occupation as a vehicle to surmount the psychosocial challenges of cancer
TRANSCRIPT
ARTICLES
Occupation as a Vehicle to Surmountthe Psychosocial Challenges of Cancer
Kathleen Doyle Lyons, ScD, OTR/L
ABSTRACT. Research indicates that cancer presents challenges to one’ssocial relationships, identity, and ability to live each day to the fullest. Oc-cupation can be a powerful vehicle that one can use to respond to and copewith these psychosocial challenges. However, literature also suggests thatoccupation can be a problematic vehicle because many persons with can-cer report frustration with their ability to engage in daily occupations. Thispaper synthesizes the research describing these psychosocial challengesand explores the nature of occupational engagement for persons withthe life-threatening illness of cancer. Interpreting the research from thestandpoint of the Person-Environment-Occupation Model suggests that va-riations in the congruence between person, environment, and occupation
Kathleen Doyle Lyons is Project Coordinator, Center for Psycho-Oncology Re-search at Dartmouth Medical School, Hanover, NH.
Address correspondence to: Kathleen Doyle Lyons, 7750 Psychiatry Department,Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756(E-mail: [email protected]).
The author thanks Susan Berger, MS, OTR/L, for her thoughtful comments andsuggestions on this manuscript. This study was supported by grants from the NationalInstitutes of Health (1R01 CA097358-01A1; 5R01 CA101704-3).
Occupational Therapy in Health Care, Vol. 20(2) 2006Available online at http://www.haworthpress.com/web/OTHC
© 2006 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J003v20n02_01 1
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is an intuitively plausible explanation for differing perceptions of thequality of occupational engagement for persons with cancer. [Article co-pies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website:<http://www.HaworthPress.com> © 2006 by The Haworth Press, Inc. All rightsreserved.]
KEYWORDS. Interpersonal relations, death, quality of life
Since 1990, 18 million new cases of cancer have been diagnosed inthe United States (American Cancer Society, 2004). While incidence ofand death rates for cancer appear to have stabilized in recent years (Weiret al., 2003), cancer remains a life-threatening disease with a pervasiveinfluence on the daily lives of people with cancer and their families(O’Connor, Wicker, & Germino, 1990). Many researchers, primarily inthe nursing and medical literature, have studied and described the expe-rience of living with cancer. Other researchers have begun to study theexperience of living with cancer from an occupational perspective(Cusick, Lawler, & Swain, 1987; Unruh & Elvin, 2004; Unruh, Scam-mell, & Smith, 2000; Vrkljan & Miller-Polgar, 2001). The word occu-pation is used to describe the meaningful and purposeful activities thatoccupy one’s time, contribute to one’s identity and community, and re-flect one’s culture (Larson, Wood, & Clark, 2003; Wilcock, 1998). Thegoal of this paper is to bring together those two bodies of literature andsynthesize the empirical evidence regarding the nature of occupationalengagement for persons with cancer. The evidence will then be inter-preted through the lens of a theory, the Person-Environment-OccupationModel (Law et al., 1996), in order to inform both occupational therapypractice and research. Such a perspective enhances our understanding ofhow engagement in occupation can positively or negatively influencehealth and well-being for those with the life-threatening illness of cancer.
THE EXPERIENCE OF LIVING WITH CANCER
Facing Mortality and Uncertainty
To understand the experience of occupational engagement for per-sons with cancer it is important to understand cancer as a contextualbackdrop. People often experience a visceral, emotional response to the
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word cancer (Kagawa-Singer, 1993). Paget (1993) illustrated this re-sponse by having actors whisper or choke on the word “cancer” whendramatizing her research in the play “On the work of talk: Studies inmisunderstanding.” For many people, the word “cancer” evokes a senseof dread because it connotes a disease often associated with images andfears of a slow and painful death (Little, Jordens, Paul, Montgomery, &Philipson, 1998). For some, the cancer is perceived as an enemy or anegative force that threatens and pervades all aspects of life (Baker,Zabora, Polland, & Wingard, 1999; Kagawa-Singer, 1993).
While oncologists are beginning to conceptualize some forms ofcancer as chronic illnesses (von Eschenbach, 2004), laypersons oftensee cancer as an event with a dichotomous outcome: cure or death(Ferrell et al., 1996). Being diagnosed with cancer, therefore, raises one’sawareness of his or her own mortality (Little et al., 1998; O’Connor etal., 1990). For many people, a cancer diagnosis invokes an attempt todevelop a personal understanding of the meaning of life, death, andillness (O’Connor et al., 1990). Some people report that one positiveconsequence of having cancer was that it prompted an evaluation oftheir values and priorities and an appreciation of the good things in theirlives (Cella & Tross, 1986; Ferrell, 1996; Fryback, 1993; Kagawa-Singer,1993; O’Connor et al., 1990; Unruh & Elvin, 2004). In both the scien-tific and the lay literature, personal accounts of persons living with can-cer often affirm the importance of and value in living a meaningful andfulfilling life while knowing that end of life may be imminent (Byock,1997, 2002; Callanan & Kelley, 1992; Jacques & Hasselkus, 2004;Kubler-Ross, 1978; Muzzin, Anderson, Figueredo, & Gudelis, 1994;Stewart, 1997; Unruh & Elvin, 2004).
However, some people find it difficult to fully engage in life whiledealing with the emotions of their potentially imminent death (Howell,Fitch, & Deane, 2003; Paget, 1993). The unknown course, pace, andprognosis of one’s cancer can be a source of anxiety. Persons with can-cer have described the stress and challenge of not knowing how longthey will live and how the disease will affect their lifestyle (Ferrell et al.,1996; Heinonen et al., 2005; Howell et al., 2003; O’Connor et al.,1990). Even those people whose cancer has been eradicated often re-port a persistent fear that it may return again at any moment and dis-rupt their lives anew (Ferrell, 1996; Howell et al., 2003; Little et al.,1998; Stewart, 1997; Vrkljan & Miller-Polgar, 2001). While cancer canbe a catalyst to re-evaluate one’s values and priorities, the awarenessof mortality and resultant uncertainty can create tension in the lives ofthose with cancer.
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Renegotiating Identity
Living with cancer can challenge a person’s conception of his orher identity (Beanlands et al., 2003; Dicks, 1998; Howell et al., 2003;Lugton, 1997; Mathieson & Stam, 1995; Unruh & Elvin, 2004). Theroles a person sees him or herself as holding may change with seriousillness, evoking a re-evaluation of one’s place in a family or in society(Kagawa-Singer, 1993; Stewart, 1997). Similar to those with chronicillness (Charmaz, 1983, 1991), persons with cancer often explore andre-construct their identity as the disease progresses (Mathieson & Stam,1995).
Cancer can often become part of one’s identity. A woman inMathieson and Stam’s (1995) study stated, “I don’t want to wear a can-cer identity . . . to my friends I’m Ruth with cancer, not just plain Ruth”(p. 294). To be a cancer patient is to be seen through a medical lens, withthe disease in focus and of primary concern. Dicks (1998), a nurse andcancer survivor, recounted her frustration and anger at having the roleor label of “cancer patient” thrust upon her. Dicks associated the term“cancer patient” with sadness, vulnerability, and futility and felt thatbeing labeled as such overshadowed other aspects of her identity and in-dividuality. The challenge facing a person with cancer is to renegotiatean identity that includes cancer while respecting and reflecting one’spre-illness identity and life story (Mathieson & Stam, 1995).
Experiencing Altered Social Contexts
Cancer can alter and influence one’s social context and relationshipswith others. These relationship changes may be perceived positively ornegatively. Persons with cancer often report that the illness has broughtthem closer to their loved ones (Holmes, Coyle, & Thomson, 1997;Rieker, Clark, & Fogelberg, 1992). Many indicate a renewed intimacyor fresh appreciation for the people in their lives (Fryback, 1993;Howell et al., 2003; O’Connor et al., 1990) and ample social support(Howell et al., 2003; Tempelaar et al., 1989). Thus, for some, the illnessexperience heightens the connection they feel to their family, friends, orcommunity.
For others, social support may be lacking. It is easy to find studieswhere persons with cancer report that other people are not sure of whatto say or how to act around them after being diagnosed with cancer(Dunkel-Schetter, 1984; Holmes et al., 1997; Howell et al., 2003; Littleet al., 1998). There are stories of people who meant to be helpful but
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ended up making a hurtful comment (Ferrell et al., 1996; Fridfinnsdottir,1997) or people being overly solicitous, overly protective, or overlycheerful (Dunkel-Schetter, 1984; Holmes et al., 1997; Peters-Golden,1982). People without cancer similarly report not knowing how to actaround a person with cancer (Peters-Golden, 1982) and even healthcarepractitioners allow their own fears and assumptions about cancer to in-fluence the communication process (Ferrell et al., 1992; Wilkinson,1991). Some researchers (Ferrell & Dow, 1997; Flanagan & Holmes,2000; Lloyd & Coggles, 1990) and persons with cancer (Ferrell et al.,1992; Howell et al., 2003; Mathieson & Stam, 1995) cast the problemas an issue of stigma, where people cannot look beyond the disease tosee the individual.
It is not surprising, therefore, that some persons with cancer reporta dissatisfaction with their social lives (Irwin, Gottlieb, Kramer, &Danoff, 1982). Some people indicate that they choose to avoid or with-draw from social situations for reasons related to their cancer (Dunkel-Schetter, 1984; Fridfinnsdottir, 1997; Howell et al., 2003; Lamb, 1993).Persons with cancer have also indicated that friends and family at timeswithdraw from them, choosing to avoid their company (Mathieson &Stam, 1995).
In sum, the experience of living with cancer challenges one’s identity,social relationships, and ability to live each day to the fullest. Some peo-ple surmount these challenges with grace and fortitude. Other peoplestruggle to reclaim or reshape their lives in the midst of a life-threateningillness.
OCCUPATIONAL PERFORMANCEOF PERSONS WITH CANCER
Concerns that are specifically occupational in nature are a recurrenttheme in the cancer literature. Persons with cancer often need to altertheir occupational engagement in response to the illness or side effectsof treatment (Cusick et al., 1987; Howell et al., 2003; Kagawa-Singer,1993; O’Connor et al., 1990; Vrkljan & Miller-Polgar, 2001). Of 22participants with cancer in Cusick, Lawler, and Swain’s (1987) descrip-tive study, 41% reported that they were engaging in more sedentaryactivities and 36% reported being less involved in school and work ac-tivities than they had been before starting chemotherapy. Researchershave reported that women with ovarian cancer often choose to withdrawfrom social or pleasurable activities because of physical symptoms of
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the disease or its treatment (Howell et al., 2003; Lamb, 1993). Rasmussenand Sandman (1998) studied the time use of patients in an inpatient on-cology ward, finding that patients in that setting had little opportunityfor engaging in purposeful activity.
While the cancer illness and treatment often results in disruption ofdaily occupations, responses to the disruptions vary. Thirty-one percentof the 22 participants in the Cusick et al. (1987) study were enjoyingtheir more sedentary lifestyle. Thus, for some people, the illness experi-ence may, at least in some ways, produce an acceptable change in theirtime use. However, a negative response to the disruption is more fre-quently described in the literature. The remaining 69% in the Cusicket al. study reported no longer enjoying their daily activities, eitherdisliking them or finding them boring. Cancer survivors say it can betroubling and frustrating to no longer be able to engage in valued occu-pations that are associated with one’s independence or identity (Howellet al., 2003; Lyons, Orozovic, Davis, & Newman, 2002).
Persons with cancer frequently gauge their health or quality of lifefrom an occupational perspective. They report feeling healthy or satis-fied with life when they can do the activities that are important to them(Fryback, 1993; Kagawa-Singer, 1993). Persons with cancer also fre-quently express their goals in occupational terms, describing the desireto regain the ability to do certain activities that allow them to fulfillmeaningful roles (Fox & Lantz, 1998; Holmes et al., 1997). For thethree women with breast cancer in Vrkljan and Miller-Polgar’s (2001)qualitative case study, regaining the ability to perform cherished oc-cupations was a way to affirm that they were still alive, healthy, andcapable. For those women, occupational engagement was also a way torestore a sense of normalcy and control over their lives and lifestyle.
The women in Vrkljan and Miller-Polgar’s (2001) study completedactive cancer treatment six months before the research interviews andhad subsequently been able to resume most of their pre-diagnosis occu-pations. Their successful experiences of occupational performance maynot reflect the experiences of persons with more advanced cancer. Lessis known in the empirical literature about occupational performance inthat population of people, who likely present with more physical symp-toms and poorer prognosis. For persons with advanced or rapidly pro-gressing cancer the resumption of previous occupations and performancepatterns may not be feasible. It can also be hard to set occupationalgoals due to the uncertainty of the future for those with an advanced life-threatening illness (O’Connor et al., 1990).
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Lyons and colleagues (2002) interviewed and observed 23 participantsin a day hospice program. The researchers found that there was a com-plexity linked to the concept of occupational performance. While par-ticipants reported frustration at not being able to independently engagein some valued occupations, they reported deriving great pleasure fromactivities in which they were fulfilling more of an observer role thanthat of an active participant. Thus, watching and conversing with a fel-low hospice participant who was completing a task (e.g., a craft project)was often very satisfying to participants. The authors used Wilcock’s(1999) notion of “doing, being, and becoming” aspects of occupationto interpret these findings. Wilcock asserts that the “doing” aspect of anoccupation involves tangible, observable actions. “Being” aspects ofoccupation refer to the enhanced experience of self as a unique individ-ual in the human race. The “becoming” aspects of occupation involvethe growth and development that comes from occupational engage-ment. In the Lyons study, watching and supporting their peers in doingan occupation fostered the observer’s sense of being in occupation. Do-ing and being were equally valuable and powerful aspects of the occu-pations of the members of the group hospice. The findings of that studysuggest that while declining health may make it difficult for personswith advanced cancer to physically perform occupations, they may stillreap enjoyment and well-being from socially participating in occupa-tion, i.e., watching and interacting with others through occupation.
OCCUPATION AS A VEHICLE FOR WELL-BEING
The empirical literature cited above demonstrates that persons withcancer have challenges, concerns, and goals that are occupational innature. Occupation can be viewed as a vehicle to address and surmountthe mortality, identity, and interpersonal challenges described in thefirst section of the paper. However, occupation can be a problematicvehicle given the struggles that persons with cancer report regardingtheir occupational performance.
Facing Mortality Through Occupation
Engaging in occupation can be one way to grapple with the tensioninherent in anticipating the end of one’s life. Some persons with cancerreport a conscious decision to not passively wait for death to arrive but touse their remaining time to do something purposeful in order to connect
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with the world and with loved ones (Fryback, 1993; Paget, 1993; Stew-art, 1997). In this way, engagement in occupation can be seen as an ex-pression of hope. To use one’s mind, body, or spirit in a meaningful taskreinforces the notion of oneself as alive, vital, and able to contribute toothers’ lives (Vrkljan & Miller-Polgar, 2001). Kubler-Ross’ (1978)book, “To Live Until We Say Good-Bye,” contains poignant vignettesof persons who used creative occupations of writing, painting, and mak-ing dollhouses as outlets for expressing themselves and leaving a legacyto others in their last year of life. Trump (2000) suggests that occu-pational therapists can facilitate “farewell activities,” in which peoplecreate scrapbooks or letters as a tangible gift for their loved ones.
Marianne Paget (1993), a social scientist who wrote of her own expe-riences of living and dying with cancer, writes of the many occupationsthat she desired to do during her cancer treatment: redoing her bedroomas a study, designing a college course, and writing a book. She writes ofthese desires to live and to engage in meaningful activities saying, “I amintensely alive in the face of death” (Paget, 1993, p. 106). At other timesshe wrote of using occupation as a way to cope with or distract herselffrom the stress of the seriousness of her cancer, a theme echoed in em-pirical studies of persons with cancer (O’Connor et al., 1990; Reynolds,2003; Unruh & Elvin, 2004; Unruh et al., 2000).
Viewing occupation as a vehicle to face one’s mortality becomesproblematic when considering that death is usually preceded by a pe-riod of physical decline for the person with cancer (Hwang, Chang,Fariclough, Cogswell, & Kasimis, 2003; McCarthy, Phillips, Zhong,Drews, & Lynn, 2000; Morris & Sherwood, 1987; Morris, Suissa,Sherwood, Wright, & Greer, 1986). As a person declines, it becomesmore and more difficult to engage in what Wilcock (1999) calls the “do-ing” aspects of occupation. In the face of physical decline it is helpfulto recognize that there are “being” and “becoming” aspects of occupa-tion that can still be experienced and savored and one need not be physi-cally active to participate in an occupation (Polgar & Landry, 2004).Hasselkus (2002) notes that occupational therapy practitioners arehighly oriented to the doing aspects of occupation; however, meaningis found in the being and becoming aspects of occupation. Hasselkusurges readers to consider that those who are actively dying can ex-perience occupations with others even when they may not be able toproduce a tangible product or maintain any semblance of physical in-dependence. The problematic nature of occupation for persons withadvanced cancer is resolved somewhat by heeding Hasselkus’ assertion
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that it is the process of experiencing occupation that is important, asopposed to the outcome or observable aspects of the occupation.
Renegotiating Identity Through Occupation
Occupation is one way that people express their identity or sense ofself (Christiansen, 1999). The occupations in which we choose to en-gage and to devote our time and energy reflect our personal and culturalvalues. Conversely, participation in occupations can also actively shapeidentity (Christiansen, 2004). Empirical reports describe the process bywhich persons with disability or chronic illness engage in occupationsas a way to test their abilities and to demonstrate to themselves andothers that they are individuals with certain preferences, personality,and goals (Clark, 1993; Jackson, 1998; Reynolds, 2003; Vrkljan & Miller-Polgar, 2001).
One reason cancer is sometimes interpreted as a threat to identity isbecause the person with cancer may struggle to independently and ef-fectively complete the occupations that define who he or she is. In thisway, impaired occupational performance can be seen as the problem.However, occupation can also be viewed as a powerful vehicle to ad-dress this problem of a threat to identity. The person with cancer canchoose to modify the occupation or the environment to facilitate perfor-mance. For example, Paget (1993) enlisted a colleague’s editorial assis-tance to allow her to continue to write and publish her life’s research. Orthe person with cancer can choose new occupations that help to culti-vate a different but equally valuable aspect of identity. In Reynolds’(2003) study of women with breast cancer and other chronic illnesses,some participants reported that the illness experience was a catalyst torevive a childhood interest in artistic endeavors. Women with breastcancer in Unruh and Elvin’s (2004) study found that the new occupationof dragon boat racing improved their well-being through increasingtheir self-confidence. Whether continuing to participate in modifiedoccupations or cultivating new interests and activities, occupationalengagement can be a way to express and assert one’s identity and placein a community.
Fostering Social Relationships Through Occupation
Talking about identity leads naturally into a discussion of one’srelationships with others, as interactions with others can shape identityand one’s sense of self. As discussed earlier, interactions with others
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can become strained and awkward when living with cancer. Occupationcan be a vehicle that minimizes this awkwardness. Interactions withothers are usually embedded in an occupation, for example, people so-cialize over dinner, while doing work or chores, or while engaging ina hobby or leisure activity. Occupations have certain activity demandsand can be recognized by their occupational form or their directly ob-servable aspects. The occupational form reflects the physical, social,and cultural elements that elicit or guide one’s performance of an ac-tivity (Nelson, 1988). Occupational form can offer a familiar and com-forting structure to a social interaction that occurs in the midst ofoccupation. Instead of “visiting my friend who is dying sooner than wehad planned and hoped” there can be two friends “watching the ballgame” or “having tea” like they have always done. The occupationalform of these familiar activities can give comfort and continuity and canbecome a vehicle to surmount the awkwardness that can be present ininteractions.
While occupation can be a powerful vehicle for facilitating connec-tions between people (Hasselkus, 2002) and managing some of the in-terpersonal difficulties elicited by cancer, it can also be problematic.One’s ability to engage in typical, unaltered occupational forms de-creases as the person approaches death. What happens when the valuedoccupation was jogging together each morning or going into the city fora full day of shopping? Some meaningful occupations are abandonedout of necessity and are replaced by others that are less physically tax-ing. In those cases, explorations of new occupations can provide thestructure to foster interpersonal connections. In other cases, personsmay choose to continue to complete the occupation but alter the occu-pational form. When the form is altered there is always the potentialthat the change in a familiar and predictable form can introduce tensioninto interpersonal interactions (Goffman, 1959; Lyons & Tickle-Degnen,2003). The tension is not insurmountable but the potential for tensionexists and needs to be acknowledged as a complicating factor in usingoccupation to surmount strained interpersonal challenges.
IMPLICATIONS FOR RESEARCH AND PRACTICE
The earlier sections of the paper summarize the psychosocial chal-lenges of living with cancer and the ways occupation can be used tosurmount those challenges. Included in the discussion is an acknowl-edgement that occupation is not an easy or uncomplicated antidote to
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the multifaceted experience of a life-threatening illness. Organizing andinterpreting the cited empirical evidence through the lens of a theorycan aid in identifying ways to proceed with practice and research withthis population. The Person-Environment-Occupation (PEO) Model(Law et al., 1996) is a useful theoretical framework for this topic.
The PEO model (Law et al., 1996) proposes that occupational per-formance is shaped by the dynamic transaction among the elements ofthe person, environment, and occupation. The person and the environ-ment are interdependent and cannot be isolated from each other; occu-pations are performed by an individual or individuals in a particularenvironment. The transaction between the elements is dynamic in thatthe relationships change as a person develops throughout the lifespanand moves through various environments. The PEO model encouragesclinicians to consider the transactions between the person, the environ-ment, and the occupation. The goal of occupational therapy interventionis to maximize the congruence between the three elements. The modelposits that more congruence enhances the quality of the person’s experi-ence of the occupation.
The thesis of this paper is that occupation can be a powerful, butcomplicated, vehicle with which to address the psychosocial challengesexperienced by many people living with cancer. The PEO Model sug-gests that the key to understanding this complexity is to attend to thetransactions between the person, the occupation, and the environment.This offers an interesting hypothesis regarding the empirical studiescited in this manuscript–perhaps there was greater congruence betweenthe PEO elements for those persons who reported that engaging incertain occupations supported their desire to feel fully alive, affirmedtheir identity, or strengthened their relationships. And perhaps thosewho struggled or were discontented had poorer congruence between theelements for their chosen occupations. For example, perhaps MariannePaget (1993) felt “intensely alive in the face of death” (p. 106) becauseshe was able to modify her environment and rely on the assistance offriends who respected her and helped her to compensate for physicalimpairments in order to engage in valued occupations in a slightly dif-ferent manner. The studies cited in this paper were not designed to testor reflect the PEO Model, so it remains a hypothesis, but variations inthe congruence between person, environment, and occupation is anintuitively plausible explanation for differing perceptions of the qualityof occupational engagement for persons with cancer.
The task for researchers is to explore this hypothesis by asking ques-tions such as: Can increased congruence between person, environment,
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and occupation help people with recovery from cancer? Can increasedcongruence facilitate a “good death?” Research that is theoreticallydriven by the PEO Model requires the unit of analysis to be the personengaged in an occupation in a particular environment. Many of the stud-ies cited in this paper focus on one or two of the elements such as personsand occupations (e.g., Cusick et al., 1987) or occupations and environ-ments (e.g., Rasmussen & Sandman, 1998). The studies that do targetall three elements tend to employ a qualitative design (e.g., Unruh &Elvin, 2004; Unruh et al., 2000). In order to move research into the hy-pothesis-testing arena to explore the questions identified in this para-graph we need to find a way to describe and measure the congruence inthe PEO elements in addition to measuring each element separately.
While researchers continue on with this line of inquiry, the task forclinicians is to use occupation to help people positively respond to thepsychosocial challenges of facing mortality and experiencing alteredidentity and social relationships. The PEO Model tells clinicians to ex-plore multiple ways to effect change by intervening with one or more ofthe elements of occupation, environment, or person to maximize con-gruence between the three elements. Evaluation must include an assess-ment of the three elements and the transactions between them. This canbe done by observing the client’s occupational performance in relevantcontexts and by using structured client-centered assessments such as theCanadian Occupational Performance Measure (Law et al., 1998) whencreating the occupational profile (American Occupational Therapy As-sociation, 2002). Intervention can target one or all of the elements withthe goal of helping surmount the challenges associated with living withcancer and being able to experience the meaningful aspects of valuedoccupations.
CONCLUSION
Many researchers, particularly those in the fields of medicine andnursing, have studied and described the experience of living withcancer. Three themes emerge from that literature, namely that cancerchallenges one’s identity, social relationships, and ability to live eachday to the fullest. The literature also shows that occupational engage-ment can be a powerful vehicle to address these challenges and enhancethe well-being of persons with cancer. However, the empirical literaturecited in this paper also indicates that there is a complexity linked to oc-cupational engagement for this population. The PEO Model (Law et al.,
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1996) helps to illuminate this complexity and urges us to attend the tran-sactions between person, environment, and occupation during practiceand research.
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