Article Commentary: A Psychospiritual Integration frame of Reference for Occupational Therapy. Part 2: Transformative Occupations and the Change Process.

This paper builds upon the first in the series on psychospiritual integration (PSI) and examines the concept of transformative occupations and the process of change underpinning occupational therapy from a PSI perspective. A repertoire of new terms highlighting finer distinctions in the concept of occupation will be introduced and explained, as will the dynamic for transformation inherent in the psychospiritual integration change process. Suggestions for PSI-informed occupational therapy practice will be explored.

Introduction

In my first paper on the psychospiritual integration (PSI) frame of reference (Kang, 2003) for occupational therapy, I proposed a new conceptual and practice framework for enabling occupational therapists to reflect and engage the area of spirituality in human occupational functioning. Here, I would like to delve into the practical aspects of PSI – the doing of PSI for occupational therapy practitioners as they work with their clients. The process of transformative change intrinsic to spirituality that is linked to health and wellbeing will be discussed in greater detail. The transformative edge of occupation itself will be examined, outlining various ways in which dimensions of spirituality are enabled and energized in persons in the course of PSI-informed occupational therapy, but the community spirituality aspect of PSI will not be the focus of this paper.

Since my first paper on PSI has been published in 2003, after a hiatus of 13 years, this second part of the planned series on PSI is finally out. During that time, there has been a marked proliferation of occupational therapy publications centred on the concept of occupation (see e.g. Iwama, 2006; Kielhofner, 2008, pp. 110–125; Pollard, Sakellariou, & Kronenberg, 2009; Townsend & Polatajko, 2013; Turpin & Iwama, 2011). The issue of spirituality has also become more salient as evolving models of occupational therapy practice continue to include discussion of spirituality in their frameworks (see e.g. Canadian Model of Occupational Performance and Engagement). Spirituality – the many-splendoured thing – refuses to be silenced. But rather than a thing, it may be more useful and accurate to describe spirituality as a wave-like process.

In this paper, I will be discussing in greater detail the process of transformative change intrinsic to spirituality that is linked to health and wellbeing. The transformative edge of occupation itself will be examined, outlining various ways in which dimensions of spirituality are enabled and energized in persons in the course of PSI-informed occupational therapy. The community spirituality aspect of PSI will not be the focus of this paper.

Occupations that transform

The concept of occupation has been core and central to much theorizing and clinical practice in occupational therapy, with models of occupational therapy practice moving away from emphasis on discrete skills, tasks, and activities to more holistic understandings of human occupation. Occupation pertains to the ‘doing’ dimension of human existence and involves more than mere productivity and work. Occupation is anything meaningful that people do to occupy time in the context of their environment. Seen in this light, there has been a call for occupation-focused, occupation-based, and occupation-centred assessment and intervention that places occupation at the front and centre of occupational therapy (Fisher, 2014). The potential for occupation to positively impact health and wellbeing of people with disability or illness is not a matter of dispute. Studies have shown that a strong link between meaningful engagement in occupation and health.

What is not so evident is the transformative potential of occupation, conceived more narrowly as individual or personal transformation and more broadly as social or collective transformation. To investigate this issue, we first define what is meant by transformation. What follows is a discussion on PSI-informed occupational therapy that points to new concepts of occupation – meta-occupation, non-occupation and trans-occupation – implicated in transformation at the most profound levels of human existence.

Transformative change

Change means alteration – shift from one state or condition into another. Conceptualizing change in human subjects is challenging. There can be different kinds and levels of change to be elaborated upon. First, there is what can be termed ‘level zero’ change – no change or no learning at all. Then, there is ‘level one’ or incremental change – “corrections, adaptations, modifications via flexibility and stretching within the box” (Hall & Duval, 2003, p. 122). Next, there is “level two’ or discontinuous change – “shift to different behaviours and responses in a different box of behaviours” (Hall & Duval, 2003, p. 122). Beyond that, there is “level three’ or evolutionary change – ‘shift beyond old box to new box, paradigm shift to new choices entirely” (Hall & Duval, 2003, p. 122). Finally, there is ‘level four’ or revolutionary change – “awakening to a new world, transformative change” (Hall & Duval, 2003, p. 122). At level four, change is transformative in the sense that there is a new order of things not previously present that has now become manifest.

PSI-informed occupational therapy

In my first paper, I articulated the PSI frame of reference using the template of model construction proposed by Kielhofner (1997, 2009, pp. 60–66). Since then various models in occupational therapy have emerged that utilized alternate structures – see e.g. Canadian Model of Client-Centred Enablement by Townsend, Polatajko, Craik, & Davis (2013) – and metaphors – see e.g. Kawa model by Iwama (2006). Subsequent reflection has prompted a shift in thinking away from mechanistic modelling to organic representations for my articulation of PSI. Hence in this paper, I will be analyzing the ‘enablement’ of spirituality and occupation and ‘technology for application’ in fluid and organic ways more akin to the spirit and style of the Kawa model (Iwama, 2006).

The Canadian Model of Occupational Performance and Engagement (CMOP-E) defines the profession of occupational therapy as “the art and science of enabling engagement in everyday living, through occupation; of enabling people to perform the occupations that foster health and well-being; and of enabling a just and inclusive society so that all people may participate to their potential in the daily occupations of life” (Polatajko, Backman, et. al., 2013, p. 27). In Enabling Occupation (CAOT, 1997, 2002), spirituality is understood as a source of meaning “that resides in persons, is shaped by the environment, and gives meaning to occupations.” (p. 33). Spirituality, understood in terms of meaning making, can be seen as both the driving force and outcome of occupational engagement (Kielhofner, 2002; Persson, Erlandsson, Eklund & Iwarsson, 2001; Polatajko, Backman, et. al., 2013).

The three zones

The psychospiritual integration (PSI) frame of reference articulates six interpenetrating dimensions of spirituality as becoming, meaning, being, centredness, connectedness, and transcendence (Kang, 2003) (). As such, meaning, while definitely important and central, is only one of six facets of spirituality and needs to be seen in context. The meaning of occupation that both drives and results from occupational engagement is strongly linked to the concept of becoming. The construction of meaning for an individual in occupation constitutes the narrative that situates and locates the person's life. Such narrative is in turn central to identity formation, of becoming.

In both meaning and becoming, language and conception play constitutive roles. In other words, the making of meaning and dynamic formation of identity are inextricably tied to language articulation and conceptualization. The linguistic and conceptual frameworks that embed and hold our doings construct the edifice of personal identity and meaning as we do everyday occupations. Together, becoming and meaning form the ‘surface zone’ of spirituality, which is the common and familiar phenomenological zone that many individuals and groups can relate to.

PSI goes further to delineate dimensions of spirituality that are less tied to language and conception, and in fact, progressively transcend language and conception altogether. Dimensions of being and centredness exemplify spirituality that goes beyond word-based, concept-based, and narrative-based self. Being and centredness form what PSI calls the ‘middle zone’ of spirituality in terms of phenomenological depth and breadth. This middle zone of spirituality is the phenomenological ground out of which the surface zone emerges and into which it returns (Nishida, 1992, pp. 3–10; Nishitani & Van Braght, 1983). The middle zone of being and centredness is at best minimally enmeshed in language and conception. It constitutes the zone of phenomenological silence and clarity that is the sea of conscious potential ever ready to coalesce into words, concepts, actions, and occupations (Wallace, 2007a, pp. 11–27; 94–134, 2007b, pp. 108–116). This dimension of spirituality while equally shared by all is less frequently experienced and cognized due to unfamiliarity and unawareness. As such, PSI would regard this condition as exemplifying the state of spiritual latency. In this case, the spirituality of being and centredness remains largely latent in the individual who is either not cognizant of or familiar with it.

Beyond the middle zone lies what PSI calls the ‘deep zone’ of spirituality. The dimensions of connectedness and transcendence are located in this zone. Phenomenologically, connectedness and transcendence are characterized by infinitude of depth and breadth. The experiential parameters of these dimensions are not measurable or calculable. They are no longer contingent upon language and conception, though language and conception can play a role in some instances but not necessarily so (Fenner, 2015, pp. 9–83; 193–245; Keating, 2009, pp. 15–36; Main, 2014, pp. 120–121; 159–164; Wallace, 2007a, pp. 11–27; 94–134, 2007b, pp. 108–116). Connectedness and transcendence point to the most profound experiential accounts of spirituality known to human history. While arguably unfamiliar to many, these two deep zone dimensions nonetheless display features recognizable by many as they manifest in the lives of persons who have or are experiencing connectedness and transcendence. Features such as unshakable composure, openness, warmth, compassion, kindness, gentleness, and luminosity of personal presence mark those who dwell in the deep zone of connectedness and transcendence.

These features are not all or nothing phenomena. They can manifest in persons who have experienced the deep zone of spirituality intermittently or temporarily on occasions. The nature of deep zone experiences is such that one is irrevocably transformed from the inside-out, to greater or lesser degrees, upon direct unmediated realization of connectedness and transcendence. Each instance of full realization of the deep zone purifies and transforms in profound ways the personality and character of the individual experiencing it. There comes a point when such realization-evoked transformation is complete and the person is irreversibly and unconditionally emancipated from afflictive delimitations. Such a person will embody and live out the deep zone in tandem with the middle and surface zones in wholeness and unity. Connectedness and transcendence suffuses and pervades the totality of being; its centre no longer the autonomous unchanging self but the whole cosmos free of circumference and centre; its meaning rich with love and wisdom; and its becoming no longer born of egocentric desires and compulsions but enacted in the service of all beings.

Dimensions and occupation

From PSI's perspective, there exists an inextricable link between these six dimensions of spirituality and human occupation. These dimensions conceptualized in three progressively deeper zones infuse, inspire, inform, and enliven our enactment of daily occupations. In particular, the new concepts of meta-, non-, and trans-occupation are profoundly linked to these dimensions of spirituality as illustrated in . Our sense of meaning enwraps the variety of everyday occupations we engaged in, even as we become more complex, differentiated, and mature through meaningful doing (Kang, 2003). Our occupations can centre us in our being, as we shape and sculpt our sense of unique identity as dynamic agents in our world (Donica, 2008; Kang, 2003).

More than that, occupations – especially those in their meta- and non-occupational forms – can facilitate a profound sense of being and centredness beyond notions of self and self-agency. Such profound existential realization can be described as the experience of primordial self (Fenner, 2015, pp. 9–83; 193–245; Keating, 2009, pp. 15–36; Main, 2014, pp. 120–121; 159–164; Wallace & Hodel, 2008, pp. 183–196) – where the dense volitional sense of self-powered agency (as the locus of personal causation and efficacy) is largely attenuated, if not absent.

While unique and individual, our personhood is not an isolated reality ontologically cut off and separate from the web of relationships that forms our living context. Every person is constituted by their embeddedness in a matrix of dynamic relationships, even as their very being constitutes part of the web for other persons (Abe, 1990; Torrance, 2016, pp. 98–109). Connectedness is thus none other than the woven fabric of our threads of existence as human beings. Whether or not we perceive and live out this connectedness depends in part on our cultural lenses, biological dispositions, and social conditioning. Culture, biology and society also influence how we seek to connect, to what degree of intimacy, with what level of importance, and with what clarity of vision.

If connectedness forms our very personhood, then every occupation that each person enacts finds its place in myriad and infinite connections with other persons, events, and things. This sense of connectedness bears resonance with the term ‘transactive’, a concept describing the relationships between person, environment, and occupation that views occupational performance as an event constituted by mutually interpenetrating – not independent isolated –factors (Law et al., 1996). Connectedness in PSI's sense can be understood as an open field of transactive relations established on a cosmic scale. Seen in this light, all occupations whether solitary or social are indelibly etched and entangled into the fabric of the cosmos (Greene, 2004, pp. 127–142; Wallace, 2007b, pp. 108-116).

Occupations can take us beyond the realm of agential self, primordial self, and connected self to a groundless ground where all notional constructs of self become utterly ineffectual or simply and timelessly cease to exist. This deepest zone of transcendence can be arrived at via the route of occupation, but not just any occupation. Transcendence require occupations of ‘a certain kind’ – not differentiated merely in terms of this activity or that, but qualitatively in terms of how persons engage in occupations (the phrase ‘a certain kind’ borrowed from Chan, 2013, pp. 35–40). In this regard, PSI gives the term ‘trans-occupations’ to refer to occupations of ‘a certain kind’ that evoke, catalyze, invite, and open up to the dimension of transcendence in everyday life.

In my first paper on PSI, I introduced the concepts of generic and spiritual occupations (Kang, 2003). Here and henceforth, I am rephrasing them as generic and spiritual occupational forms respectively to highlight their formal nature rather than their semantically broader nature as ‘occupation’. Seen in this new light, while non-occupation most certainly requires engagement in spiritual occupational forms, the other two – meta-occupation and trans-occupation – do not necessarily require so. Generic occupational forms (as well as spiritual ones) can be the basis for meta-occupational and trans-occupational engagement and experience. That said, contemplative and meditative occupational forms can be more conducive to the experience of trans-occupation than extroverted and distracting ones. These occupational forms are found extensively and richly in Asian cultures such as Indian ashrams, Chinese Taoist and Buddhist monasteries, Japanese Zen temples, Tibetan mountain retreats, and Burmese and Thai forest monasteries; as well as in Benedictine, Carmelite and Franciscan monasteries in the western Christian tradition.

Meta-occupation

In this paper, I introduce new concepts of occupation as seen through the lens of PSI. The first is meta-occupation. Meta-occupation suggests a condition of ‘going above’ and ‘hovering outside’ occupation in an experiential and phenomenological sense. Meta-occupation is not a special or esoteric occupation accessible only to circumscribed and elite groups of individuals, but everyday occupations engaged and experienced at a meta-level. Engaging in and experiencing an occupation at a meta-level requires an ability to step aside from and outside of the matrix of occupational experience, to abide in a posture of mindfulness and clear knowing. Thus, meta-occupation does not refer to any specific occupational form but to adopting mindfully a meta-perspective to any and all occupations. A quality of doing is infused with a mindful sense of self that serves as context rather than content of experience (Hayes, Strosahl, & Wilson, 2012, pp. 85–91). In relation to the PSI model of spirituality, meta-occupation positions itself to the dimensions of becoming and meaning, where its active outworking contributes to positive becoming and resourceful constructions of meaning.

Mindfulness (Pali: sati; Sanskrit: smrti) is defined here as the moment-by-moment presencing of awareness in the immediacy of experience, without emotional reactivity and judgmentalism but with responsive calm and wise discernment (Analayo, 2003, pp. 57–61; Wallace, 2011, pp. 55–60; 275–315). As a mental factor and skill, mindfulness can be trained, nurtured, cultivated from an unfamiliar and relatively weak condition to one where mindfulness is natural, robust, and ubiquitous. In such a condition, mindfulness unobtrusively and spontaneously accompanies every act of occupational performance and engagement. Occupational mindfulness ensues – a condition of moment-by-moment presencing of awareness in the immediacy of occupational experience. Such occupational mindfulness is compatible with a variety of everyday occupations, particularly those that tend towards a contemplative nature such as strolling through a park, walking by the beach or in a rainforest, gardening, cooking an unhurried meal, and giving or receiving a relaxing massage.

Clear knowing (Pali: sampajanna: Sanskrit: samprajanya) is a mental factor concomitant with mindfulness that enables wise discernment between skillful and unskillful states of mind (Analayo, 2003, pp. 57–61; Wallace, 2011, pp. 55–60; 275–315). Clear knowing confers a degree of attentiveness and phenomenological acuity that helps ensure a moment-by-moment flow of unbroken mindfulness and wholesome attitudes. Wholesome or skillful attitudes are defined as those that conduce to peace, contentment, joy, release from affliction, and freedom from inner turmoil and confusion. By early detection and recognition of unwholesome or unskillful states of mind in the midst of occupational experience, the factor of clear knowing supports mindfulness in letting go of afflictive states and attitudes. Such letting go enables the person who is occupied to participate more deeply in the texture and nuance of each occupational experience as it arises, abides, and passes away. It makes possible a gradual deepening of mental unification with increase in cognitive malleability and pliancy (Wallace, 2006, pp. 1–10).

Taken together, mindfulness and clear knowing synergistically enable the person to adopt a meta-level perspective to occupational experience, derive cognitive and meta-cognitive insights into that experience, and hone their attention away from distractibility towards profound levels of focus and flow. In short, meta-occupation is a condition of adopting a meta-perspective to occupational experience, evoking cognitive and meta-cognitive insights into that experience, and directing attention into deep focus and flow imbued with heightened malleability and pliancy. As such, meta-occupation enabled by the synergy of mindfulness and clear knowing confers the person access to that middle zone of spirituality where agency-attenuated being and centredness prevail.

Non-occupation

The second new occupational concept in PSI is non-occupation. First, I need to demarcate non-occupation in the sense it is used in PSI from the sense it is normally understood in common parlance – that of dysfunctional non-performance of and non-engagement in health-promoting occupations. Far from being a dysfunctional state, PSI's non-occupation describes a highly functional and health-giving condition. From an individual perspective, occupational dysfunction is present when one has difficulty choosing, organizing, or performing his or her valued occupations, or when occupations fail to provide quality of life or meet demands of the environment (Finlay, 2004, p. 78). From a population perspective, occupational imbalance exists when a certain population is unable to enjoy the rewards of economic production, where over-employed and underemployed groups are excluded from life-enriching occupations resulting in socio-economic segregation, disparities, and imbalance in privileges and benefits associated with occupations of higher socioeconomic status (Townsend & Wilcock, 2004). Unrelated to and distinct from occupational dysfunction and occupational imbalance, non-occupation occurs when individuals consciously and intentionally release all cognitive, affective, and conative involvement in occupations to rest deeply in the luminous vacuity of awareness that underlies all cognitive-behavioural activity.

Non-occupation is the conditional stilling of occupational performance and engagement, not in the nihilistic or dysfunctional sense, but in a positive life-giving sense. First, a note on terminology. The term ‘conditional’ is used here to refer to the fact that stilling of occupational performance and engagement is seen as an intentional act, necessitating the assembly of varied conditions to elicit the outcome of stilling. The term ‘stilling’ refers to the temporary but profound quietening of cognitive, verbal, and behavioural activity in the context of human occupation. The terms ‘positive’ and ‘life-giving’ allude to the reality of restorative vitality, fulfilment, and joy that comes from non-occupation. This brings me to my next point on the nature and role of non-occupation.

PSI conceives non-occupation as a condition elicited by and through a very specific occupational form that can be termed attentional balancing (Sanskrit: samatha). Attentional balancing is a sophisticated yet entirely naturalistic process of settling a person's consciousness in its natural state of sheer luminosity, bliss, and non-conceptuality (Wallace, 2006, 2007a, pp. 11–27; 94–134). Attentional balancing leading to non-occupation occurs within the occupational form of meditation. As a technique of meditation with roots in ancient Buddhist teachings, attentional balancing can also be found in variant forms in other Asian spiritual cultures such as Hinduism, Taoism, and to a lesser extent Confucianism, as well as in some Indigenous cultures and less normatively in Judeo-Christian and Islamic cultures (see e.g. Feuerstein, 2001, pp. xxv–xxxii; Smart, 1999, pp. 166–195; Wong, 2015, pp. 1–14). It is fair to say that among the world's vast legacy of spiritual texts, the Buddhist discourse contains some of the richest informational content, most detailed instructional pedagogies, and clearest exposition on the occupational form of attentional balancing.

Attentional balancing as an occupational form is intrinsically contemplative in nature, designed to bring the person engaged in it to gradually release all coarse conceptual activity, emotional reactivity, and dwell single-pointedly on consciousness's very centre. While details of this pedagogy fall outside the scope of this article, suffice to say that attentional balancing requires ongoing intensive practice. While generally not a common or shared experience in our highly industrialized society, perfect attentional balance is a potential open to everyone. Anecdotal evidence suggests traditional Asian Buddhist societies as fertile grounds for the rise of attentionally-balanced contemplatives, for example in Tibet (Wallace, 2006, pp. 1–10) as well as Thailand and Burma (Kornfield, 1993, pp. 21–31). Increased research and publications in recent decades have seen a surge of interest among Western researchers and practitioners in contemplative occupational forms and the aim of perfect attentional balance (Lutz, Jha, Dunne, & Saron, 2015).

As such, it is postulated that deeper levels of being and centredness are becoming manifest as the everyday experience of persons immersed in contemplative occupational forms. The middle zone of spirituality begins to take precedence in the lives of these individuals. As like-minded individuals gather for group practice, support, and continuing education, new forms of intentional community centred on contemplative occupations are formed. From PSI's perspective, the spiritual latency of individuals and communities are being activated more and more powerfully as greater numbers of persons delve more and more deeply into contemplative occupational life as a matter of choice. PSI recognizes the possibility of spiritual fulfilment beyond what is normatively defined and casts its conceptual net wider and deeper to capture the farther reaches of human nature (Maslow, 1971, p. 268).

In summary, the enactment of attentional balancing as occupational form is the chief condition for a person entering into the condition and experience of non-occupation. As a temporary stilling of cognitive, verbal, and behavioural activity, non-occupation paradoxically evinces a depth of peace, joy, vitality, and fulfilment not commonly experienced in common everyday occupations. This fact underscores the importance and need for a new occupational category – that of non-occupation.

Trans-occupation

The third new occupational concept in PSI is trans-occupation. Trans-occupation is the a-temporal, nonlocal, trans-linguistic, trans-conceptual cessation of all conditioned occupational experience into an open field of spontaneity and emergent possibilities. Trans-occupational cessation is an ever-present reality waiting to manifest in the unconditioned awareness of the now. Trans-occupation is egoless, occupational-less occupation where the occupier, the occupying, the occupied are simultaneously and incisively deconstructed and de-reified into a centreless clearing (Fenner, 2015, pp. 9–83; 193–245). In trans-occupation, our occupational performance and engagement no longer operate in their usual mode but either stop completely as self- and world-reifying activity falls away, or operate dynamically in an unconditioned mode denuded of fixation, luminous and free. Occupational performance and engagement transcend themselves, even as the reified nuclear self and sense of self-agency dissolve into naked empty presence beyond configuration and words.

Trans-occupation is not delimited to a single specialized occupation where it is enacted but is immanent in every occupation as well as non-occupation. In every instance and occupation, there is the opportunity for occupation to be self-reflexive, self-deconstructing, and self-transcending, thus opening up a centreless absent presence defying all formulae and verbalizations. Trans-occupation is immanent within all occupations. Having said that, trans-occupation is more likely to occur within the occupational form of contemplative practice than in other forms. Specifically, contemplative practice conducive to enactment of trans-occupation belongs to a category of ‘naked awareness’ meditation that is panoramic in scope, fluid in action, untethered to place or time, non-directive, and non-effortful.

Entering and resting in the sphere of trans-occupation depends not on self-driven effort but on self-releasing surrender in openness and trust. As such, trans-occupation can be enigmatically characterized as ‘being nobody, going nowhere; with nothing to gain, nothing to lose, nothing to prove, and nothing to hide’ (Chan, 2011, pp. 79–99; 133–138; Khema, 1997, pp. 129–168). In trans-occupation, there is transcendence of the bifurcating dichotomy of reified self and other, subject and object, spatial and temporal delimitations, and all dysfunctional reactions of craving, hostility, and confusion rooted in misapprehension of the reified self. Again, paradoxically, immanent and total release of self-reification and self-agendas in the midst of occupations takes us straight to transcendence, the deepest zone of spirituality as articulated in PSI (Kang, 2003).

One final note on the ontological status of trans-occupation. The foregoing discussion is an epistemological and phenomenological one, that is, it does not purport to make ontological claims of what transcendence is. In other words, PSI does not state whether and how transcendence and trans-occupation truly exist in their own right –whether they are real, objective, self-authenticating entities or not. Rather, PSI is saying that any statement we can make about transcendence, trans-occupation (and anything for that matter) is inextricably bound up with linguistic and conceptual reification that in a sense constitutes them. Hence, PSI and all its constructs including transcendence and trans-occupation are dependently designated, nominally constructed, and contextually bound within the shared matrix of language and conception that frames them (Newland, 1999, pp. 63–93). Having said that, these constructs are utterances of experience at once effective and real in the lives of those who directly encounter and know them. The reality of felt experience is indubitable but the ontological status of what is experienced is less easy to determine and define.

Enabling change in occupational therapy

Clinical application of PSI in occupational therapy is founded upon the transformative change process alluded to earlier in this paper. To recapitulate, transformative change in PSI is nothing short of awakening to a new world, where a new order of transcendent meanings and way of being has replaced the old order of self-focused, self-occupied, self-driven existence. A radical reorientation of one's life away from mundane concerns towards trans-mundane existence ensues, characterized by nondual integration, wholeness, unfettered freedom of spirit, diminution or eradication of afflictive, toxic tendencies of mind and personality. That said, there can be transformative change of varying degrees where the radical shift away from mundane to trans-mundane concerns do not take place to its fullest extent.

There can be transformative shifts in one's sense of becoming, meaning-making, and being as a result of life-changing events and the processes of occupational adaptation. Such transformative shifts testify to the power of enabling occupational performance and engagement for health and wellbeing (Wilcock & Hocking, 2015, pp. 3–12). PSI extends this view of occupational adaptation beyond the mundane concerns of everyday life to the space of self-transcendent, world-transcendent experience. In this regard, PSI recognizes and valorizes a realm of human experience that has all too often been marginalized, devalued, and discarded by mainstream society with its dominant paradigms of rationalism, positivism, materialism, and consumerism. PSI seeks to re-invigorate the introverted, contemplative, transcendent, hidden, and silent voice in humanity's history by reclaiming their essence in contemporary culture.

To enable and elicit transformative change in persons, PSI provides an enabling pathway comprising the processes of transmission, instruction, coaching, co-presencing, and immersion. This enabling pathway is one of constant recalibration and openness, like the incessant flow of a river but with a difference. PSI views the transformative process as like a river that flows upstream to the mountain top. In a very real sense, the directional flow that transformation takes in PSI is counter to that of the mainstream, commonplace, hyper-masculinized world. PSI's transformative direction can be said to represent a counter-hegemonic stream of socio-discursive praxis (integrating theory with practice). It is a praxis that is more a quiet revolution than a violent confrontation.

In PSI's enabling pathway, five transactive (not interactive) processes co-mingle and work synergistically to draw forth deep transformation in persons. These five processes pertain to the occupational therapist's therapeutic use of self in the therapist-client relationship (i.e. transmission, instruction, and coaching); the active participation of the client in transformation (i.e. co-presencing); and the making of transformative environmental contexts (i.e. immersion). These five processes are transactive because in every instance of each, the other elements are co-present in an ecology of interpenetrating processes working seamlessly together as one.

Transmission

In the therapeutic setting that can include clinical and nonclinical contexts, the occupational therapist versed in PSI utilizes the process of transmission to kick-start transformative change in the client. The process of transmission is essentially a catalytic encounter between therapist and client whereby the meta-occupational, non-occupational, or trans-occupational consciousness of the therapist elicits a deep spiritually heightened response from the client (Fenner, 2015, pp. 9–83; 193–245; Jennings, 2010, pp. 35–106). Such response involves direct cognizance of unmediated meta-, non-, and trans-occupational awareness on the client's part, evoking new learnings into one's spiritual potential and unlearning of old habituated patterns of thought and emotion.

A simultaneous quantum leap out of spiritual latency is made possible by transmission. Perhaps for the first time, the client leaves the density of thought- and worry-laden cloudstorm to plunge into the sky-like vastness of meta-occupation, non-occupation, and trans-occupation. Such a catalytic encounter is made possible by a concomitance of multiple factors, the chief of which is the profundity of consciousness and presence of the therapist. What this means is that the therapist necessarily needs to be familiar with meta-occupation, non-occupation, and trans-occupation on a personal level and in a meaningful way. Personal unmediated knowing of these occupations and sharp distinctive embodiments of each will enable the therapist to offer such transmission to the client to begin the journey of transformative change.

Practically, transmission involves both client and therapist being co-present in the therapeutic space set up between them. The mutual willingness of therapist and client to enter into the therapeutic process sets the scene for transmission. Behaviourally, a fluid blend of deep silence, Socratic dialogue, and contemplative inquiry can be observed. Phenomenologically, the therapist personally embodies and enacts unmediated awareness of meta-, non-, and trans-occupation as part of his or her ground of relational being and experience. Culturally, the process of transmission is profoundly salient and highly regarded in the meditative cultures of India, China, Japan, and Tibet, where master contemplatives play a quintessential role in evoking deep insights that catalyze positive transformative shifts in the consciousness of their trainees and apprentices (Fenner, 2015, pp. 9–83; 193–245).

Instruction

A second process in PSI's enabling pathway is instruction. On the basis of transmission, the client recognizes for the first time the hidden occupational potentials within his/her consciousness and being. Such recognition invites further exploration and cultivation in order that these new occupational experiences can be consolidated and bear fruit in everyday life. A key process to facilitate this movement of exploration and cultivation is that of therapist instruction. Again, therapist consciousness and mastery of meta-, non-, and trans-occupation is crucial for a positive instructional experience and outcome.

Specifically, instruction involves therapist informing, reviewing, guiding, and mentoring the client in the details and nuances of meta-, non-, and trans-occupation. This would entail instructing in occupational skills of mindfulness and clear knowing in particular, but also a range of skills on fine-tuning awareness that includes holding and relaxing, suffusing and pinpointing, inverting and releasing, focusing and scanning (Wallace, 2011, pp. 55–60; 275–315). Auxiliary skills such as mindful recollecting and imagining from a meta-perspective that integrates first- and third-person viewpoints are also part of the instructional package. As more skills and subskills are identified and deemed pertinent and useful, the therapist may include them as part of the instructional content.

Coaching

The third process, coaching, entails drawing forth the client's hidden potentials for change through therapeutic rapport, listening and questioning, awakening and challenging, probing and evoking, co-creating and actualizing, reinforcing and testing (Hall & Duval, 2003, pp. 125–147). In PSI coaching, the therapist may build upon client experience in transmission and instruction to enable ongoing growth and development of the new transformed life. The therapist may also engage the client in a coaching process within which transmission and instruction might later take place, depending on circumstances. In the coaching process, the therapist listens and questions, engaging the client in a dance of change that elicits and strengthens a transformed occupational narrative comprising both plot and metaphor (Kielhofner, 2008, pp. 110–125).

Ultimately, this new narrative is constructed and shaped on the basis of transformative enactment of meta-occupation, non-occupation, and trans-occupation. In particular, trans-occupation has the greatest potential to disrupt a person's taken-for-granted assumptions about reality and life, and cause a dramatic rupture of old worldviews, beliefs, attitudes, and habitual tendencies. A whole new narrative may emerge from such trans-occupational rupture that changes every aspect of life for the person. Coaching them through this radically reorienting process would take a therapist skilled not only in coaching but deeply artful in the therapeutic use of self for coaching change.

Co-presencing

The fourth process of co-presencing involves both therapist and client in a mutual creative space of mindful presence and sensing. Presencing is a term inclusive of both presence and sensing (Scharmer, 2016). According to Scharmer, individuals and societies are not sufficiently aware of what they pay attention to and how they pay attention – a condition of being ‘blind’ to the inner place from which we operate. Unawareness of our ‘blind spot’ prevents a creative and constructive shaping of a world in need of profound systemic changes. Scharmer (2016) proposes presencing as a way of coming to the quiet foundations of our being so that heart, mind, and will can be open and free to envision from (rather than towards) an emerging future. Learning from such a future and realizing that future in the world then follows. As a composite term, presencing thus encompasses presence – the state of being fully present in the still ground underlying each moment where cognitive, affective, and volitional capacities can be unconstrained and freely utilized – and sensing – the shift in awareness constituted by free utilization of cognitive, affective, and volitional capacities that enables fresh learnings from an emerging future.

In occupational therapy, transformative change can be sustained by means of therapist-client co-presencing where both parties enter into that creative nondual space of quiet mutuality. Quiet because of meta-occupational and nonoccupational awareness of both therapist and client creating a space of silent cognizance. Mutuality because two persons are simply present with each other just as they are, in a mutual gaze of attentiveness and connectedness. In such co-presencing, there is an openness to new possibilities and unseen futures that call forth new ways of thinking, feeling, and doing from both therapist and client.

Furthermore, by virtue of the therapist co-presencing with the client, the transformative impact of client's meta-occupational, non-occupational, and trans-occupational experience is reinforced and enhanced. In a sense, co-presencing can be seen as an ongoing flow of transmission from therapist to client even as the client's new awareness feeds into that of the therapist to augment the effects of presencing.

Immersion

The fifth process, immersion, relates to the adaptation, alteration, or creation of transformative environments for optimal realization and sustenance of transformative change. Physical, social, cultural, psychological, and spiritual factors are involved in the making of such transformative environments. Dunn, Brown and McGuigan (1994), in their Ecology of Human Performance model, underscore the importance of creating, adapting, or altering the environment for optimal occupational performance. For example, adaptation and alteration of existing environments to optimize the conditions for the process of transmission is one option. Another option is the creation of a new environment – whether through new construction or through sourcing an appropriately configured environment in another location – to provide the necessary environmental context for transmission. The same principle works for processes of instruction, coaching, and co-presencing.

Immersion serves to enhance, reinforce, and embed PSI's transformative processes in the everyday lives of clients receiving PSI-informed occupational therapy. Apart from the spatial adaptation, alteration, and creation of transformative environments, immersion as a process also has a temporal component. Temporally, immersion involves having clients reside in a transformative environment for an extended period of time that can range from one full day to several days or a week up to several months on end. An example of such transformative environments would be retreat centres set in quiet, natural, and scenic locations with or without a rich spiritual or sacred history. It is hypothesized that such environments particularly suited to contemplative and meditative occupational forms are key to assimilating and consolidating meta-occupational, nonoccupational, and trans-occupational learnings, relearnings, and unlearnings.

Conclusion

The PSI frame of reference for addressing spirituality in occupational therapy acknowledges and valorizes hidden dimensions of human occupation in consonance with the six layers of spirituality that PSI identified. Becoming, meaning, being, centredness, connectedness, and transcendence are facets of spirituality that find expression in occupational performance and engagement. New concepts of meta-occupation, non-occupation, and trans-occupation give epistemic and praxiological space for deeper understandings and experience of these six layers. Particularly, layers of being, centredness, connectedness, and transcendence gain salience and significance when viewed in light of these new occupational concepts. The role of the occupational therapist as transformative change agent is emphasized, enacted through the five PSI processes of transmission, instruction, coaching, co-presencing, and immersion. The relevance and value of PSI-informed occupational therapy, a critically reflexive and counter-hegemonic discourse fashioned in postmodernity, will only be seen with the passage of time and accumulation of testimony from contemporary occupational therapy practice on the ground.

Table 1

Dimensions of Spirituality in Psychospiritual Integration.

Dimensions of Spirituality	Description
Becoming	Volitionally directed growth and development of the self through active doing and consequent experience of flow. Associated with independence, personal growth, autonomy, and choice through active doing (Kang, 2003, p. 97).
Meaning	Sense of intrinsic purposefulness and vitality rooted in personal, collective, or transpersonal spaces that informs the direction of, and inspires the process of living. Involves creation of life themes that forge sense of purpose and resolution, functioning as an ordering and integrative force in consciousness to shape life into a unified flow experience (Kang, 2003, p. 97).
Being	A pervasive quality that forms the foundation of our existence as human beings. It is not the ‘doing’ or ‘achieving’ self but a primordial presence prior to all involvement in occupations. Experience of being includes the creative, intuitive, insightful, and devotional energies of human consciousness (Kang, 2003, pp. 97 –98).
Centredness	Centredness refers to an inner stability based on knowing and recognizing that which lies at the core of one's being. It is the nucleus of one's being, the ‘divine centre’ of self from which all activities flow. It is located within the sphere of being but distinct from it (Kang, 2003, p. 98).
Connectedness	Seeing the self as a fluid process embedded within a larger interrelational context. The ‘self’ is observed as motion rather than as a solid, isolated ‘thing’ separate from all that is external to ‘it’. Connectedness allows for a fullness of being to emerge into profound relationship with all of life and the universe (Kang, 2003, p. 98).
Transcendence	The final dimension of spirituality having two aspects: drive and goal. As transcendent drive, it innately seeks to find ultimate meaning and happiness and manifests as an ongoing search for freedom from all limitation, or rather freedom in spite of limitation. As transcendent goal, it a state of inner freedom and a consciousness that has grown beyond all ego-identification, suffering, pain, and unwholesome actions. In essence, transcendence is meta-linguistic, non-spatial, and atemporal (Kang, 2003, p. 98).

Table 2

Transformative Occupations Matched to Dimensions of Spirituality in Psychospiritual Integration.

Dimensions of Spirituality	Transformative Occupations
Becoming Meaning	Meta-occupation: not a specific occupational form but a discerning mindfulness that occupies the cognitive and phenomenological space at meta-level to everyday occupations.
Being Centredness	Non-occupation: total absorption of consciousness into zero-point singularity beyond language and conception by ‘non-occupational’ form of deep meditation.
Connectedness Transcendence	Trans-occupation: a-temporal, nonlocal, trans-linguistic, trans-conceptual cessation of all conditioned occupational experience into an open field of spontaneity and emergent possibilities, where the occupier, the occupying, the occupied are simultaneously and incisively deconstructed and de-reified into a centreless clearing (Fenner, 2015, pp. 9–83).