, in order to use th e m aterial for research,
consent was re q u ire d T he H u m an Subject Protection C om m ittee at
UCLA a n d the U niversity of S outhern C alifornia's Research
C om m ittee provided approval an d guidance regarding appropriate
procedures for this study in retrospect. By 1995, w h en the subjects
granted th eir w ritten consent for m e to use th e in terv iew m aterial for
research, the subjects w ere all adults an d capable o f signing w ith o u t
parental consent. The consent form was review ed an d approved by
both Institutional R eview Boards.
S am ple Selt
T here w ere basic req u irem en ts expected of th e adolescents in
4 4
order to be considered for the study. They were as follows:
1. T he adolescent had to be identified as a patient of UCLA
N europsychiatric Institute and Hospital, either as an inpatient on w ard
A -W est or A-South o r as an outpatient in the Adolescent Partial
H ospitalization Program (See chapter four for descriptions).
2. The adolescent m ust not have h ad a DSM-IV Axis II diagnosis
of M ental Retardation (Frances, 1994).
3. The adolescent m ust have been w illing to participate in tape
recorded interview s.
4. The adolescent m ust have a signed form of consent for
audiotape recording w ithin the hospital in h is/h er m edical chart.
5. T he adolescent m u st have been able to verbalize and answ er
questions w ith m ore than one w ord answers.
6. T he adolescent m u st have been able to fill o u t an
occupational activity log (See Appendix B) w hen requested by the
researcher.
7. The adolescent m ust have signed a consent form releasing
their interview data for use in a retrospective study (See Appendix D).
T he cooperation of the adolesoents was insured as the above
4 5
requirem ents were followed. For exam ple, o n e m ale adolescent was
n o t chosen for the study. A lthough h e initially expressed interest,
w hen the tim e cam e for a recorded in terv iew h e was obviously
uncom fortable an d refused to be recorded. C hristine, the second
adolescent interview ed, was also sensitive to being recorded. H ow ever,
she continually agreed to the in terv iew process.
For the protection of the hospitalized adolescents, confidentiality
w as upheld and pseudonym s were used in th is presentation of the
data.
Lincoln and G uba's (1985) m e th o d of pu rp o siv e sam pling was
incorporated into th e sam ple selection in order to attain m ore
trustw orthy results, w hich w ere transferable, or repeatable (Krefting,
1991). M axim um variation sam p lin g w as aim ed for in order to
m aintain a broad base on w hich to build em erging them es. The
dem ographic inform ation an d dates of hospitalization for the three
adolescents w ere as follows, w ith greater detail follow ing in chapter
four:
1. V ince was a 17 year o ld H ispanic m ale from Los Angeles,
California diagnosed w ith O bsessive-C om pulsive Disorder. H e was
46
adm itted to th e in p atien t A -South U n it October 5 ,1992 and discharged
on December 1, 1992. Before being discharged from inpatient services,
he w as tran sitio n ed to the A dolescent Partial H ospitalization Program
on N ovem ber 30,1992 an d stayed in the outpatient program u n til
M arch 15,1993. He w as attending the partial day program w hen
interview ed on the follow ing dates: (a) January 26,1993; (b) February 2,
1993; an d (c) February 9,1993.
2. C hristine w as a 16 year old Filipino fem ale from San Dim as,
C alifornia diagnosed w ith Lupus Gerebritis w ith psychotic features.
She was adm itted to th e in p atien t A -W est U n it on A pril 26,1993 and
discharged to h o m e on M ay 14,1993. She was interview ed on three
separate days of the sam e week: (a) May 10,1993; (b) M ay 12,1993; and
(c) M ay 13,1993.
3. M elanie was a 17 year old Caucasian fem ale from Indio,
C alifornia diagnosed w ith A norexia N ervosa. She was adm itted to the
in p atien t A -South U n it o n M ay 13,1993 a n d discharged to h o m e on
June 30, 1993. She participated in interview s on the follow ing dates:
(a) June 7,1993; (b) Ju n e 15,1993; an d (c) Ju n e 24,1993.
Each adolescent, representing a different ethnicity, was chosen
4 7
from o n e of each of the three adolescent program s offered at UCLA NP1
& H. Each in d iv id u al w as diagnosed w ith a un iq u e disorder w hen
com pared w ith the rest of the sam ple.
T im e sam pling (Krefting, 1991) also adds credibility to a study.
Som e elem en ts of this m easure of trustw orthiness were incorporated
in this study by the fact that each adolescent w as interview ed on three
separate occasions. V ince an d M elanie w ere interview ed w eekly ov er
an approxim ate three w eek period, w hereas C hristine participated in
three interview s in one week. A lthough a com prehensive tim e
sam ple w as n o t attained, the fact th at the adolescents participated in
interview s three tim es w ith m e added to m y u n derstanding of them
an d th eir stories establishing greater credibility to the outcom e.
C onsistent w ith th e recom m endations of Lincoln an d Guba
(1985), a new subject was only selected after the previous adolescent
had been observed and interview ed. T his allow ed for the purposeful
expansion of data. The data from each adolescent was review ed p rio r
to addressing the next teenager. Finally, after M elanie, th e final one
interview ed, V ince was again briefly questioned in order to establish
consistency w ith the em erging results. By generating inform ation as
48
the g ro u n d ed theory em erged, th is allow ed for greater ability to check
th e results w ith th e m em bers of th e study thereby increasing the
credibility factor (K refting 1991; Lincoln & Guba, 1995).
Data C ollection
T he researcher's fam iliarity w ith th e adolescent p o pulation in a
psychiatric setting p ro v ed to be of great advantage. I was em ployed as a
full tim e O ccupational T herapist Q on the A -W est A dolescent U n it at
UCLA NPI & H seven m o n th s before beginning th e in terv iew process.
Prior to em ploym ent, I sp en t one year as a stu d en t in the U niversity
A ffiliated Program at UCLA NF1 & H w orking w ith children and
adolescents. T his m ean t th a t I h a d in terv iew ed a n d w orked w ith over
o n e h u n d re d patients in th is setting before initiating the research
process w ith subjects. Included in typical occupational therapy
adolescent in terv iew s w ere questions regarding th eir history, daily
occupations, and fu tu re goals.
All three of th e adolescents chosen for this study w ere initially
e v alu ated in occupational therapy by myself. By interacting w ith the
adolescents as th eir therapist, a sense of rapport w as already established
49
p rior to scheduled research interview s. In addition, I frequently
interacted w ith the three selected teens d u rin g the tim e betw een and
after scheduled interview s.
Data w ere also collected via hospital m edical chart records-
These records included inform ation from the collective disciplines
in v o lv e d w ith each case inclu d in g psychology, psychiatry, nursing,
recreational therapy, speech and language, education, an d social work.
T he adolescent's m edical chart p ro v ed to be a detailed source of
background in fo rm atio n , dates of hospitalization, a n d diagnostic
term inology regarding the adolescents.
Three adolescent patients at UCLA N PI & H participated in three
separate in terv iew sessions. T hey each com pleted an activity log,
describing typical occupations at ho m e, either independently o r d u rin g
the in terv iew w ith myself. All interview s were tape recorded to
increase data accuracy. Transcribers provided by UCLA N PI & H typed
u p th e data from th e recorded interv iews. O ne transcriber sent a letter
to m e com m enting on the therapeutic v a lu e of the in terv iew process
(See A ppendix E).
The occupational activity log (See A ppendix B) w as discussed
50
d u rin g the second or th ird interview . T he purpose of th is was to yield
an o u tlin e of occupations w hich the adolescents engaged in at hom e.
This allow ed m e to explore a typical day outside of the hospital and
provided a com parison w ith occupations engaged in w ith in the
hospital setting. Two of the teens created a typical day at h o m e from
m em ory, w hereas one docum ented a specific w eekend day prior to our
in ter v iew.
T hree in terv iew s were com pleted w ith each subject before the
next adolescent was chosen. By n o t overlapping interview s, the
opportunity for m em ber checking w as increased. After th e final
adolescent com pleted th e in terv iew process, the first subject w as asked
w hether h e agreed or disagreed w ith a concept that had em erged.
Im m ediately after each in terv iew , h eld observations w ere
recorded by m yself or spoken in to a tape recorder and later transcribed.
These n a rra tiv e style n o tes included a description of the physical
setting, a picture of th e adolescent, non-verbal actions, a n d the
thoughts an d observations of th e researcher. O bservational notes
regarding an in terv iew session p ro v id ed greater m ean in g and added
density to th e data (Krefting, 1991). A s suggested by Lincoln an d Guba
51
(1985) an d K refting (1991), reflexive jo u rn alin g was included in the
field notes. T his included m y th o u g h t process, perceptions, reactions,
a n d personal biases an d added credibility an d confirm ability to the
study (Krefting, 1991).
The interview s began on January 26, 1993 an d com eluded on
June 24,1993 w ith as m u ch tim e as three m o n th s betw een subjects.
Once the interview process was in itiated w ith an adolescent, how ever,
subsequent interview s occurred w ith in one to seven days.
1 perform ed th ree interview s w ith each adolescent on separate
occasions for 20 to 60 m in u tes each. M ost of the in terv iew s were 45 to
60 m in u te s long. Two h u n d re d an d fifty-four double spaced pages of
data were the result of n in e interview s. Fifty-two single a n d double
spaced pages of field observations w ere m ade. Finally, 13 pages w ere
w ritten after m eetings w ith other professionals an d m en to rs to en su re
th e triangulation process. T hus, a total of 319 single and double spaced
pages of data w ere collected and later edited, coded, and analyzed as
necessary.
T he progression of the interview s was sim ilar for each
adolescent. First, the topic of fu tu re orientation was pursued, then
52
daily occupations prior to an d d u rin g hospitalization, an d finally
future orientation in conjunction w ith in d iv id u a l occupations. T he
three sections below sum m arize each in terv iew and its c o n te n t
Interview Che: F u tu re O rientation
T he adolescent participants w ere asked a variety of questions
d u rin g the interview . My ultim ate goal w as to uncover the m ean in g
of future for each adolescent, w hat th e ir daily occupations consisted of
outside an d inside the hospital, a n d th e relationship between future
orientation and daily occupations. D uring d ie first interview , the focus
was on th eir future orientation, defined in th is study as th e
anticipation or ev alu atio n of the fu tu re (Agarwal & T ripathi, 1984;
T rom m sdorff & L am m , 1980). The adolescent’s m o tiv atio n , planning,
an d evaluation of th e fu tu re (N u rm i, 1989, 1991; N u ttin , 1984) guided
the form at for the first interview . Below is a list of sam ple interview
i
questions posed after the adolescent first established the m ean in g of the
w ords "goal" an d "future" according to h is o r h er understanding.
1. W h at are your fu tu re goals/plans?
2. W h at are your academ ic/vocational /personal goals?
3. W h at k in d of h o p es/d ream s do you have?
53
4. W h at are your fears w hen th in k in g about th e future?
5. W h a t are your goals for today/this m o n th /th is year?
6. Do you th in k you w ill actually attain your goals? If so, w hich
ones?
7. H ow far into the future do you dream /plan?
T he adolescents were fu rth er questioned on w hen these
aspirations w ill be realized, the degree of interest in each goal, how
m u ch p lan n in g h e /sh e has carried out, an d how m uch know ledge
h e /s h e has about the stated plans (N u rm i, 1987).
In terv iew Two: Daily Occupations
W ith the guidance of the structure provided by the activity logs,
die researcher explored the occupations of these adolescents. Typical
tim e at h o m e as w ell as scheduled hospital activities were investigated.
In fo rm atio n from the occupational therapy evaluation and m edical
chart p ro v id ed fu rth er d u e s as to the daily occupations of the teens.
S om e questions she asked included:
1. W h at activities fill a typical w eek/w eekend day at hom e?
2. Describe a typical daily schedule w ith in the hospital p ro g ram .
3. Do you belong to any d u b s, groups, o r organizations?
54
4. W h at hobbies and special interests do you have?
5. W h at is your favorite way to spend your tim e?
6. W h at activities do you participate in th at you do n o t enjoy
doing?
7. How m uch of your tim e is d eterm ined by others
in side /outside of the hospital?
8. W h at activities are you unable to participate in d u rin g your
hospital stay?
9. H ow have your activities or d u ration of activities changed
due to your hospitalization?
Interview Three: Future O rientation a n d Daily O ccupations
Finally, the adolescents w ere rem in d ed of their stated outlook
on the fu tu re and encouraged to m ake connections to th ier daily
occupations. D efinitions w ere again clarified to ensure accuracy w ithin
the relay of inform ation from person to person. Each teen was also
show n a w ritten sum m ary of h is or h e r stated goals. T hey num bered
them according to priority a n d reorganized an d added as they felt led
according to th eir u n d erstan d in g of goals. Som e exam ple questions
follow below, ho w ev er I adapted m y lin e of questioning as necessary to
55
fit the individual.
1. W h at present activities will h e lp you reach your goal
regarding...(state specific goal)?
2. W h at plans h a v e you m ade to h elp you attain your goal
of...(state specific goal)?
3. Are there any activities you engage in w hich m ay obstruct the
a tta in m e n t of your goal/dream ?
4. W h at goals h a v e you attained d u rin g your hospital stay?
5. W h at m akes you do the thing? (state specific activity) you do
n o t like doing?
6. Looking at your life now , w hen do you realistically expect to
reach your goal of...(state specific goal)?
7. W hich goal is m ost/least likely to be attained?
8. W hich goal are you m ost/least w illing to give up?
T he hospitalized adolescents w ere given a chance to verify the
data w hich h a d been collected du rin g th e p rev io u s interview sessions.
U nansw ered or vague m aterial from each adolescent’s first two
in terv iew s w as included by th is tim e. T he adolescents w ere presented
w ith the statem ents of th eir peers as w ell as th eir own an d asked to
5 6
react to th em . By confirm ing, denying, adding, and rev isin g p rev io u s
statem ents, the credibility of the study w as enhanced (Lincoln & Guba,
1985).
T his process of m em ber checking, discussed earlier in the
chapter, was incorporated into the sessions in order to confirm and
com pare in form ation gathered by each interview ee. For exam ple, after
first allow ing C hristine to create h e r ow n definition of "future," I said
to her, "A nother adolescent defined th e fu tu re as....; do you agree or
disagree?" Each adolescent was asked to co m m en t on th e responses of
the o th er study participants. To m ain ta in anonym ity and decrease bias,
th e adolescents w ere n o t nam ed. Even V ince, the first participant
in terv iew ed was again questioned after C hristine and M elanie, "Is one
w eek from no w th e future?" His answ er verified the consensus of the
entire group. By u sin g th is retesting an d refin in g process, I w as
directed tow ard a consensus regarding definitions a n d perceptions and
n o ted sim ilarities an d differences a m o n g th e three respondents. As a
final check, they w ere also offered th e o p p o rtu n ity to review the final
thesis product for corrections a n d revisions. A fter reading the
m aterial, how ever, they indicated n o n eed for change due to inaccuracy
57
or discom fort.
Data Analysis
By using the constant com parative m eth o d of Glaser and
Strauss (1967) for theory generation, the data were collected, coded, an d
analyzed. T he n arrativ es of the participants were analyzed and
presented to add a rich, qualitative picture to the findings- T his final
section focuses on the coding an d analysis process, w hich led to the
resu ltin g them es, recorded in chapter four a n d discussed in chapter
five.
T his phase w as guided by the constant com parative m eth o d as
described by Glaser an d Strauss (1967). The four steps of the process
included: (a) com paring incidents applicable to each category; (b)
integrating categories an d th eir properties; (c) delim iting the theory, or
taking o u t non-relev a n t properties; an d (d) w riting th e theory. The
applied analysis is o u tlin e d below.
A fter th e in terv iew data w ere transcribed, I edited the m aterial,
w hich w as n o w ready to be coded. I labeled them es th ro u g h o u t each
in terv iew w ith a key w ord o r phrase. Initially, the a m o u n t of codes
58
were lengthy. H ow ever, over tim e, th e codes w ere grouped an d
refined to a set of 14. Six of these codes, or them es, addressed th e m ain
questions of this study regarding fu tu re orientation an d daily
occupations. They were: (a) future; (b) goal/dream ; (c) m o tiv atio n ; (d)
planning; (e) evaluation; an d (f) fears/feelings.
The six categories were analyzed in detail. T his m eant
com bining all of the data u n d er each code, from all of th e interview s
w ith each adolescent. Once th is step w as accom plished, the analysis for
each of the three adolescents was com pared.
Due to the trem en d o u s nu m b er of stated goals a n d occupations, I
focused on the goal each adolescent perceived as m ost im portant.
H ow ever, th e other reported gpals h av e been categorized an d discussed
in chapter four to provide a com plete a n d w ell-docum ented picture of
the adolescents' future goals.
Initially, I had only in ten d ed to study occupations p rio r to
hospitalization. To m y surprise, occupations w ith in th e hospital and
the changes in occupation d u e to hospitalization could n o t be ignored
as the adolescents told their stories an d spoke of daily life. T hus,
analysis and finding? shifted w ith the em erging data a n d th em es in an
59
inductive m an n er. Sim ilarly, the foundational definitions of "future"
and "goal" used in this study w ere com pletely created by the three
participants.
E ven th o u g h each teen represented a unique n arrativ e
fram ew ork w ith dem ographic variability, m o tiv atio n al them es w ithin
future o rien tatio n were strikingly sim ilar. W hen differences
consistently arose, there still em erged patterns and parallel
relatio nships am o n g the deviations.
Finally, after m ap p in g o u t them es an d relationships, the results
were recorded in chapter four. T he adolescents' perspectives and
stories w ere w ritten u tilizin g m an y of th eir ow n w ords through quotes.
I also used th e first person voice. This style of presentation was
adopted because of the participant observation style. My participation
as in te rv ie w e r a n d observer w as m ea n t to enrich the data an d results.
Spencer et al. (1993) p o in ted o u t th e advantage to this approach,
"Participation also m ay m ean in te rv ie w in g people in an em pathic
way, in w hich persons are encouraged to express th eir experiences and
beliefs in th eir ow n w ords, draw ing on th e ir ow n m etaphors, stories,
an d personal experiences" (p. 304).
60
T his chapter has discussed th e use of the blended techniques of
n arrativ e analysis an d naturalistic inquiry. M easures of
trustw orthiness h a v e been delineated an d described. T he setting,
sam ple selection, an d data collection an d analysis process h as been
recounted. C hapter four outlines the results of the qualitative research
an d finally, chapter five concisely discusses their m ea n in g and
im plications for society.
61
CHAPTER FOUR
R esults
In tro d u ctio n
T his chapter begins w ith a n arrativ e description of th e hospital
culture, the setting for the interview s, an d th e participants in the study.
Next, the adolescents' definitions of th e fu tu re an d goals are
introduced to set the stagp for the results in th e areas of future
orientation a n d daily occupations. Q u o tatio n s were draw n directly
from the data to su p p o rt th e findings an d present the study from the
adolescents' perspective.
The C ulture
T he N europsychiatric Institute an d H ospital consisted of six
in p atien t u n its, three of w hich belong to the C hild an d A dolescent
D ivision. In addition, there w ere a n u m b e r of ou tp atien t services and
program s offered to both ad u lts an d children. T he h o sp ital's m ission
w as to provide an e n v iro n m e n t w hich integrated th e excellence of the
educational a n d research program s w ith co n tin u o u sly im p ro v in g
6 2
exem plary p atien t care.
The m u ltieth n ic staff represented a variety of disciplines.
Psychiatry a n d psychology, as well as m ost of the o th er fields,
constantly h ad interns ro tatin g through the v ario u s p atien t w ards w ith
one w ard chief, attending psychiatrist to oversee one or two u n its each.
Both of the adolescent units h ad controlled access to the ward.
N o t only w as the front door locked, but frequently the n u rsin g station,
hallw ays, bathroom s, an d m ain liv in g room doors. Each w ard h a d its
ow n liv in g room and d in in g area w ith a kitchen shared betw een the
two units. O nly A-W est h ad an enclosed deck area im m ediately off th e
liv in g room space. Both u n its had a treatm ent room for physical
exam inations and concerns, a seclusion room , and a set of leather
restraints, used in extrem e situation and w ith scrupulous staff
m o n ito rin g an d training. Patient status (such as suicide observation,
close observation, or constant eyesight) and patient privileges (such as
w ard restricted, hospital grounds, cam pus, or W estw ood privileges)
were indicated on visible boards an d in charts located in the n u rsin g
station, enclosed by a glass-like barrier. A lthough adolescent u n its, A-
W est and A -South also served adults an d children u n d er th e age of 13
63
w hen appropriate.
A -W est was an in p atien t u n it consisting of adolescents w ith
m ultiple diagnoses in clu d in g em otional im p airm en ts, developm ental
delays, an d even physical disabilities at tim es, the u n it program is
organized a ro u n d a structured, behavioral fram ew ork. Its m ajor goals
were to help adolescents increase their self-confidence, take
responsibility for their actions, an d function safely and m ore
independently in their e n v iro n m en t.
A -south w as an in p atien t u n it com posed of em otionally
disturbed adolescent boys and girls w ith a variety of psychiatric
disorders. The u n it was w ell know n for its program dealing w ith
A norexia N ervosa and o th er eating disorders. T he u n it w as organized
around in d iv id u al and group psychotherapy w ith the goal of helping
adolescents deal m ore effectively w ith th e ir feelings, to h e lp them
t
function m ore independently in th eir e n v iro n m e n t, an d to build th eir
skills a n d strengths.
O ne subject, Vince, also participated in the A dolescent Partial
H ospitalization Program [APHP] at UCLA. T he AFHP provided a link
between th e adolescent in p atien t u n its (A-W est an d A -South) and
6 4
o u tp atien t services. The goal of th is program w as to provide
c o n tin u ity of care to those patients being discharged from the in p atien t
setting w ho cannot yet be m ain tain ed as outpatients. T he APHP
operated weekdays from 8:30 am to 3:30 pm on th e sam e floor w here
the adolescents attended school.
R egular m eetings and consistent com m unication took place on
all three services. W eekly treatm ent p lan n in g m eetings, w here all of
th e disciplines gather, were h eld regarding each adolescent th ro u g h o u t
h is or h e r stay. T his was a tim e w here concerns w ere addressed, goals
established, and evaluation data revealed. A sm aller team of people
(such as th e case coordinator, attending n urse, an d social worker) m e t
an d spoke at frequent in terv als w ith the caregivers. At the tim e of the
p a tie n t's discharge, often a com prehensive team m eetin g was
scheduled w ith the caregivers, school representatives, a n d /o r
residential placem ent advisors in order to provide final assessm ent
su m m a rie s a n d recom m endations.
Each adolescent participated in the occupational therapy
program , w hich addressed functional abilities such as task
perform ance, social interaction, tim e m anagem ent, an d peroeptual-
6 5
m otor skills as well as others. All patients were encouraged to
participate in therapeutic activities inclu d in g task skills, cooking group,
games, an d treasure h u n ts to n a m e a few. G roups an d independent
sessions w ere h eld on the u n it, in th e occupational therapy clinic and
other designated room s, an d outside on th e play decks. Each adolescent
in this study received an occupational therapy evaluation, com pleted
by myself, prior to participating in the interview s.
T he Setting
The interview s w ere h e ld in a sm all square shaped room near
the occupational therapy office at UCLA NF1 & H. T he w hite walls
stood out in contrast to the oak-stained doors, w hich rem ain ed closed
d u rin g the interview s. The room h ad am ple lighting in addition to the
sunlight, w hich poured in th ro u g h the three large w indow s behind
Venetian blinds. A ren o v ated office, the room contained book
shelves, a filing cabinet, an d a bulletin board full of paraphernalia left
behind by th e ro o m 's prev io u s occupant. T he counter, un d ern eath the
w indow s, h e ld distracting ele m e n ts in clu d in g plants, staplers, coffee
m ugs, an d an array of paper m aterial. The room w as com plete w ith a
66
sink, towel dispenser, an d a typew riter or videorecording m achin e on
occasion.
Each adolescent an d m yself sat in a m au v e chair w ith a silver
fram e. T he chairs su rro u n d ed a ro u n d table, w hich filled the sm all
ro o m . The long, black tape recorder w as ro u tin ely placed on the table
w ith the built-in m icrophone closest to the teen.
All b u t one interview , C hristine's second, was h eld in this room .
In attem pts to m ake h e r feel m ore com fortable, 1 chose a patio table
outside, w ith an overhead um brella to protect C hristine from the sun.
H ow ever, e v e n this session concluded in the room due to w indy
w eather conditions.
From the room , outside noises could be heard d u rin g the
interview s. These distractions generally originated from the
therapeutic activity taking place in the nearby clinic or from office
conversation and laughter. D uring the second in terv iew w ith Vince,
how ever, irritatin g construction sounds created a d e a r distraction. In
addition, d u rin g h is th ird interview , V ince noticed a high pitched buzz
originating from the fluorescent lights overhead. Finally, occasional
telephone su m m o n s w ere the only o th er in terru p tio n s to the flow of
6 7
the interviews.
The A dolescents
Vin «
V ince was a dark-haired H ispanic 17 year old. He ro u tin ely wore
a pu rp le and black Laker's cap, w hich m atched h is very thick jacket. He
w ore excessive layers of clothing considering the tem perature of the
room a n d hospital. V ince h ad O bsessive-C om pulsive D isorder [OCDJ.
He has h a d difficulties since n in th grade a n d his parents
described him as reserved and shy. He becam e increasingly isolative
a n d finally w ithdrew to the point of sp en d in g the m ajo rity of h is tim e
in h is room w ith h is face covered, engaging in a variety of ritualized
behaviors. He h ad stopped attending h is senior year of school an d
rarely left the house by the spring of 1992.
V ince's psychologist referred him to psychiatry at NP1 & H. He
w as in v o lu n ta rily adm itted to the A -South U n it in October of 1992
w ith d ie initial diagnosis of an atypical psychosis. He agreed to stay
v o lu n ta rily by th e next day. He was discharged tw o m o n th s later on 80
m illigram s (mg.) of Prozac and 2 m g of A tiv an a day, w hich targeted
h is clear diagnosis of O bsessive-C om pulsive D isorder, how ever,
68
A nxiety D isorder N o t O therw ise Specified still needed to be ruled out-
He transferred directly to the A dolescent Partial H ospitalization
Program w here th e anxiety disorder w as confirm ed. Follow ing h is
participation in th is study, h e w as again adm itted to the inpatient u n it
on M arch 15,1993 due to an increase in obsessive th o u g h ts and m arked
feelings of su id d ality an d hopelessness. A n affective com ponent to his
disorder was recognized and h is m edical trial included daily Prozac (20
mg.) a n d Paxil (40 mg.).
A fter three days, h e retu rn ed to th e partial program u n til h is
final discharge on N o v em b er 23,1993. H is diagnosis w as concluded to
be OCD an d Bipolar D isorder N o t O therw ise Specified. H is
m edications at th a t tim e included Zoloft (200 m&) and L ithium (1200
mg.) daily in d ivided doses. A lthough the treatm ent team
recom m ended residential plaoem ent, he retu rn ed h o m e against
m edical advise w ith referral inform ation.
D uring interview s in the spring of 1993, V ince kept h is left h a n d
gripped to a cotton cloth, w hich covered h is nose an d m o u th . T his
w o rn w hite tee sh irt m aterial h a d been cut into a circular shape; one
p art of the cloth rested below his chin leaving the upper part of his face
6 9
exposed. H is large h a n d cupped h is nose and m o u th w hile h is th u m b
secured the m aterial on his left cheek. He w o u ld squeeze h is cheeks
together at tim es as he spoke. V ince w as m o tiv ated to keep th e rag in
place so th a t n o th in g terrible m ig h t happen to h is fam ily.
His dark eyebrows and h air w ere recognizable below h is baseball
cap. He w as n o t cleanly shaven and appeared to sm ile a lot u n d ern eath
the cloth, but it was difficult to tell. His eye contact n e v e r lasted for
m ore than five seconds before h e looked away. H is dark brow n eyes
w ould gaze to the side an d upw ards for the m ajo rity of the sessions.
T his lack of eye contact m ay fit into h is obsessive-com pulsive
fram ew ork, as w ell as die fact th at h e was fo u n d clenching a purple
bead tigfitly in h is fist d u rin g th e th ird interview .
D uring h is initial occupational therapy assessm ent in October
1992,1 fo u n d that h e h ad difficulties in the areas of so d al interaction
an d task perform ance. H is obsessive-com pulsive tendencies h a d a
negative im pact in m any areas of V ince's daily living. He w as only
able to identify a few strong interests, and he spent m u ch of h is tim e
cleaning a n d exercising w ithin h is ow n hom e. H e was unable to
identify friends at the tim e of the evaluation. A recreational therapist
70
in the A dolescent Partial H ospitalization Program described V ince as
very quiet a n d rarely in itiatin g social conversation w ith others.
V ince lived in the h e a rt of Los Angeles. His fam ily consisted of
h is parents, younger hrother a n d sister, an d tw o older brothers w ho
live elsew here. The p a re n t's h ad a h istory of legal altercations. The
father claim ed that h e has been the victim of harassm ent by the police
system because of h is activist role in th e com m unity, an d the m o th er
left th e h o m e w ith th e children after altercations w ith the father. The
unsafe neighborhood in w hich he resided m ay have contributed to his
feeling o u t of control in the w orld a ro u n d h im , w ith a fear of bad
things h ap p en in g to others o r him self. He also w itnessed a girl as she
was nearly ru n over by a car h a d V ince n o t throw n h e r to the side. His
brother, in v o lv e d in gang activity, h a d been sh o t and w ounded, and
h is grandfather died four years ago.
V ince w as a w ith d raw n b u t considerate young m an w ho found
it very im p o rtan t to give to others. He w anted to m ake a difference, to
be som eone, an d to create a w orld th at w as m ore peaceful. He appeared
hright a n d capable a n d was able to answ er open-ended questions and
expound on subjects.
71
Physically, h e h a d a m edium -sized build and h is jeans and
ten n is shoes fit the picture of the athlete w hich he tru ly was. Sports
rem ained a big part of h is life even though h is OCD kept him o u t of
organized team sports. In fact, V ince still ruled the baskethall court and
won boxing m atches even though he w as lim ited to the use of o n e free
hand, w hile the o th er h a n d h eld a cloth to h is face.
Vince did n o t dw ell on h is obsessive-com pulsive sym ptom s
w ith any self-pity. In fact, he described him self as a fighter. He said
"{It's] h ard for m e to give up. I ju st - n o m atter w hat, I ju st d o n 't give
up...w ith sports, ju st from life in general." H is sense of courage an d
determ ination was ev id en t as h e talked about attain in g h is gpals and
conquering obsessive-com pulsive disorder.
C hristine
C hristine was a 16 year old Filipino gjrl in the elev en th grade.
She liv e d w ith h er stepm other, her dad w ho recently u n d e rw en t h eart
surgery, her uncle, and h er eight year old brother w ho w as adopted,
like herself. She was adopted as a baby, m o v ed to th e U n ited States
w hen she w as four, an d w as n o w liv in g in San Dim as, C alifornia.
In October 1992, C hristine developed a rash on h e r face and legs.
7 2
By January, fu rth er sym ptom s h a d e v o lv e d in clu d in g jo in t pain an d
arteriole spasm s. Subsequently, she experienced headaches and fevers
an d w as diagnosed w ith m ononucleosis. She suffered an acute
confusional episode in M arch of 1993.
Finally, she was diagnosed w ith System ic L upus E rythem atosus
and initially becam e m ore cognitively organized on Solu-M edrol.
U nfortunately, h e r m en tal status deteriorated again. A psychiatrist in
Sam Dim as was consulted an d she was placed on H aldol as w ell as
Zoloft w ith no success as sym ptom s of catatonia developed.
On M arch 23, 1993 she w as adm itted to UCLA Medical C enter.
Prior psychiatric m edicines w ere discontinued, and she tried Co gen tin
w ith notable decrease in h e r rigidity a n d im p ro v e m e n t in her m ental
status. She u n d erw en t an am obarbital in terv iew on A pril 15, w hich
revealed a detailed delusional system a n d auditory hallucinations.
T his prom pted a Loxitane trial the follow ing day secondary to psychosis
and A tivan due to anxiety. It was recom m ended th at C hristine be
transferred to UCLA NPZ & H w hen m edically stable, w hich w as A pril
26.
A t the tim e of adm ission, she w as also being treated w ith 45 m g
73
of prednisone per day. T his dosage was tapered to 30 mg. by th e tim e of
h e r discharge. In addition two 5 m g. doses of C im etidine was
prescribed daily as a prophylactic m easure. She was discharged to
h o m e on M ay 14,1993 from the A-W est U nit w ith the two m edications
m en tio n ed above as well as Loxapine an d A tivan.
D uring interview s, C hristine appeared quite talkative for a girl
w ho w as recently m ute due to organic delirium . S he appeared to h av e
difficulty understanding th e questions an d at tim es needed them
repeated three or four tim es, in a variety of ways, before she could
answ er directly. These data supported the team discussion th at took
place in th e m iddle of M ay regarding C hristine's difficulty w ith
processing auditory and visu al inform ation. C hristine's feelings also
appeared to differ from w hat she agreed to or stated verbally. For
exam ple, initially she stated th at being tape recorded did n o t bother her.
H ow ever, she w as clearly distracted by it an d sat facing the recorder
focused on the m achine m ost of the tim e. She asked th ro u g h o u t th e
sessions if she could listen to her voice, w hich she described as "sm all".
D uring d ie second interview , she w as able to express her fear of
som eone else listening to th e tapes; h e r fears w ere relieved through
74
discussion an d by giving h e r a copy of the tapes.
C hristine's tan face w as accentuated by the red-fram ed glasses,
w hich w ere delicately balanced on the en d of h e r nose. She pulled h e r
dark h a ir off of her face w ith a barrette, initially, she sat still w ith little
m o v em en t th ro u g h o u t th e interview , squarely facing the table and
tape recorder. She did appear to becom e m o re com fortable d u rin g
subsequent interview s and also m ore talkative. T he setting in which
she was m o st comfortable appeared to be outside at a patio table.
C hristine was a highly m otivated, hard-w orking girl w ho had a
strict an d religious u p b rin g in g She w as goal-oriented and exhibited a
drive to w ork h ard an d please others. H er parents played a very
influential role in h e r life a n d she was quite aw are of th eir expectations
and w anted to give to h er fam ily in a variety of ways. For exam ple, she
chose to spend h er allow ance on gifts for h e r fam ily. She h ad difficulty
th inking of ways to spend m o n ey on herself. She also expressed her
w ish to h e lp h e r ill father.
...I w ish I was older, b u t if 1 w as a n u rse, 1 could h elp m y dad,...
/k n o w , that’d be cool, cause m y dad ju s t h a d a - open, open
u h h e a rt surgery, a n d if I was only a little bit older, maybe ten
75
years older, y'know , I could be m y dad's nurse.
S he also offered th at she was n o t like n o rm al teenagers. She
stated, "I d o n 't go out on dates. I d o n 't go o u t to parties." Instead,
C hristine chose to dedicate herself to an extrem ely im p o rtan t goal to
her, w hich w as fin ish in g high school on schedule. She described
herself as one w h o h as substantial w ill-pow er, believing she h ad the
right attitude to accom plish m any of h e r goals.
D eterm ined, w ith a strong desire to help others, she also
described h e r participation in activities as a way to n o t waste resources.
For exam ple, she did n o t w ant to waste h e r education, n o r the
o pp o rtu n ity to m ake use of the piano in h e r hom e, n o r th e recipe
books available to her.
C hristine was frightened by h e r Lupus, w hich had affected her
function in all areas. On h er occupational therapy assessm ent, 1
recorded th at sh e h ad deficits in the areas of task perform ance, social
interaction, an d visual-m otor integration. In the latter, she was
fu n ctioning at an age equivalent of 11 years, 2 m onths. She also
experienced decreased physical endurance an d strength because of her
disorder. A n o te w ritten by th e recreational therapist also described h e r
76
as socially w ithdraw n a n d confused in h er th in k in g w ith decreased
problem -solving ability.
H ow ever, C hristine was in v o lv e d in the program a n d enjoyed a
variety o f activities. Som e of h e r hobbies in clu d ed listen in g to classical
m usic, w riting, an d reading. In th e hospital, she appreciated the chance
to learn in cooking and task groups and even gave h e r best effort
d u rin g physical activities.
O verall, she appeared to be a good-natured, gentle, quiet person.
In a one to one setting, especially as h e r th o u g h t process cleared, she
was able to carry on conversation. T his is a drastic contrast to w hen she
initially arrived on the u n it, w hen she appeared extrem ely paranoid
and afraid, h u d d led in th e com er, h id in g from u nseen things, w hich
she could n o t describe verbally.
C hristine often talked about looking forw ard to going ho m e,
rejoin ing h e r fam ily, a n d participating in church activities. U pon
arriv in g hom e, h e r first task was to clean o u t h er room a n d give any
excess or unnecessary thin g s to th e Salvation Arm y. T hese types of
errands, as w ell as h er school progress, w eighed h e av ily on h e r m in d .
77
M elanie
M elanie w as a 17 year old Caucasian fem ale w ho w as described
by therapists as quiet, shy, an d reluctant to socialize w ith h er peers. She
h ad a four year h isto ry of A norexia N ervosa, an d she h ad lost 30
p o u n d s since th e birth of h e r baby, approxim ately six m o n th s agp, w ith
little w eight gain d u rin g h e r pregnancy. S he typically ate a bowl of
cereal an d m ilk for breakfast, skipped lunch, and h ad a sm all dinner.
Follow ing each m eal, she exercised vigorously, previously by bike, now
by Stair m aster. H er w eight loss a n d long history of undereating
follow ed by vigorous exercise caused enough concern to ad m it h e r to
the A -South U n it at UCLA N PI & H on M ay 13,1993. U pon adm ission,
she stood less th an five feet three inches tall an d w eighed 89.75 pounds.
S he did n o t receive m edication d u rin g h er stay, how ever h er
calorie intake w as carefully m onitored. U pon first adm ittance to the
hospital, th e w ard psychologist ordered 400 calorie food trays three
tim es per day a n d restricted h e r from participation in Recreation
Therapy. T he staff observed h er closely for three h o u rs after each m eal
(to in su re that she did n o t purge) an d counted h er calorie intake at each
m eal. M elanie w as w eighed two tim es per week.
78
By June 1,1993,18 days after adm ission, she was n o longer
observed after m eals, could attend recreational activities, and received
cam pus privileges. Her food trays h ad steadily increased in calorie
a m o u n ts u n til she was eating 800 calorie m eals w ith 450 calorie snacks
two tim es a day by June 8. D uring h e r final three weeks, she was
allow ed to select h er ow n foods an d progressed to counting calories
in d ep en d en t of staff.
M elanie was a pleasant, sweet teen w ho reported that she was
w orking on becom ing m ore assertive. She h a d bright blue eyes and
blond h air, w hich was th in an d e ith er tightly p u lled across h e r head
into a ponytail or hanging straight dow n covering part of h e r face. H er
eyebrows were dark in contrast to h e r hair, an d she h ad a th in fram e
and braces on h e r teeth. She h ad a beautiful sm ile w hen she laughed.
D uring the first interview , she played w ith h e r h a n d s in a
slightly n e rv o u s fashion. H ow ever, h e r face appeared relaxed an d she
gave excellent eye contact M elanie was very open and h o n est an d did
n o t appear to be bothered by th e tape recorder. She paid little attention
to it an d did n o t even flinch w hen th e recorder snapped off. A lthough
she d id n o t discuss w anting to help o th er people, she did display
79
characteristics of one w ho pleases people. She did w hat was asked of
h e r m o st of th e tim e, fulfilling others' expectations.
M elanie was the quiet one in a group. She w o u ld n o t be the one
you w o u ld find speaking o u t o r raising h e r h a n d to be chosen to lead a
gam e of charades. One w ould m o re likely find h e r w ith h er son at
ho m e, cleaning the h o u se and n o t leaving the prem ises by herself.
She enjoyed h e r role as m o th er and w anted to engage in dom estic
activity. She did n o t initiate the topic of academia, but instead was
optim istic about h e r fu tu re fam ily life. She anticipated that her
boyfriend w o u ld become h e r husband a n d that she w o u ld h av e the
chance to h a v e m ore children.
She liked being w ith o th er people and expressed a fear of being
alone to the p o in t that she did n o t go outside by herself. She resisted
change/ an d h e r daily ro u tin e consisted of frequent h a n d w ashing and
teeth brushing. H er typical w eek, prior to being adm itted to the
hospital, consisted of 20 o r m ore h o u rs of w ork as a sales clerk an d two
to th ree h o u rs per day of h o m e schooling at the elev en th grade level.
She sp en t tim e every day exercising, cleaning, an d tending to h e r baby.
She w as able to identify m an y interests including cleaning, w ritin g
80
crocheting, a n d typing. She did n o t utilize c o m m u n ity resources and,
although she w anted to be m ore independent, h a d fears in v o lv e d in
th e steps required in th is process.
Qn h e r occupational therapy assessm ent, areas needing
im p ro v em en t w hich I identified included her self-esteem , social
interaction, an d ability to plan. She dem onstrated good task skills but
fell short in the social dom ain. C om m unicating by letters, she
infrequently saw friends at h o m e or spent any tim e in group activity.
H er psychiatrist described a fu rth er com plication being h er
refusal to eat, especially w hen she was angry. P rior to adm ittance, she
w as living w ith both parents, two uncles, her brother, and h e r baby.
M elanie expressed her goal d u rin g hospitalization as "I'm w orking on
talking about m y feelings because m y fam ily d o n 't do that. I'm
w orking on that...leam ing how to express myself; to be assertive."
M elanie required the m o st structure an d guidance th ro u g h o u t
th e interview s, frequently responding w ith one w o rd answers.
M elanie guided the interview er by either agreeing or disagreeing,
contributing m ore details as she was able. She appeared h o n est an d u p
front, but needed m ore assistance w ith lengthy conversation and open-
81
ended questions.
M elanie w as a candid person w ith a lot of dream s. S he hoped to
continue back in regular public school classes and become a Physical
Therapy A ssistant in a few years.
F u tu re Defined
T his hospitalized group of adolescents perceived the future as far
off in tim e. T hey said th at one or m ore years from the present was
definitely the future. In contrast, o n e week from n o w was n o t
classified as the future. W h en asked to describe one m o n th from now ,
although vague an d incom plete, th e ir responses u n ifo rm ly reflected
the fact th at ev en that was n o t far enough away to be considered
"future".
Laura: In your opinion, u h , if I asked you about the
fu tu re, w o u ld one m o n th from no w be considered the future or
not?
C hristine: N o. ’Cause one m o n th from no w Til, I'll be getting
ready for high school again, senior year.
Laura: OK. T hat's, th a t's still pretty close. "Future" w o u ld be...?
82
C hristine: W h en I'm like about 21, 22. I th in k Til, I th in k th at's
the age w here Til, I w anna know w here I'm gonna be.
Laura: So sounds like "future" to you is also being m o re settled
on w h o you are, h a v in g m ade som e of your goals, a n d is m ore,
"N ow I'm finally at a place th at I'v e been aim in g for"?
C hristine: U h h m . Yes.
M elanie fu rth er clarified the com plexity an d degree of the term future
as she guided m e tow ard understanding.
Laura: From w hat y o u 're saying it so u n d s like...that a week
from now is n o t the future. A m o n th from now is m o re the
fu tu re or closer to being the future.
M elanie: Yeah.
Laura: A nd a year from now definitely is.
M elanie: Yeah.
Laura: So it's kin da like you gpt levels.
M elanie: Yeah.
V ince created a definition of future w ith w hich all the
adolescents agreed. H e explained, "The fu tu re is w hat you are going to
be or w hat you see yourself doing, and the fu tu re I guess is w h at you
83
see yourself doing...not ju st you but ju st w hat you see happening."
W h en asked to first com e up w ith h e r ow n picture of the future,
C hristine said the future is "like w h at's gonna happen ten years from
now or five years from no w or four years from now or 20 years from
now . T h at's the future." M elanie h ad a m ore difficult tim e putting
w ords to the definition, ho w ev er she still conveyed th e sam e idea. She
stated, "U m , it m eans [pause] later on. I d o n 't know [she laughs]. I
d o n 't know how to explain the future, later....just later, n o t now but
later on in the years."
G oals D efined
W hereas the fu tu re was less tangible to th e subjects, all three of
them came u p w ith several goals for th eir personal lives w ithin the
structured interview s. In contrast to th e future, their goals appeared to
h av e a present focus. C hristine stated th at a goal can be one week from
now , an d she seem ed to define h e r goals as h e r cu rren t pursuits v ersu s
fu tu re plans. For exam ple, she w as n o t w illing to describe m arriage
and fam ily as a goal because th at was som ew here in th e future n o t
som ething she was w o rk in g on presently. T hus, in h e r case, a
84
com plete separation between present goals and fu tu re plans was m ade.
C hristine an d M elanie agreed w ith V inoe's definition of a goal as
"so m eth in g th a t you set yourself o r w hat you w ant to accomplish."
T heir identified personal goals fit into one of four categories: (a)
love/affiliation; (b) career; (c) independence; or (d) health. Below, the
gpals are defined, an d exam ples are provided from the lives of the
adolescents.
L ove/A ffiliation Goals
Love or affiliation gpals included such p u rsu its as helping
others, participation in sports, m arriage, and h a v in g children. For
exam ple, V ince initially described h elping others as the m ost
im p o rtan t goal to him . He explained w h y this goal was significant to
h im :
1 th in k Tm going to h elp a lot of people. T hat’s w hat I d like to
do....I know Tm n o t going to be able to fix everything, but I w ant
to at least help - help a little bit in society or som ething....rm ju st
going to try and do m y part....I w ant to h e lp people 'cause,...to
m e, th a t's the best feeling you can feel; know ing th at yo u 're
h elp in g som ebody th at really needs it...Seein' a sm ilin ’ face is
85
way better than seein' a fro w n in ' one...T hat can...like give you
such a..statural high.
V ince p lan n ed to start playing team sports, in clu d in g boxing and
football, as soon as he gpt well. He w ants to get m arried an d h av e two
children, a boy an d a girl. By th e age of 60 h e said, "I guess I ju st see
m yself being a grandfather. [Pause] Yeah, I th in k th a t's it, ju st bein' a
grandfather and ju st trying1 to h e lp m y grandkids o u t [as] m uch as I
can."
C hristine, sim ilarly, focused on h elp in g oth ers as an im p o rtan t
goal in this category. Her plans, once she re tu rn e d ho m e, included
w alking the dog, helping h e r stepm other cook, an d giving away old
clothes to the Salvation A rm y. She expects to m arry a "decent guy"
w ith a "decent job", have no m ore than one or tw o kids, a n d later visit
h e r grandchildren w hen she is older. She m en tio n ed w anting to be
w ith h er friends by graduating on tim e w ith h e r h ig h school classmates
in 1994.
M elanie nonchalantly stated, "O h yeah, I w as th in k in g about
calling u p my,...well she used to be m y best friend, b u t we h a v e n 't
talked in aw hile. I thought about calling her." M ost of h e r affiliation
86
goals rev o lv e d aro u n d h e r fu tu re fam ily. She pictured herself m arried
in two years to the father of h e r first child an d h av in g two m ore
children. S he did n o t verbalize m any goals regarding h elp in g others or
participating in sports, but M elanie did add a novel perspective on the
quality of life she anticipated:
Laura: A ny dream , fantasy k in d of th in g for your future?
M elanie: Just to be happy and, y1 know , being w ell off.
Laura: 'W ell o ff m ean in g ..
M elanie: ...m eaning w ith the fam ily an d financially and
ev ery th in g .
Later, she depicted h e r life as a 60 year old w om an, "I w ould like to be
w ith m y grandkids, u m , ju st enjoying life...and happy I guess."
Career G oals
Career gpals consisted of college plans an d choice of profession.
M elanie, w ith o u t e x p o u n d in g sim ply stated she p lan n ed to attend
college an d becom e a physical therapy assistant.
V ince provided m ore detail regarding h is gpals in th is area. He
h as always w anted to be a psychologist since h e was little. After
finishing h is senior year, a feat in itself, he plans to attend college in
87
California. Electronics w ould be the area he w ould fall back on if
becom ing a therapist w as n o t feasible. H ow ever he said w ith
d eterm in atio n :
Tm gonna try h ard to [be] a psychiatrist or psychologist. I know it
seem s k in d of h ard to m e, but Tm gonna try. I th in k I [can] do it.
Even right now it doesn't look so bright for m e, but I'm gonna
try real hard, and I thin k I can do it."
C hristine spoke m ost often of h e r career goals a n d ranked them
a close second to getting well. She h as always w anted to be a nurse.
She grew u p in a fam ily of doctors an d n u rse s an d her a u n t m arried a
m an w ho h a d polio. After h e r hospitalization at UCLA NP1 & H, she
began considering o th er health allied careers, such as occupational
therapy.
School was of th e u tm o st im portance to C hristine. She saw h e r
school perform ance as a stepping stone to college adm ission and
explained fervently:
M issing high school [because of illness] is...im portant. Even if I
have to deal w ith m y sickness, Tm ju st gonna h a v e to try. My
goal..m ow is to go back to school...to fin d o u t w hat I h a v e to,
86
y'know , do, because, so far, I'm really behind....’Cause I sill w ant
to attend m y senior year....If I w ork really h ard th is sum m er and
gpt all m y hom ew ork done and tu to rin g an d everything, maybe
L ..w on't be behind 'cause I do ..still w an t to attend m y senior
year.
Independence G oals
Independence goals incorporated financial well b e in g m eans of
transportation, an d geographical location. All three adolescents were
n o t especially eager to em brace th eir independence yet. T he two m ajor
issues of independence for the teens at th is stage were m o v in g away
from h o m e a n d getting a d riv e r's license.
M elanie did n o t plan to m o v e out of th e h o m e for at least two
m ore years, she clarified, "N o t u n til I'm m arried." In fact, she
expressed fear about going outside alone a n d basically rem ained
housebound. H ow ever, even being alone at h o m e stirred u p anxious
feelings, an d she coped by calling and visiting h er boyfriend and h is
fam ily.
A lthough C hristine w as set on attending college, leaving hom e
w as a difficult issue for her. She began en tertain in g thoughts of dorm
89
life after questioning m e on the subject. The idea of liv in g in a college
dorm itory was still a fearful concept for her.
V ince was straightforw ard regarding h is desire to leave the Los
Angeles area. In h is case, it was h is fam ily th at h eld him back.
T hrough o u r discussions, it became obvious that he felt responsible for
and indebted to h is parents. It was h is parents w ho told h im that they
did not w ant him m oving o u t w hen he tu rn ed 18 n o r did they w ant
him to leave h o m e to attend college. V ince gave n o indication th at he
w ould p u rsu e h is independence despite th eir request.
A ll three teenagers spoke of th eir plans to obtain a d riv er's
license, plans w hich were in terru p ted due to hospitalization in two
cases. C hristine p lan n ed to attain h e r license once she w as well, in a
few m onths. M elanie had p u t off the idea of taking h er d riv e r's test
until she was 18. A lthough Vince could identify obtaining a license as
a goal, h e explained the low priority ranking it received, "It is like a
goal, but it's like one of the last things Tm really th in k in g about.
T here's a lot of things going on in m y life...l ju st can barely take this
thing [doth] off m y face an d stuff like that."
90
Health Goals
H ealth goals included freedom from th eir illness an d discharge
from the hospital. It is crucial to n o te th at all three adolescents, by the
end of the th ird interview , identified overcom ing th eir cu rren t
disorder an d getting well as top priority, above all o th er gpals. The
A m erican H om e Econom ics A ssociation survey (1988) fo u n d that out
of a list of 32 concerns posed to adolescents, health ranked th ird w ith 24
percent of th e subjects expressing a great deal of concern about health.
By the th ird in terv iew in th is study, all three adolescents ranked their
goals regarding health as first in im portance. For this reason, th eir goal
regarding attain in g health w as the m ain focus th ro u g h o u t th e study
and w ill be discussed in detail in these final two chapters.
F u tu re O rientation
As described in the R eview of the Literature, fu tu re orientation
will be discussed w ith in the three division fram ew ork of (a)
m o tiv atio n , (b) planning, a n d (c) evaluation (N urm i, 1991). The
fram ew ork w as applied to th e participants’ num ber o n e goal: to get
w ell.
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Motiy.atiop
First, the adolescents' m otivation, or interests in the fu tu re
(N urm i, 1989), was considered. The results indicated th at they w anted
to be healthy an d free of th eir disorder prom ptly. For exam ple, Vince
expressed:
I w ant to get rid of this as fast as I can, you know ? Ju s', it's w eird
'cause I like, I w ant to do it and everything, but I'm just, I’m n o t
in control of it....I'm ju st getting like fed u p or som ething,
just....All of a sudden I just, T ve ju st started to get m ad.
V ince reacted strongly against h is doctor's prediction th at h is obsessive-
com pulsive sym ptom s m ight persist for at least a year. He w anted the
h ealin g process to go faster an d hoped to conquer h is Obsessive-
C om pulsive D isorder soon.
C hristine's goal was to be well in one m o n th . S he explained,
"T h at's part of m y w ish, y'know , to get better." She talked of h e r desire
to retu rn h o m e and finish incom plete projects, retu rn to school, and
engage in physical activities once again. A lthough sober about h er
prognosis, she was highly m otivated to p ursue h e r goal of getting well.
"M y Spanish teacher...she h as Lupus, an d she's on rem ission now . So,
92
she's fine, an d she just, she’s h a n d lin g h e r Lupus well, and if she can
handle it, I can handle it."
Sim ilarly, M elanie rated being h ealth y as h e r n u m b er o n e goal
an d getting o u t of the hospital a close second. She sta te d ," I w o u ld like
to be o u t as soon as possible." M elanie certainly m issed h er baby at
hom e and appeared eager to retu rn to th e structure of h e r daily
activities p rior to hospitalization.
Planning
T he second process of future orientation pertained to h o w the
adolescents' interests a n d goals w ill be realized in the future (N urm i,
1989). P lan n in g was difficult for th e teens because of th eir avoidance of
the concept of future. For two of the teenagers, discussion about the
future evoked an em otional response. As depicted below, it was
difficult for tw o of the teens in particular to entertain the topic. It
appeared to be discouraging for V ince a n d a cause of uncertainty for
C hristine. V ince explained:
Vince: It's h a rd to look into your future. For m e it is, 'cause I'm
living, like Tm ju s t liv in g day by day, ju st h o p in ' if ev er I'm
e v er gonna be able to conquer it or not. I th in k I am . {I’m ] ju st
93
h o p in ' th at today1 s gonna be the day or tom orrow .
Laura: Are there tim es you ever th in k you w o n ’t?
Vinoe: Yeah, th ere's som etim es I just, like, I really try h a rd to
say n o th in 'll happen, then, like 1 ju s 1 , like I can’t do it, and I just
w an t to say to m yself, "Am I ever gonna be able to do it?” I ju st
try n o t to think. I just try to think positively.
As V ince battled a lingering O bsessive-Com pulsive D isorder,
C hristine realized that she had a disease that could surface at any tim e
in h e r future.
Laura: N ow has finding o u t you hav e Lupus or dealing w ith all
th at you...Boy, you’ve dealt w ith a lot this year. It's been quite a
year for you, and does that at all affect the way you see your
fu tu re?
C hristine: Yes, because Lupus, the disease, it d oesn't ju st gp
away, it comes back, an d I d o n 't know h o w old I'm gonna be
w hen it does com e back.
A ll of the adolescents avoided p lan n in g th e future to som e
degree an d chose to focus on daily life. The three agreed th at
acknow ledging their goals was im portant, an d th ey gave exam ples of
94
personal, im m ediate strategies in order to attain th eir goals for health.
They chose to focus on th e present and take life one step at a time.
V ince described it m o st clearly after he w as asked w hat he w as
currently doing to reach h is goals:
I guess ju st th in k in g of 'em ....I th in k it's th in k in g of 'em the
m ost. 'Cause right n o w I'm really n o t doing that m uch. I th in k
{italics added] I'm n o t I guess ju st acknow ledging th at there are
goals that I w anna accom plish, I th in k th a t's a big step
and....that's th e h a rd part is to find o u t your goals. To m e th at's
w hat it is....Once you find w h at you w anna do an d you're
dedicated to do 'em , th en you could just, the rest w o u ld be easy,
easier....So like deciding, w hen y o u 're o u t of high school,
w h eth er to go to college or ju st get a job, everyone could pick.
T hat is gonna be fire h ard part, is picking, th en as soon as you
pick it, then th e rest w ill com e a little bit easier.
V inoe's plan of action w as to p u t forth a lot of effort on h is part and,
w ith o u t rushing, take lots of little steps, such as taking h is h a t off by the
en d of the week.
C hristine h a d begun keeping a jo u rn al, atten d in g church m ore
95
frequently, an d reading m ore inspirational and spiritual writing^.
M elanie's personal plans included talking about h e r feelings,
scheduling free tim e, an d rem em bering to eat. M elanie saw A norexia
N ervosa as affecting h e r present, n o t h e r future goals. H er focus, as
well as the other adolescents', was on daily liv in g w ith a step by step
approach. C hristine verbalized how she coped w ith h e r sickness, "I tell
m yself that, taking...it day by day and one step at a tim e and, like w hat
Dr. H u n ter said, 'R om e w asn't built in a day'...I believe in that."
E valuation
E valuation refers to the possibility of achieving and actualizing
constructed plans (N urm i, 1989). O verall, the adolescents were
experiencing uncertainty regarding th eir goal of attaining health. T he
a m o u n t of reservation and degree of realism v aried in each case.
M elanie w as the m ost optim istic, C hristine the m ost sober, a n d Vinoe
co n tin u ally w avered betw een the two extrem es.
M elanie concurred m ore than once that she w as confident about
attaining an d co n tin u in g in healthiness. She was consistently positive
about h e r battle against Anorexia N ervosa. For exam ple, she
responded below:
96
Laura: How is like getting h e alth y goin'?
M elanie: It's doing good.
Laura: Yeah?
M elanie: Yeah, I'm on m y way Qaughing slightly].
H ow ever, M elanie did n o t identify potential effects of her
disorder on h er future. As touched u p o n earlier, M elanie h a d a four
year history of an eating disorder; she did n o t eat en o u g h an d engaged
in vigorous exercise after m eals. She h a d significant difficulty
expressing anger w ithin h er fam ily an d subsequently refused to eat,
hoping others w ould notice. H er discharge plans w ere to retu rn to the
sam e fam ily se ttin g take on h e r new role as m o th er, en ro ll in public
education again, and m arry an d attend college in th e next couple years.
There was only one m o m en t d u rin g th e interview s w here she
recognized h e r present illness. She cam e to this realization as she
t
spoke:
M elanie: Tve been eating fine lately. It h a sn 't really bothered
m e. U nless Tm m ad, or so m e th in g at I d o n 't know w hat. Just
being h ere som etim es I get m ad ...Like, I d o n ’t w an t to eat m y
snack right now , but I did. 'C ause I was upset about being
97
here....So Tm still h a v in ' a problem w hen I get upset or
som ething; I d o n 't w ant to eat.
Laura: T h at's great that you recognize that, gosh.
M elanie: G uess Tm n o t ready to go [laughing w ith Laura].
It was n o t surprising to discover th at M elanie did not n am e any goal
w hich she considered to be least likely to reach.
In contrast, C hristine m ade sober statem ents in regards to
overcom ing h e r illness. She quietly expressed th at overcom ing Lupus
w as the goal she w as least likely to attain. C hristine described h er
fu tu re as frightening because of h e r disease stating, "You n ev er know
w h at's gonna happen."
Even w ith a realistic u n derstanding of the undeniable
uncertainty of h e r future, C hristine still p o in ted o u t th e fact that she
w as getting better. D uring the first interview , she initially was
ad am an t about p u rsu in g health:
Lupus, the disease, it d o esn 't ju st go away. It com es back,
an d I d o n 't know h o w old Tm gonna be w hen it does come
back,...Because it could h it you a ro u n d 40 or 30, because m y
Spanish teacher...she has Lupus, an d sh e's on rem ission now .
98
So, she’s fine, and she just, sh e 's h a n d lin g h e r L upus w ell, an d if
she can handle it, I can handle it.
By the th ird interview , how ever, she was less optim istic. H er voice
became alm ost inaudible and h e r affect depressed as she discussed the
topic.
Christine: [The future] seem s kinda frightening.
Laura: W h at's frightening about it?
Christine: Because of m y Lupus, you n e v er k now w h a t's gonna
h ap p en .
Laura: W ould you say you th in k about the fu tu re m aybe once a
m o n th ? Once a week? O toe a day?
C hristine: [Silence]
Laura: Is it h ard to talk about?
Christine: 'Cause I w ish I n e v e r h a d it. I w ish I n e v e r received
it, 'cause the doctors say that 'It w a sn 't your fault, you ju st ggt it.'
Laura: Do you believe that?
C hristine: I d o n 't know....Maybe th e way I w as eating or
som ething. Or it could be anything.
V ince w avered the m o st in h is ev alu atio n of attain in g h ealth in
99
h is fu tu re . A t one point, h e predicted he w ould become healthy
w ith in the year and w as aw are of his progress u p to the p re se n t He
rated com bating O bsessive-C om pulsive Disorder as one of the gpals he
w as m o st likely to attain.
Laura: W hich goal do you th in k you w ill definitely [italics
added] reach?
Vince: Definitely? C onquering m y OCD.
Laura: All right!
Vince: I’m gonna do i t
H ow ever, consistently th ro u g h o u t the interview s, V ince m ade
statem ents th a t contradicted h is convictions.
Yeah, th ere 's som etim es I just, like, I really try h a rd to say
n o th in 'll happen. T h en , like 1 just, like I can 't do it, and I ju st
w an t to say to m yself, "A m I e v e r gonna be able to do it?" I ju st
try n o t to think. I ju st try to th in k positively.
In addition, h e w as skeptical about th e m edication helping. Vinoe
expressed doubt about achieving health in a tim ely m an n e r as he
exclaim ed, "I th in k Tm gonna live (italics added] h ere [at the hospital]
or som ething. I d o n 't know ." His ad am an t claim of soon conquering
1 00
OCD was balanced by h is verbal confession that h e was n o t in control of
the disorder.
Daily O ccupations
Occupation, as defined at the beginning of th is study, refers to
chunks of purposeful activity th at m ake u p o n e’s days (USC, 1991). In
other words, occupation is w hat fills a p erso n ’s tim e w h eth er it be
related to w ork, self care, rest, o r leisure. As the adolescents in th is
study discussed th eir daily activities, tw o m ajor th em es em erged.
W hether they realized it or n o t, the adolescents' disorder and resu ltan t
hospital stay greatly affected th eir daily occupations. In addition, all of
the teens identified goals w hich had to be postponed as a result of their
significant change in occupations.
Occupational C hanges
Once hospitalized, the adolescents experienced change in th e ir
daily occupations in six m ajor areas. T he categories included (a) degree
of control, (b) fam ily interaction, (c) transportation, (d) school an d
work, (e) leisure and sports, a n d (f) personal focus.
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Degree of control.
W ith in the hospital setting, the days were highly structured for
the adolescents. E valuation an d treatm en t sessions were scheduled
and lead by a variety of disciplines. A typical day often included three
h o u rs of school, predictable m ealtim es, therapeutic group activities,
an d in d iv id u al tim e w ith th eir assigned doctor. Despite possible lack of
interest or en th u siasm , the adolescents w ere encouraged to participate
in all p ro g ram m ed activities.
The allocation of tim e in the hospital varied from the standard
provided by C sikszentm ihalyi an d L arson's study of upper an d low er
class high school students (1984). They determ ined that adolescents
typically spend 32 percent of th eir tim e in school, 27 percent in public,
and 41 percent at h o m e, w here 19 percent of the portion at h o m e is
actually sp en t w ith fam ily m em bers.
M elanie reported th at 100 percent of h e r tim e was decided by
others d u rin g h e r hospital stay. T his was a drastic contrast in
com parison w ith h e r life at h o m e, w here sh e decided ho w to spend all
of h e r tim e, except for the 20 h o u rs a w eek at work. A lthough V ince's
exam ple w as less extrem e, m o st likely because he participated in a
1 02
partial day program as an outpatient, he also found m ost of h is tim e to
be d eterm ined by o th ers w hile enrolled in UCLA’s program .
H ow ever, m an y unhospitalized adolescents m ay feel a lack of
control regarding decision m aking. Frequently, they are guided by
parental a n d other ad u lt sources. Despite the age appropriate feelings
of lack of control, these adolescents experienced additional restraints.
For exam ple they encountered doors they could n o t open w ith o u t a
staff m em ber first unlocking them , they functioned in large group
settings w here they w ere u n d er close observation, and M elanie n oted
th at her personal goals (e.g. w riting a letter) were often in terru p ted by
scheduled program activities.
Degree of control can be an im p o rtan t m otivational factor. Even
for healthy teens, o n e study (Csikszentm ihalyi & Larson, 1984) fo u n d
the general pattern to be th at adolescents are least m o tiv ated w hen
doing things they h a v e to do in order to become productive adults.
C sikszentm ihalyi & Larson (1984) stated:
It is apparent th at the low est m otiv atio n occurs in those places
w hich are m ost structured by adult society (class, job, school
halls, school library, church) and the highest m o tiv atio n occurs
103
in those w hich are furthest from adult control (the student
center, the lu nchroom , the basem ent, parks, an d friends'
hom es) (p. 89).
Fam ily interaction.
C hristine an d M elanie, w ho w ere hospitalized on inpatient
units, spent reduced am ounts of tim e w ith their family. For C hristine
this also m eant m issing Catholic m ass and healin g services, w hich she
regularly attended w ith h er fam ily each m onth. A lthough daily
visitation h o u rs an d scheduled passes w ere offered by the hospital,
C hristine experienced significantly less tim e w ith her fam ily as
com pared to liv in g at hom e.
M elanie expressed m issing h er seven m o n th old baby. Her
fam ily lived 130 m iles away from UCLA, w hich lim ited visits an d tim e
w ith her son to two tim es a week. D uring the interview s, M elanie
often spoke of her son and expressed sadness du rin g this tim e of
necessary separation from h im .
T ransportation.
T ransportation became an issue during hospitalization for the
adolescents an d their fam ilies. For m onths, Vinoe spent u p to a total of
104
three h o u rs a day w aiting for the bus and com m uting through the
heavily congested streets of Los Angeles to and from the partial
p ro g ram .
M elanie's fam ily also lived a significant driving distance away
(130 m iles) from the hospital, requiring six h ours round trip in the car
two tim es a week for six weeks. C hristine's fam ily drove over 35 m iles
for a few weeks to visit their daughter as well.
At hom e, Vince was able to drive the fam ily's autom atic car,
fortunately n o t a stick shift. Because of the one-hand-to-the-face
posture he consistently held in public, he only had one h an d free w ith
w hich to operate the car. A ny changes in his driving habits at hom e,
should they hav e occurred, w ould have been the result of h is illness
an d n o t directly due to hospital stay.
School an d work.
V ince's grades dropped prior to hospitalization reportedly due to
h is Obsessive-Com pulsive Disorder. He said regarding h is grades, "A t
first, they were good. I got real good grades, an d then w hen I started
h a v in g really OCD... I started getting like C s an d D 's and stuff." In fact,
he com pletely stopped attending school once th e illness became severe.
1 05
However, onoe in the hospital, he was again able to participate in his
student occupations for the alloted three h o u rs a day. He reported that
the hom ew ork load was lighter an d the content easier w hen compared
to the level of w ork expected in the high school he was attending in
Los Angeles.
C hristine also noted less assigned hom ew ork required in the
hospital. H ow ever, her overall stress level regarding school appeared
to rise in the hospital, because C hristine w as pulled away from her
course w ork in progress. She fell behind in h er studies after the onset
of Lupus and subsequent m edical an d psychiatric hospitalizations. One
of her m ost im portant goals, over which she expressed consistent
concern, was being able to graduate on tim e w ith h er high school class.
The hospitalization stay caused Christine to rethink her plans. She
intended on adding m ake-up tim e via su m m er school and by taking a
larger class load h er senior year. C hristine's disorder and
hospitalization stay affected h er school plans and created a great
am oun t of concern regarding her goals in this area.
M elanie noted how h e r occupation was affected in the area of
work. She was recently hospitalized for m edical and psychiatric needs,
1 06
like C hristine, a n d subsequently w as unable to w ork h er 20 h o u rs per
week. D ue to h e r diagnosis of A norexia N ervosa an d pregnancy,
M elanie was hom eschooled two to three h o u rs a day. Once
hospitalized, the a m o u n t of school h o u rs per day did n o t drastically
change. H ow ever, w ith in the hospital setting, school was held w ith a
group of peers in a highly structured form at and predictable hours.
T his w as different in contrast to h e r recent private, in-hom e schooling.
Leisure a n d sports.
Leisure a n d sports activities were provided by the rehabilitation
staff at UCLA NP1 & H. In specific cases, such as M elanie, the A -South
treatm en t team lim ited the a m o u n t of exercise w hen decreased body
weigh* w as an issue of concern. T he purpose of this strategy was to
relay the message th a t one m u st focus on health and eating over the
obsessional desire to lose w eig h t T hus, M elanie w ent from several
h o u rs of daily w orkouts at hom e to a restricted, m o n ito red sports and
exercise regim e w ith in the hospital.
V ince an d C hristine w ere n o t restricted from the therapeutic
recreational activities. H ow ever, C hristine participated w ith a low
level of intensity due to pain an d sw elling of inflam ed joints. She also
107
com m ented about an occupation inaccessible to h er in the hospital
sta tin g ," I w ish 1 could bring m y rollerblades in here an d skate around."
Sim ilarly, although she h ad access to the use of a p iano at tim es on the
u n it, piano lessons were also tem porarily postponed d u rin g
hospitalization.
V ince's participation in sports w as n o t im peded d u rin g h is
hospital stay. H ow ever, the m an n e r in w hich he participated, using
one free h an d , w ill significantly im pact h is in v o lv e m e n t in fu tu re
occupations and team sports. T his w ill be described in a later section of
th is chapter.
Personal focus.
As a result of their disorders, the focus w ithin these adolescents'
personal liv es took a shift. N ew feelings an d goals w ere created in
response to their illness an d hospitalization.
i
For exam ple, V ince adm itted to th in k in g about death m u ch of
the tim e, reporting that it was alm ost constantly on h is m in d . He
explained:
I feel m yself being m ore lim ited, ju st n o t being able to do...like as
free as I was before, ju st doing w h at I w ant. A n d I'm always
108
w orrying about som ething, p] w orry about m y parents m ost of
the tim e.— It's like, I d o n 't know , th at's part of m y OCD. O r I
th in k so m e th in g 's going to happen to [my parents]....They could
get into an accident or som ething like that.
A frequent occupation for Vinoe was spending tim e th in k in g about his
goals for w ellness in o rder to reach a level of functional health in h is
life.
D uring a conversation about religion, C hristine was asked by
Laura if she fielt angry tow ards God because of h er Lupus. She
responded, "I used to, but I sh o u ld n 't, an d it's not...G od to blam e. I
m ean, th a t's w hy Tm starting to go to church m ore often and read
m ore and, /k n o w , inspirational things— God— read the Bible." T hus,
the focus w ith in h e r personal life and thoughts became increasingly
spiritual due to h e r illness.
Included in M elanie's disorder, A norexia N ervosa, was an
increased em phasis on h ouse cleaning, exercise, and other
com pulsions such as frequent face w ashing a n d teeth brushing.
H ow ever, once hospitalized, sh e was unable to participate in these
activities to die sam e degree. H er weekly goal became being w ell
1 09
enough to be allow ed to choose h e r ow n food. She reported th at h e r
daily goal was to, "Maybe try to talk m ore, instead of ju st sittin g there
and w aiting for them to ask m e som ething. T h at's m y goal alm ost
every day [laughing]...to talk in c o m m u n ity m eetings."
In addition, as a result of th e in terv iew questions posed to them
du rin g this study, the adolescents noted an increase in th e a m o u n t of
tim e they spent th in k in g about th eir goals an d contem plating w here
their lives were headed.
Goals Delaved
All of the adolescents adm itted to at least one goal p u t on h o ld
due to their disorder an d resultant hospitalization. T he degree of
aw areness of th is fact v aried drastically.
On one e n d of the c o n tin u u m , M elanie did n o t rep o rt any
change in h e r life structure or effects of hospitalization o n h e r daily
occupations. Sim ilarly, she did n o t see h e r baby as affecting h e r future
or changing h e r future goals. A lthough she denied that h e r illness
affected h er goals, she verbalized, "It's ju st affected m e n o w .”
H ow ever, w h en I specifically asked for goals p u t o n h o ld d u rin g
hospitalization, it was clear th at M elanie h a d to delay getting h e r
110
d riv e r's license, w hich she w as scheduled to test for the week she
arriv ed at UCLA N PI & H.
V ince discussed w hy getting a d riv e r's license was low priority to
h im :
Vinoe: It is like a goal, but it's like one of the last things I'm
really th in k in g about. T here’s a lot of things going on in m y life.
So w hen I ju st can harely take this th in g off m y face an d stuff like
that, I'll just, th en {italics added) Til deal w ith everything else.
Laura: So y o u 're concerned about o th er issues first?
Vince: Yeah, th in k about the future later.
In contrast to focusing on goals outside of h is illness, V ince's goals
rev o lv ed a ro u n d ridding h im self of OCD. Sim ply finishing his senior
classes became h is biggest goal for the year and one th at w o u ld be
difficult to attain considering h is illness a n d length of hospitalization.
Like h e r peers, C h ristin e's d riv e r's license attain m en t w as also
postponed. She revealed a stark aw areness of the unpredictability of
h e r disease but appeared to feel m o re comfortable w ith topics of the
present versus the uncertainty of h e r future. Her present goals became
focused on the v ery basics. She shared h e r goals, w hich w ere, "Just to
1 1 1
go hom e, an d get well, [and] go hack to school."
F uture O ccupations
These teenagers m ay be expected to en counter difficulties w ith
their future occupations. T heir lives h ad already been affected and
th eir daily occupations d early altered by illness and psychiatric
hospitalization. D epending on th e progress of th eir illness a n d
a m o u n t of hospitalization required, th e adolescents can expect to
encounter further occupational obstades in th e future.
Vince was the m ost verbal regarding th e effects of OCD on h is
future. For exam ple, his grades h ad fallen at school, w hich h e
attributed to h is illness. He interpreted this as an obstade to achieving
college status as well. He explained, "It affects m e right now , ...but
especially w hen I graduate [from] high school, an d I h a v e to go to
college and everything. Tm gonna need two hands ju st to carry m y
books. It'll affect m e a lot." His concerns w ere n o t fin an tial n o r
academic, but rather, functional.
In addition, V ince expected h is illness to influence h is dating
life, even though h e dem onstrated an attractive personality. H e was
112
surprised th at girls w anted to date him w ith in th e hospital setting. He
exclaim ed, " ’Cause, m an , I w o u ld n ’t go w ith som eone I...can't even
see.” H is hand-over-the-face p o stu re created an intim acy barrier for all
w ho encountered h im , w ith any facial expression hidden below the
level of h is nose. O ther patients an d the hospital staff, along w ith
myself, m ost likely h ad n e v e r seen V ince’s face.
V ince h o p ed to participate in organized sports team s outside of
the hospital setting. H e dem onstrated excellent skills in boxing and
basketball ev en w ith h is OCD sym ptom s. H ow ever, he h ad to
postpone h is p lan s for team sports, recognizing the fact that h e m u st be
w illing to use tw o h an d s in o rder to com pete.
C hristine, diagnosed w ith Lupus, did n o t describe w hat h e r
future occupations m ig h t look like. She was, how ever, w ell aware of
the unpredictability of h e r disorder an d th e role that unpredictability
m ay play in h e r future. Her m ood changed, an d she became
despondent w h en the issue was discussed in the th ird interview as
described in th e p lan n in g section of fu tu re orientation in th is chapter.
After a period of silence, I asked if it w o u ld be best to m o v e on, and
C hristine agreed.
1 1 3
In contrast, M elanie did n o t anticipate any changes in h e r fu tu re
occupations due to her illness. In fact she did n o t identify any daily
activities that m ight in h ib it the attain m en t of h e r goals. She w as quite
optim istic regarding h e r long term plans, and yet she did n o t identify
the building-block steps necessary in attaining h e r goals. S he w as a
new m other, liv in g at h o m e w ith her parents, and fighting A norexia
N ervosa. Clearly she w ould be faced w ith the challenges of creating a
fam ily, m ain tain in g a relationship w ith h e r boyfriend, a n d attem pting
w ork a n d college courses sim ultaneously. A lthough she h a d desires to
become a physical therapy assistant, the steps necessary to m ake that
dream possible h a d n o t been initiated yet. In m y clinical experience,
m ost late adolescents, if n o t developm entally challenged, hav e begun
to th in k about the details necessary for preparing for college an d career.
Pre-college exam s, college visitation, an d selected coursew ork in
anticipation of college all take place at th is tim e. M elanie’s future
occupations w ill m ost likely be affected ev en if she does n o t identify
that as a present conoem . The possible positive effects of th is coping
strategy are discussed in chapter five.
In conclusion, if the daily occupations of these adolescents
1 14
continue to be affected by illness an d hospitalization, it is likely th at
occupations w ill be affected in th e future, d a r k et al. (1991) even
included an exam ple of potential research topics in occupational
science as "the contribution of childhood occupations to ad u lt
com petency and ach iev em en t m otivation" (p. 303). T here is m ore
than likely a relationship to be discovered betw een childhood
occupations and fu tu re ones.
T his chapter focused on the findings th at em erged from the data.
Each adolescent p ro v id ed an in d iv id u al picture of a person struggling
w ith a psychiatric disorder w ith in a hospital se ttin g T hey defined the
term "future" in th eir ow n w ords a n d gave th eir perspective on the
way they see th eir future. A s a result of th eir hospital stay, th eir daily
occupations have been radically affected in six categories specifically:
(a) degree of control, (b) fam ily interaction, (c) transportation, (d) school
and w ork, (e) leisure a n d sports, an d (f) personal focus. The
adolescents' future occupations m ay c o n tin u e to be affected as th eir
n u m b er o n e priority for w ellness supercedes other goals in the areas of
affiliation, career, a n d independence. T im e, along w ith the
adolesoents' sense of w ellness an d d eterm in atio n , w ill tell.
115
CHAPTER FIVE
S um m ary, Discussion, an d R ecom m endations
Summary
The purpose of this investigation was to explore the fu tu re
orientation a n d daily occupations of adolescents hospitalized for
psychiatric disorders. Three adolescents, ages 16 to 17, participated
in d iv id u ally in three separate in-depth interview s. Interview and
observational techniques w ere utilized du rin g th e qualitative research
process, w hich was guided by Lincoln an d G uba's (1985) m eth o d of
naturalistic in quiry and presented by blending n arrativ e analysis
(P olkinghom e, 1988).
T he data were coded, grouped, an d analyzed w hile m easures
e n su rin g trustw orthiness of th e E ndings were applied in four areas: (a)
credibility; (b) transferability; (c) dependability; and (d) confirm ability.
P atterns a n d relationships ev o lv e d d u rin g the analysis of the subjects'
fu tu re o rien tatio n and daily occupations.
N u rm i's (1991) future orien tatio n description, consisting of
m o tiv a tio n , p la n n in g and ev alu atio n , pro v id ed the fram ew ork for
1 1 6
this study. It allow ed m e to observe adolescent fu tu re perception
w ithin a structured process.
Occupation was defined as purposeful activity m aking u p o n e's
daily life (USC, 1991). O ccupational changes due to illness and
subsequent hospitalization w ere discussed in several categories: (a)
degree of control; (b) fam ily interaction; (c) transportation; (d) school
and work; (e) leisure an d sports; an d (f) personal focus. The
descriptions the adolescents contributed regarding th e ir occupations at
hom e an d in the hospital w ill certainly be of interest to th e fields of
occupational therapy an d occupational science.
Finally, the results w ere com piled and th e conclusions and
recom m endations shall now be m ade.
D iscussion
The adolescents described th eir fu tu re as seem ingly far off in
tim e; literally, a m atter of years. By th eir responses, the participants
appeared to be living in the present. C hristine h a d difficulty discussing
the future, becom ing em otionally distraught o v e r the uncertainty of
h e r illness. M elanie casually spoke of lofty dream s w ith o u t realistic
117
plans to back them up. V ince w avered between fearful a n d determ ined
ev alu atio n s of h is future.
O ne interpretation for the way these adolescents distanced
them selves from th e future by focusing on daily life, was that they
fo u n d a way to cope w ith th eir illness. By concentrating on the present,
they m ain tain ed th eir goal for health a n d sim ply put their dream s on
h o ld for a later tim e. O vercom ing their disorder became th eir num ber
one priority for a tim e, inhibitin g the progress of other goals in the
areas of love an d affiliation, career, a n d independence.
C sikszentm ihalyi an d Larson (1984) gathered 4,489 self reports
from 75 high school students in their study. They found th at the
adolescents identified being w ith friends as the m ost chosen and
desired activity. In contrast, the adolescents in th is study ranked love
an d affiliations goals always secondary to health and in som e cases after
am bitions in the areas of career and independence.
D ream s a n d goals such as participating in team sports, finishing
high school, an d obtaining a d riv er's license were delayed for these
three adolescents. T his m ay h a v e added stress to the lives of these
adolescents. A s defined by Com pas a n d W agner (1991) " the m ean in g of
1 1 8
a stressful e v en t is represented in the goal [italics added] of the
in d iv id u a l that h as been threatened, challenged, or lost....M uch or
m o st behavior that is significant in an in d iv id u a l's life is m otivated
tow ard a goal" (p. 80).
On the other hand, pu rsu in g anv [italics added] goal can bring
order an d organization to one's life, because it causes a person to focus
th eir attention on the task at h a n d an d n o th in g else (C sikszentm ihalyi,
1990). In th at respect, striving for health above ail o th er goals can be
positive. Csikszentm ihalyi (1990) w en t so far as to claim , "W h en we
choose a goal and in v est ourselves in it to th e lim its of o u r
concentration, w hatever we do w ill be enjoyable" (p. 42).
A lthough putting m ost all o th er goals on h o ld except the
attain m en t of health, the adolescents did n o t, out of futility, give u p
th eir lifelong goals. T hough th eir dream s m ay h av e been far away or
i
unrealistic at the tim e, they continued to dream . T hey w ere highly
m o tiv ated to conquer th eir illness and face the present obstacle.
Sim ilarly, in a study of non-hospitalized high school students,
C sikszentm ihalyi an d Larson (1984) fo u n d th a t "despite deficits in th eir
m o tiv atio n * a lack of harm o n y betw een goals - teens usually report
1 19
em otion al harm ony. They m igfit n o t be com m itted, but they are
reasonably content" (p. 87).
T he adolescents d early indicated that th eir daily occupations
w ere altered considerably due to th eir illness an d subsequent
hospitalization. C hanges w ere m ade in a variety of areas in d u d in g
fam ily interaction, transportation, school, and leisure activities. One
category, discussed in chapter four, was a decrease in personal control
since hospitalization. Decreased personal control w as inevitable
w ith in a psychiatric setting in order to enhance h ealth y developm ent
in a safe en v iro n m en t. T hus, due to the n atu re of the institution,
patients undoubtedly experienced less control o v er th eir occupations
the hospital setting.
It appeared th a t their tim e an d energy rev o lv ed a ro u n d their
first priority, to becom e healthy. The occupations these adolescents
engaged in w as indicative of th eir m ain focus and goal. These daily
occupations m ay play an im p o rtan t role in fire degree of health the
adolescents u ltim ately m aintain. "The difference betw een confident
a n d productive adults an d disillusioned ones is to be found in how
they [adolescents] experience th eir day-to-day activities"
(Csikszentm ihalyi & Larson, 1984, p. 5).
Q uestions regarding causal relationships arose. For exam ple, did
the teens decide to focus on the present as a coping m echanism , w hich
forced th eir attention onto th eir present need for health; or w as it the
unavoidable shift in occupations rev o lv in g a ro u n d health issues that
created the focus of th eir goal for wellness; or finally, was it som e
com bination of the two? The scope and purpose of th is study was n o t
to answ er these questions but to create them for fu rth er investigation.
A lthough the shift in daily occupations after illness and
hospitalization became e v id e n t through this study, the aw areness of
that fact still varied am ongst the subjects. For exam ple, M elanie did
n o t directly acknowledge changes in h e r occupations. She was also the
m ost casual regarding h e r future w ith an abundance of goals but few
specific plans leading to actualization of fu tu re am bitions. The lin k
between daily occupations an d future orientation in h e r case w as that
h er decreased aw areness of daily occupational changes paralleled h e r
idealistic evaluation of h er future a n d cursory focus on planning. H er
m otivation was intact, but the tools w ith w hich to carry it o u t a n d the
realistic anticipation were n o t at die tim e of th e interview s.
121
In contrast, V ince and C hristine w ere m ore aware of the changes
in th eir daily life brought about by their illness. This realization, on a
daily, p resent level, appeared to have lead to m ore thoughtful
p lan n in g w ith an uncertain ev alu atio n of the future. H ow ever, their
m ore sober outlook regarding th e future took its toll em otionally, to
the p o in t w here C hristine em otionally sh u t dow n w hile discussing her
future.
In all cases, m o tiv atio n w as geared tow ards attain in g health w ith
the hopes of m eeting th is goal as soon as possible. Sim ilarly, th e three
teens all focused m ain ly on th e present, defining the fu tu re as farther
off in tim e. The degree of p lan n in g an d evaluation varied, how ever,
as w ell as the aw areness of changes in daily occupations.
The adolescents' plans reflected th eir present focus as they took
each goal an d trial one day at a tim e. In a sim ilar study of ten adults
with schizophrenia, nearly h a lf stated a preference for im m ediate or
proxim al p la n n in g (Suto & Frank, 1994). They m ade alm ost identical
com m ents as th e subjects studied here by revealing "I ju st take it day by
day” or "I ju st take it as it comes" (p. 14). Can we expect both children
and ad u lts to engage in present, im m ediate p lan n in g as a m eans of
1 22
coping w ith psychiatric illness? T his question dem ands fu rth er
research a n d will profoundly affect the degree of fu tu re p lan n in g
clinicians and researchers can expect from those w ho are experiencing
m en tal illness.
In sum m ary, it is hoped for the adolescents th at a positive
experience can still arise from th eir encounter w ith a psychiatric
disorder. They are learning how to choose am ong goals, h o w to
persevere, how to h av e patience, a n d ho w to recognize th e challenges
of life an d enjoy m eetin g them (Csikszentm ihalyi & Larson, 1984).
Even am idst difficult circum stances, m ean in g in life can be found.
C sikszentm ihalyi (1990) com m ented on tim es w hen one is com pletely
in v o lv e d and focused on a goal [optim al experience):
G etting control of life is n e v er easy, an d som etim es it can be
definitely painful. But in the long ru n optim al experiences add
u p to a sense of m astery — or perhaps better, a sense of
participation [italics added] in determ in in g the co n ten t of life —
th at com es as close to w hat is usually m ean t by happiness as
anything el9e we can conceivably im agine (p. 4).
T hrough th is qualitative study, adolescents h a v e been attended
1 2 3
to as a therapeutic relatio n sh ip was tem porarily established (See
A ppendix D). T he im portance of listen in g to adolescents1 view points
is described eloquently below:
A ttending to adolescents' v iew p o in ts does m ore...than sim ply
provide us w ith interesting data or inform ation for use in
im p ro v in g in terv en tio n s. M ore im portantly, it supports the
underlying p hilosophy that the beliefs and attitudes of youth are
in h eren tly im p o rtan t an d w orthy of consideration. Such a
philosophy suggests th at we n o t o n ly ask but also listen to
adolescents, include them in discussions relev an t to th eir lives,
and allow them to participate in decision-m aking forum s. In
doing so, we unequivocally dem onstrate to adolescents th at they
are valuable participants in th eir social en v iro n m en t. These
messages m ay be am o n g the m ost crucial ones we com m unicate
to youth in order to prom ote th eir healthy developm ent
(M illstein, 1993, p. 114).
R eco m m en d atio n s
It m ay be im p o rtan t to observe h o w th e adolescents alter their
124
fu tu re orientation as they eith er m eet or fail to m eet the goals they
h av e created in the tim e fram e they expect. For exam ple, if V ince is
n o t able to rem ove the cloth from h is face w ith in the year, w ill h e alter
his ev alu atio n of the future a n d change the length of tim e in w hich h e
expects to m eet that goal? Or w ill it ultim ately affect h is m o tiv atio n
and interest in accom plishing the task, creating discouragem ent and
cycle of resignation? C sikszentm ihalyi & Larson (1984) fo u n d data to
support th at w hen the p u rsu it of personal goals becomes im paired,
adolescents can lose interest a n d m otiv atio n in the tasks set before
them . T hus the results of V ince's daily occupations m ay significantly
affect his v iew of the future.
F urther questions to explore arose as a result of this study;
1. H ow does the future orientation an d daily occupations of
hospitalized adolescents differ from non-hospitalized adolescents?
2. Do non-hospitalized adolescents h o ld the sam e definition of
the future an d personal goals as the teens w ho participated in this
study?
3. As an adolescent, w hich allow s for best adaptation to life an d
later realization of goals: a h ig h ly optim istic or sober ev alu atio n of th e
12 5
future?
4. W ith further observation, or in another setting, does
aw areness of changes in daily occupations affect adolescents’ p lan n in g
and evaluation of the future?
"The im portance of developing students' aw areness of the
future should be a priority for today's educators" (M orris, 1992, p. 178).
This applies in the field of health an d psychiatry as well. The
relationship between adolescent fu tu re o rien tatio n and daily
occupations is an im p o rtan t n ew field for research. Occupational
scientists and occupational therapists w ill play an im p o rtan t role in
determ ining the daily occupations in adolescence an d h o w it relates to
their perception of the future.
126
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136
APPENDIX A
D escription of Study
D ecem ber 1992
A QUALITATIVE STUDY O N THE RELATIONSHIP OF THE FUTURE
ORIENTATION A N D DAILY OCCUPATIONS OF ADOLESCENTS IN
A PSYCHIATRIC SETTING
The goal of m y study is to discover how the fu tu re orientation of
adolescents in a psychiatric in stitu tio n is related to th eir day to day
occupations. It is a qualitative study, guided by the m eth o d of
N aturalistic Inquiry (Lincoln & Guba, 1985). I w ill look at them es,
arising from th e data, w hich w ill be collected through interview and
observation.
I am p lan n in g a series of three interview s of no m ore than 60
m inutes each. A tape recorder w ill be used, w ith the know ledge and
consent of th e patient, so th a t the interview s m ay b e transcribed and
analyzed in detail. The first in terv iew w ill address th eir future
orientation, du rin g w hich I w ill ask such questions as:
1. W h a t are your fu tu re academic, vocational, an d personal
goals?
2. W h a t kind of hopes a n d fears do you h av e in regards to your
1 37
fu tu re?
3. W h at h av e you done to reach your goals?
T he second interview w ill focus on their daily occupations- By
occupations 1 m ean "chunks of purposeful activity th at m ake u p our
days" (USC, 1991, p. 1). The adolescent m ay fill o u t a 24 h o u r activity
log of a typical day as well as be asked the follow ing questions:
1. W h at hobbies and special interests do you have?
2. Describe a typical w eekend schedule.
3. W h at is your favorite way to spend your tim e?
T he th ird in terv iew w ill aim to connect the two topics, future
orientation an d daily occupations. P revious in terv iew m aterial will be
clarified an d the adolescent w ill be given the chance to respond to
other an o n y m o u s study m em b er's input.
I w o u ld like to begin by in terv iew in g a patient in Partial
H ospitalization. I w ill talk to team m em bers and read th e chart for
fu rth er background inform ation. D iscussions w ith the parents m ay
add to th e reliability of the subject's testim ony as well. H ow ever, the
m ajority of in fo rm atio n will be obtained th ro u g h the th ree interview
sessions w ith th e adolescent
1 38
A ll of m y interview m aterial falls w ithin th e dom ain of
occupational therapy [OT]. The clinical findings w ill be relayed to team
m em bers as OT findings and, if necessary, progress notes can record the
results of m y detailed analysis of occupational function. 1 w ill rem ain
in the role of occupational therapist to th e adolescents, rath er than
"researcher". The adolescents w ill be told that, as an OT, I am
interested in th eir experience of daily activities and th eir ideas on the
future. This study will add to th e base of u n d erstan d in g regarding
future orientation as related to occupation and applied specifically to
these hospitalized adolescents.
T he subjects m u st be verbal adolescents of 16 years or older.
A lthough the adolescent m ay h a v e developm ental delays, I w ill n o t be
considering those w ith m ental retardation. The adolescent w ill be
in fo rm ed of all expectations required a n d m u st be w illing to participate
in three tape recorded interview s. O bservations w ill be n o te d d u rin g
interview s an d regular OT sessions. A n anticipated total of 5-10
adolescents w ill be recruited for th e study. H ow ever, I w ill be u tilizin g
purposeful sam pling techniques (Lincoln & Guba, 1985) w here the
sam ple size is determ ined by in fo rm atio n al considerations. 1 am
1 39
anticipating adolescents w ith w hom I am fam iliar, either on A -W est or
those transitioned to Partial H ospitalization.
I h a v e included a copy of the first chapter of m y thesis, w hich
defines the purpose an d im portance of m y study.
Laura N elson, OTR
(310) 825-0161
R eferences
Lincoln, Y.S. & Guba, E.G. (1985). N aturalistic inquiry. Beverly Hills,
CA: Sage.
U niversity of S outhern California. Dept, of Occupational Therapy
(1991). O ccupational science at U SC USC Occupational Therapy
& Occupational Science, 1 (1), 1-7.
1 4 0
APPENDIX B
O ccupational A ctivity Log
ACTIVITY LOG
N a m e___________
Day______________
Date______________
A ctivity Description C o m m e n ts
5:00 am_____________________________________________________________
&QQ_______________________________________________________________________________
7M ______________ __________________________________________
mi__________________________________
9 M _______________________________________________________________________________
i s m_________________________________
11:00_________________________________________________________________
N oon________________________________________________________________
1M _______________________________________________________ L .
2M ________________________________________________________
mi__________________________________
mi _______________________________________________________________________________
mi__________________________________
_______________________________T u rn over to com plete harlcsidp pleaap.
141
A ctivity D escription
5;W pm_____________________
C o m m en ts
m i
2 M .
m i
m i
m m.
11:00
Midnight
i m .
z m .
£QQ_
i m .
m i
142
APPENDIX C
Letter of A ttestation
I m et w ith Laura N elson on A ugust 26,1994 to participate in an
external a u d it T he purpose of th is au d it was to review the m easures
Laura h ad taken to establish trustw orthiness in h e r m aster's thesis
study. W e discussed the process of data collection an d analysis and
exam ined the follow ing docum ents: (a) audit trail notes; (b) categorical
codes; (c) triangulation notes; (d) m ethodological steps; and (e) critical
sections of the final diesis draft. It was apparent th a t Laura paid careful
attention to each phase of the process from the literature review a n d
fram ew ork guiding the interview s to th e m an n e r in w hich the
interview s were carried o u t an d analyzed. Upon ex am in in g L aura's
audit trail, it w as d eterm ined th at she im p lem en ted several m eth o d s to
ensure the trustw orthiness of h er study, and th at the findings clearly
em erged from th e data.
In L aura's study she explored an issue that is highly rele v an t to
the field of occupational therapy regarding die fu tu re o rien tatio n a n d
daily occupations of adolescents. Laura interview ed adolescents in a
psychiatric hospital in order to gain insight into th e ir perceptions on
1 4 3
the topic. The findings she obtained w ere both unprecedented and
unexpected.
T he credibility of these findings was enhanced by the rapport
w hich she established w ith the adolescents. Laura, unaw are that they
w ould later participate in h e r study, adm inistered the initial
occupational therapy ev alu atio n s to each of the adolescents. The
adolescents appeared to h a v e enjoyed and gained therapeutically from
the interview s. T his level of com fort, in addition to her established
rapport over tim e, facilitated h o n e st and frank responses from the
adolescents. T hus, a relatio n sh ip w as established w ith die participants
of the study, w hich was critical to the tru th v alu e of the findings.
Laura m et w ith h e r peer debriefer several tim es, form ally and
inform ally, to discuss personal biases and feelings as well as details
regarding the study design. P h o n e conversations an d m eetings were
h eld w ith h e r thesis chairperson regarding the em erging them es an d
findings. She an d I, the external auditor, frequently m et d u rin g each
phase of the study. T his constant reflection an d critical analysis w ith
colleagues p ro v id ed the fo u n d atio n for obtaining results of
o u tstan d in g caliber.
144
Laura adhered to the m ethods suggested by Lincoln & Guba
(1985) to ensure the credibility, transferability, dependability, and
confirm ability (Krefting, 1991) of h e r study. These m ethods included
the follow ing: (a) triangulation; (b) m em ber checking; (c) peer
debriefing; (d) reflexivity; (e) detailed description of data collection and
analysis; and (f) an external audit trail.
In sum m ary, after review ing L aura's data, findings, an d
interpretive process, it is m y im pression that she h as m ore than
included the necessary steps to ensure the trustw orthiness of the study.
Elisabeth A nderson, M A, OTR
Elisabeth A nderson is exceptionally qualified to act as external auditor
for th is qualitative study. She was recom m ended by Dr. Florence d a r k ,
PhD, OTR, FACT A, the chairperson and advisor for this thesis, an d
accepted by th e com m ittee m em bers to carry o u t th is function. She
received h e r M aster of A rts degree in occupational therapy at th e
U niversity of Southern California in 1993. She is a professional peer
14 5
w ith experience in the m eth o d of naturalistic inquiry (Lincoln & Guba,
1985). Her firsthand know ledge of qualitative research u tilizing
naturalistic inquiry provided h e r w ith a keen aw areness of the
im portance an d role of an external auditor. H ow ever, h e r theoretical
and practical occupational therapy experience created an objective po in t
of view . At the tim e of the study she was em ployed at the Ayres Clinic
in Torrance, California as a Staff Occupational T herapist w orking w ith
children w ith disabilities in a sensory integration setting.
146
UNIVERSITY O F CALIFORNIA, LOS ANGELES
BERKELEY • DAVIS * IRV INE « LOS ANGELES ■ RIVERSIDE * SAN D1ECO • SAN FRANCISCO
UCLA
SANTA BARBARA • SANTA CRUZ
NEUROPSYCHIATRIC INSTITUTE AND HOSPITAL
CENTER FOR THE HEALTH SCIENCES
700 WESTWOOD PLAZA
CONSENT FORM LOS a n c e l e s . C a l i f o r n i a #00241750
A Q ualitative Study on the R elationship of Future O rientation and
Daily Occupations of A dolescents in a Psychiatric Setting
Prim ary In vestigator: Laura (Laurie) Evon N elson
931 Dos Robles Place, A lham bra, CA 91801
(818) 282-5903
Faculty Sponsor: Florence d a r k , PhD, OTR, FAOTA
U niversity of S outhern California
D epartm ent of Occupational Therapy
1540 Alcazar St. #133, Los Angeles, CA 90033
(213) 342-2850
PURPOSE OF THE STUDY:
The purpose of m y thesis is to study the future orientation and daily
occupations of adolescents in a psychiatric hospital. In other words, I
explore relationships between ho w you view your future and w hat you
do everyday.
PROCEDURE;
I w ould like to use your interview m ateria), w hich you shared w ith m e
d u rin g o u r tim e together in 1993, in the content of m y thesis in partial
fulfillm ent of a m aster of arts degree in occupational therapy. T his w ill
require n o further interview s or w ork on your part. I am asking for
your perm ission to use the data w hich I collected to help people better
u n d erstan d adolescents' future perspective and goals and w hat they do
every day.
1 47
Consent Form - Page 2
RISKS:
The possible risk in v o lv ed w ould be accidental disclosure of identity
due to a breech of confidence by a health care w orker reading th e thesis.
BENEFITS:
There are no specific personal benefits in volved. H ow ever, therapeutic
gains m ay have been m ade as a resu lt of th e interview s, w here an
occupational therapist presented valuable questions regarding
plan n in g for the future and daily routines.
ALTERNATIVE OPTION:
Your participation is voluntary. You do n o t h av e to agree to these
term s and m ay choose n o t to participate in th is study.
CONFIDENTIALITY STATEM ENT:
The results of th is research m ay be published for th e inform ation of
other scientists, how ever, your n am e w ill be changed to in su re
confidentiality. I w ill send you a copy of the results for you to review .
If there is anything you are uncom fortable or disagree w ith, it can be
revised or deleted.
OFFER TO ANSW ER QUESTIONS:
A ny questions or concerns th at you hav e regarding your participation
in this study m ay be directed to th e prim ary investigator, Laura E.
N elson at 818-282-5903, or h er faculty sponsor, Dr. Florence Clark at 213-
342-2850. If you h a v e fu rth er questions regarding your rights as a
subject in a research study, you m ay contact the U n iv ersity of S outhern
C alifornia's Institutional R eview Board Office at 213-223-2340. You w ill
be given a copy of th is form to keep.
148
Consent Form - Page 3
COERCION A N D W ITHD RAW AL STATEM ENT:
Y our decision w h eth er or n o t to participate will n o t interfere w ith any
future care at the U niversity of California, Los Angeles
N europsychiatric Institute an d Hospital. You are free to contact the
investigator regarding any revisions of the thesis after signing the
consent form and before the final edition is printed.
INfUKY STATEM ENT:
N o financial rem u n eratio n is available for injury.
AGREEM ENT:
YOUR SIGNATURE INDICATES THAT YOU HAVE DECIDED TO
PARTICIPATE H A V IN G READ THE INFORM ATION PROVIDED
ABOVE.
S ignature of the Participant Date
S ignature of the W itness R elationship to the
P articipant
Signature of the Investigator Date
149
APPENDIX E
N o te from T ranscriber
UCLA N eu ro p sy c h ia tric In stitu te
H ospital a n d C linics
R oute S lip
Date: 7/14/93
To: Laura N elso n , OTR
C om m ents: I claim th is is in fact therapy, th erap eu tic, w ith th e rap p o rt
you get w ith these people. So m u ch la u g h te r, so m u c h w a rm th .
P hil
F rom : Clerical Services, C8-201
P hone: (310) 825-0268/825-0373
150
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Asset Metadata

Creator Nelson, Laura Evon (author)

Core Title A qualitative study on the relationship of future orientation and daily occupations of adolescents in a psychiatric setting

School Graduate School

Degree Master of Arts

Degree Program Occupational Therapy

Degree Conferral Date 1995-05

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health sciences, mental health,health sciences, occupational health and safety,OAI-PMH Harvest,psychology, personality

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Clark, Florence A. (committee chair), Frank, Gelya (committee member), Zemke, Ruth (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c18-7029

Unique identifier UC11357840

Identifier 1376494.pdf (filename),usctheses-c18-7029 (legacy record id)

Legacy Identifier 1376494-0.pdf

Dmrecord 7029

Document Type Thesis

Rights Nelson, Laura Evon

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA