Scandinavian Journal of Occupational Therapy

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Occupational balance from a clinical perspective

Brightlin Nithis Dhas & Petra Wagman

To cite this article: Brightlin Nithis Dhas & Petra Wagman (2022) Occupational balance from
a clinical perspective, Scandinavian Journal of Occupational Therapy, 29:5, 373-379, DOI:
10.1080/11038128.2020.1865450

To link to this article: https://doi.org/10.1080/11038128.2020.1865450

Published online: 31 Dec 2020.

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SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY
2022, VOL. 29, NO. 5, 373–379
https://doi.org/10.1080/11038128.2020.1865450

SHORT REPORT

Occupational balance from a clinical perspective

Brightlin Nithis Dhasa,b and Petra Wagmanc
a
Nova Southeastern University, Fort Lauderdale, FL, USA; bOccupational Therapy, Hamad Medical Corporation, Doha, Qatar;
Department of Rehabilitation, School of Health and Welfare, J€onk€oping University, Jonkoping, Sweden
c

ABSTRACT ARTICLE HISTORY

Background: Occupational balance is a central concept in occupational therapy and is com- Received 16 May 2020
monly defined as an individual’s perception of having the right amount and variety of occupa- Accepted 12 December 2020
tions in daily life. This individualistic and subjective nature of occupational balance brings with
KEYWORDS
it certain challenges when applied in practice. The aim of this discussion paper is to highlight
Community; external
the challenges associated with the lone application of individualistic occupational balance in perceptions; occupational
practice situations, and propose some way forward. patterns; occupa-
Methods: The Meleis’ Theory to Practice to Theory strategy was used. Practice-based vignettes tional therapy
were used as a point of departure to discuss these challenges. This was followed by theorising
the importance of including the others’ perceptions of a person’s pattern of daily occupations.
Conclusion: Besides a goal of increasing a person’s occupational balance in clinical practice,
striving towards creating a suitable pattern of daily occupations from a community perspective
also seems to be a relevant goal.

Introduction judgement. For example, an occupational therapist

Occupational balance (OB) is commonly defined as
an individual’s perception of having the right amount
and variety of occupations in one’s daily occupational
pattern [1]. Various authors have suggested that this
‘right amount and variety’ is desired among diverse
occupational categories such as work, play, leisure,
and rest [2]; physical, social, mental, and rest occupa-
tions [3]; relaxing, exacting, and flowing occupations
[4]; and challenging versus relaxing occupations,
occupations meaningful for oneself versus occupations
meaningful to others, and occupations intended to
care for oneself versus occupations intended to care
for others [5]. Although there are multiple opinions
on the type of occupations to be considered for
describing OB, there is consensus that OB is individu-
alistic [1,5–7]. OB is related to the overall health and
well-being, satisfaction with life, and low stress levels
[3,8–12], which makes it an important aspect to be
considered in clinical practice.
However, when OB is considered in the clinical
settings, its individualistic and subjective nature might
limit the consideration of any external perspectives.
This could be challenging, especially when clients
have cognitive deficits leading to errors in their
(OT), a close relative, or the community might
assume that there is a problem with an individual’s
occupational pattern, whereas the individual considers
himself/herself to have good OB. How does one help
a client who has lost the mental capability to deter-
mine the right amount and variety of occupations,
and seeks assistance in improving his/her OB? These
situations might necessitate external perspectives to be
added to the subjective perception of OB; however,
this is rarely discussed in the literature.
In this discussion article, we argue that the individ-
ual perceptions of OB might sometimes benefit by
being considered simultaneously with the external
perception of the occupational pattern by close mem-
bers of the community. The aim of this discussion is
to highlight the challenges associated with considering
only an individualistic occupational balance in prac-
tice situations, as well as propose some way forward.
Materials and methods
The method used in this paper can be described as
development of a theory in the broad sense, described
by Meleis as a Theory to Practice to Theory strategy
[13]. This method attempts to make an existing

CONTACT Brightlin Nithis Dhas brightlindhas@gmail.com Qatar Rehabilitation Institute, PO 3050, Occupational Therapy, Hamad Medical
Corporation, Doha, Qatar
ß 2020 Scandinavian Journal of Occupational Therapy Foundation
374 B. N. DHAS AND P. WAGMAN
theory practically useful, and begins by selecting a
theory to be used in practice and then using practice
to further refine the theory [13]. In this article, this
strategy is used to advance discussions on the prac-
tical applications of OB, by reviewing the current
publications on OB (theory phase) followed by a
description of two practice-based vignettes (practice
phase). The vignettes are used as a point of departure
for reflections on the challenges with the current con-
cepts of OB, when applied in practice. Thereafter, the
benefits of combining OB and external perceptions of
the patterns of daily occupation (PDO) is proposed as
a way forward in clinical settings. The method is also
similar to the Type 1 scientific inquiry described by
Mosey (1992), wherein theory and practice are used
back and forth, with an aim to develop a con-
cept [14].
Theory phase: literature review of
occupational balance
A literature search was conducted in CINAHL,
MEDLINE, and PsycINFO using the search term
‘occupational balance’, to review the current state of
OB research, and is summarised below. This was lim-
ited to articles that contributed to the theoretical
approach of OB. Articles that primarily aimed at find-
ing associations between OB and other factors, and
those that used other terminologies to describe the
balance of occupations in daily life were excluded.
Meyer [2] was the first to recognise the need for
balance between work, play, rest, and sleep for healthy
survival in his philosophy of occupation therapy in
1921. Since then different conceptualizations of OB
have been proposed. Some authors [3,4], following
Meyer’s legacy, conceptualised OB as a state of bal-
ance that could be attained by spending a certain pro-
portion of the time in different types of occupations
reinforcing the time use perspective of OB.
Qualitative studies aimed at primarily describing
OB, revealed the various occupational dimensions
that an individual needs to balance to perceive OB,
thereby supporting the individualistic perspective of
OB [5,15,16]. For example, from a qualitative study of
10 subjects with rheumatoid arthritis, Stamm et al. [5]
identified three dimensions in which an individual
needs to strike a balance: challenging versus relaxing
occupations, occupations meaningful for oneself ver-
sus occupations meaningful to others, and occupa-
tions intended to care for oneself versus occupations
intended to care for others. Yazdani et al. [15] identi-
fied that complexity, obligation-willingness, and
purpose-meaning are important occupational dimen-
sions that shape OB. While exploring the meaning of
the term OB among Iranian OTs, Yazdani, Roberts,
Yazdani, and Rassafiani [16] found four themes:
integrity in being, equilibrium in doing, contentedness
in becoming, and harmony in belonging. Other quali-
tative studies exploring the perception of OB follow-
ing conditions that basically change people’s PDOs,
such as retirement or onset of a physical disability,
found that people were able to restructure their PDOs
to reconstruct positive OB [17–20], implying that OB
is a relative state.
In addition to the use of time and individualistic
conceptualisation of OB, some authors found rele-
vance in the contribution of external social elements
on the perceived state of one’s OB. Wagman and
Håkansson [21] highlighted the importance of consid-
ering the perspectives of both the individual and
those around him or her in terms of how one’s OB
affects and is affected by others. Yazdani et al. [15]
stated that ‘the right occupational balance is not only
about an individual’s own satisfaction but it must also
follow the principle of no harm to others’ [p.295].
Yazdani et al. [16] suggested that a person’s occupa-
tions need to be in harmony with shared values of
the family and the community in order to perceive
OB. Clouston [22] maintained that general assump-
tions of a neoliberal market culture that favours paid
work over other types of occupations, force individu-
als to make occupational compromises that affect the
perception of OB.
Among other factors, time and financial constraints
were found to prevent new OT students from achiev-
ing OB [23]. Backman [24] suggested that societal
expectations specific to life phases, and occupational
restraints and opportunities extended by the specific
environment influence OB in addition to the personal
factors. Moreover, reports of experiencing poor OB
among carers of people with disability suggest that
external caring demands affect one’s OB [25–28].
Anaby, Backman, and Jarus [29], suggested that occu-
pational balance and imbalance are rather two distinct
dimensions that co-exist within an individual. Thus,
they added another theoretical angle to OB; however,
this perspective was not further discussed in
the literature.
Five review articles were found in the literature
that contributed to the definitions, theoretical con-
structions, and knowledge gaps in OB [6,21,24,30,31].
In terms of measurement, self-reporting has been the
sole method of assessing OB in quantitative research,
and standardised questionnaires [32–34] have been

developed for this purpose. One known exception to
the self-reporting method of assessing OB is the exter-
nal assessment of the client’s OB by the OT, based on
PDOs derived from activity diaries [35].
Temporal organisation of time, which can be
objectively observed through time use patterns, is
sometimes considered as an important aspect of OB
[36,37]. Essentially, patterns of daily occupations
(PDO) are seen as objective facets closely associated
with OB resulting from the same occupational inter-
actions, and the importance of addressing both, OB
and PDO simultaneously has been emphasised [6].
In summary, OB is theorised to be a perceived
state that is individualistic, relative, and being affected
by external social elements. OB is considered as a
subjective construct with PDO as its objective coun-
terpart. Although it is acknowledged that external ele-
ments contribute to the perceived state of OB and
one’s state of OB could affect others, the appraisal of
OB and PDO contributing to the state of perceived
OB is primarily considered from the individual’s per-
spective. There is a paucity in literature about the
external appraisal of an individual’s OB and PDO.
Practice phase: practice based vignettes
The current subjective and individualistic concept of
OB throws some challenges when applied in practice.
These challenges are formulated in the form of fol-
lowing vignettes. These vignettes were adapted from
real-life examples faced by the first author while
working in a city from Southern India, and will be
considered as a point of departure for further reflec-
tions and suggestions.
Naomi and Peter
Naomi and Peter are married and have a 3-year-old
daughter. In addition to a full-time job, Naomi is
pursuing her PhD through distance education. Peter
also has a full-time job and has his non-work time
filled with child-care occupations. He developed clin-
ical depression and was admitted to a hospital.
Among other issues, Peter’s discontentment with
Naomi’s daily occupational pattern was a major
source of stress for Peter. For instance, Peter felt that
Naomi could spend more time on child-care occupa-
tions. The couple was referred to occupational ther-
apy services. During the initial visit, Naomi’s scored
high on a self-reported OB question while Peter
scored less. Peter felt that Naomi’s occupational life
was imbalanced. He was concerned that Naomi’s cur-
rent schedule did not accommodate the expectations
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 375
of her family. On the advice of the OT, Naomi com-
pleted an occupational diary. Indeed, most of Naomi’s
day was devoted to work, or education related occu-
pations. Naomi acknowledged that the constraints of
a complex life situation with a lack of insight on the
impact of her occupational patterns on her spouse
has led to a false sense of good OB and neglect of val-
ued family occupations such as spending time with
her daughter. She was willing to make some compro-
mises to create an occupational pattern that is also
harmonious with the entire family, and reduce the
stress experienced by Peter.
Kumar and his family
Kumar has schizophrenia. Although Kumar has
recovered from the acute stage of illness, he continues
to have negative symptoms. Kumar’s father runs a
small shop and according to him, Kumar, being the
elder son in the family, is expected to take over the
business from him soon. However, Kumar does not
participate in the family business as he used to before
the illness; instead, he sleeps for most of the morning.
Kumar’s father has a pre-determined schedule for
Kumar based on his family norms, which include tak-
ing Kumar’s younger brother to school and buying
things for the shop in the morning, and spending
time with him in the shop in the evening. In addition,
he wants Kumar to maintain a good relationship with
his regular customers. Kumar could not complete a
self-reported measure of OB due to his cognitive limi-
tations. He acknowledges that his daily occupational
pattern lacks variety in occupations but at the same
time does not know how to create a better schedule
that promotes balance. However, he wants to fit in
with his community and be a good son to his father.
Hence, he would like to follow the expectations of his
father and his family. For the time being, Kumar pre-
ferred someone else to create a schedule that is also
in accordance to his family expectations, as this would
make him feel confident. As a long-term goal, he
would create his own schedule. Kumar’s father was
happy as Kumar acknowledged the family expecta-
tions and felt that he should create a schedule for
Kumar with the help of an expert. He was ready to
assume partial responsibility for helping Kumar to
maintain that schedule.
The vignettes were presented to contemplate on
some fundamental questions related to the concept of
OB as follows. What if a client considers his OB to be
right, but his/her context disagrees? What if a client
cannot decide the right amount and variation of
occupations to achieve OB? Who can decide the
376 B. N. DHAS AND P. WAGMAN
A more the client feels that external perceptions are
Intervenons focusing on external
consideraons of the clients’ PDO
B tary interventions focussing on externally acceptable
C no importance to the external perception of their
D OB might be sufficient. If a client expresses the need
E
Figure 1. Various levels of need for external PDO intervention
in a client.
‘right’ occupational balance: the client, an expert, or a
close community member? From the current concep-
tualizations of OB, seen through the review of litera-
ture, the client is solely responsible for determining
his/her OB, whether the context agrees or disagrees.
The vignettes portray situations wherein consideration
of individual perspectives of OB alone is insufficient.
Rather, a clinically useful goal could be to facilitate
the individual’s perception of OB as well as an occu-
pational pattern that is in line with the community
expectations or with that of significant others. In the
following section, a framework is proposed to facili-
tate such an outcome.
Theory phase: the benefits of combining OB with
an external perception of the PDO from a clinical
perspective
In situations where a client’s perceived state of OB is
challenged, the OT could begin by assessing the OB,
discussing the results with the client to make the cli-
ent aware of it, and thereafter, in collaboration mak-
ing plans for potential changes in the client’s
everyday life i.e. in the PDO [38]. However, when
necessary, this may be complemented by examining
the external perception of the client’s PDO, by identi-
fying the perceptions of significant others. When
there is a conflict between the client’s perceptions of
OB with his/her family members’ perception of the
PDO, or if the client’s PDO is clearly unhealthy
although the client is satisfied with his/her OB, an
intervention to recreate new PDOs based on external
inputs may be considered. The external inputs might
come from an expert OT and/or a close family mem-
ber. Since the PDOs created based on external inputs
should also be satisfactory to the client, consideration
of the level of significance the client attaches to the
external perception of his/her PDO is important. The
important, the higher is the relevance of supplemen-
PDO (depicted in Figure 1). For a client who places
PDO, interventions focussing solely on their personal
to live harmoniously within a community but is
unable to understand the influence of his/her PDO
on others in the community, a discussion on the sig-
nificance of this external perception is warranted, and
possibly creating a PDO that is personally satisfying
and acceptable to the community. When a client is in
a situation where he/she is unable to judge his OB, a
PDO based on external input could be considered as
a form of healthcare intervention in the short term,
while the long-term goal would be to enable the client
to create his/her own balanced occupational patterns.
In this way, the degree of importance that the client
attaches to the external perceptions of his/her PDO is
seen as a lens that helps determine the extent of inter-
ventional occupational therapy towards changing the
client’s OB and/or his PDO.
Discussion
The aim of this discussion paper was to highlight the
challenges associated with the lone application of
individualistic OB in practice situations. The solution
proposed is in line with the recommendations to sim-
ultaneously consider OB and PDO [6]. It is argued
that clients often live alongside others in the commu-
nity; hence, the perceptions of significant others about
the client’s PDO assumes significance for harmonious
living. When the external perceptions of an individu-
al’s PDO conflict with the individual’s self-perception
of OB, OTs may intervene by helping clients to create
socially harmonious PDOs that are also satisfying to
the client.
Individuals living together as families often negoti-
ate their daily occupations considering the needs of
others, to have a sense of balance [39]. It has been
reported that for both partners living together to per-
ceive high OB, mutual satisfaction of the division of
household work is necessary [40]. Therefore, external
appraisals about an individual’s PDO by significant
others becomes meaningful. Although the vignettes
highlighting these challenges were derived from a col-
lectivistic cultural viewpoint where external interfer-
ences on an individual’s OB by the significant others
is a socially acceptable norm, external interference on

an individual’s OB is assumed to be present in all cul-
tures, though in different forms [22,25,41] and inten-
sities. Therefore, it is reasonable to consider the
subjective perception of OB, and the external percep-
tions of occupational pattern when working
with clients.
However, when conflicts between the subjective
perception of OB and the external perception of PDO
are identified, it would be good if the OT has theoret-
ically sound descriptions of externally good occupa-
tional patterns, for any type of mediation from an
expert perspective. Descriptions of externally good
OB patterns do exist in the literature on OB. For
example, in a pilot study, Wilcock et al. [3] proposed
that OB can be derived from spending equal amounts
of time in physical, mental, social, and rest occupa-
tions Another example was by Jonsson and Persson
[4], who proposed an experiential model of OB in
which they represented OB as spending 50% of the
time in relaxing occupations and 25% of time each, in
exacting and flowing occupations based on the aver-
age time use data among healthy adults in their study
sample. They referred to exacting occupations as
those with demands that exceeded a person’s skill,
flowing occupations as those with demands matching
a person’s skills, and calming occupations as those
with demands lesser than a person’s skills. However,
these configurations cannot be used as activity pre-
scriptions per se, because what is considered physical
or flow occupation for an individual, might not be
the same for another.
Potentially, a way forward could be to focus on
community occupation patterns. Community occupa-
tion patterns (COP) is a concept put forward by
Reilly in 1966, who stated that the society operates a
social clock that schedules the daily occupations for
its members, and reasoned that the community occu-
pation patterns could serve as a model for planning
daily occupations for individuals [42]. Using COP for
promoting OB could be formed by examining the
PDO of individuals in the community, who report
high OB in the existing OB measures. The resulting
community PDO exemplifies the PDO that is accept-
able by the community and the one that promotes
OB, as this is derived from the community itself and
from community members who report good OB.
Community PDO should not just focus on occupa-
tional categories such as work, leisure, rest, and sleep
but also on broader aspects, and include physical,
mental, social, and rest occupations [3], actual and
desired occupations [3,15], relaxing and challenging
occupations [4,5], occupations meaningful to self and
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 377
occupations meaningful in a sociocultural context
[5,16], and occupations intended to care for oneself
and occupations intended to care for others [5].
Community PDOs can be considered only as time
prescriptions and not activity prescriptions, because
they guide the time to be spent on different occupa-
tional categories and the actual occupations under
each category should be decided by the client. For
example, if it is known that individuals who perceive
good OB spend 25% of their time on activities mean-
ingful to self, 25% on activities meaningful to others,
and the remaining 50% of time on activities meaning-
ful to both self and others, OTs can help the clients
to list down specific occupations under these catego-
ries, and help create a pattern that reflects community
PDO in terms of the time spent. By practicing the
PDO created by the OT, the client gains experience
in creating their own PDOs in the future [43]. It is
known that PDO could change with changes in the
stages of life [17,19], disease conditions [18,20,44,45]
caregiving role [25–28], and culture [15]. Therefore,
the PDOs of those reporting good OB need to be
explored for distinct population groups. For instance,
in a study among the patients with stroke, it was
identified that one-fourth of the participants still
experienced high OB [46]. If the PDOs of such indi-
viduals could be studied, important insights would be
gained regarding what a good PDO looks like for a
person with stroke. From a clinical perspective such
PDOs could be used as inputs and as a yardstick,
based on which expert practitioners could make sug-
gestions for OB.
Research implications
The significance of external appraisal of an individu-
al’s OB in promoting harmonious living as proposed
in the paper, needs to be verified through research.
Studies comparing the individual perception and
external perception of a family member on an indi-
vidual’s OB and or PDO could add to further explor-
ation of this line of thought. Another implication for
research is to design time-use studies exploring the
patterns of daily occupations among people belonging
to different cultures and disease conditions who
report high OB, to describe an externally good occu-
pational balanced pattern. This could help describe
population specific, health promoting COP. Finally,
the effects of health promotional interventions based
on COP, on the subjective perception of OB among
the population identified as high risk for occupational
imbalance is warranted.
378 B. N. DHAS AND P. WAGMAN

Conclusion [6] Eklund M, Orban K, Argentzell E, et al. The linkage

The review of literature on OB reinforced its indi-
vidualistic nature while the practice-based vignettes
described the challenges faced by OTs when working
with clients and families on OB, which is the primary
aim of the paper. The best way to preserve the indi-
vidualistic nature of OB while making it relevant for
practice is to combine it with PDO, also from an
external point of view when necessary. Therefore, the
focus of OB-based intervention should not be just
promoting individual OB, but facilitation of occupa-
tional patterns that are personally satisfying, resulting
in a state of perceived high OB and at the same time
are harmonious with the community expectations.
Therefore, OB interventions are not just person-
centred but also socially oriented. The theoretical
approach of OB could benefit from exploring the col-
lective perceptions of OB by the communities to
describe health promoting OB.
Disclosure statement
No potential conflict of interest was reported
the author(s).
Funding
Open Access funding provided by the Qatar
National Library.
ORCID
Brightlin Nithis Dhas http://orcid.org/0000-0002-
5894-0658
Petra Wagman http://orcid.org/0000-0002-7964-7143
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