Article Canadian Journal of Occupational Therapy

2024, Vol. 91(1) 100-109

DOI: 10.1177/00084174231178440

Occupational Balance and Emotional © CAOT 2024

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Serious Mental Illness

Équilibre occupationnel et régulation émotionnelle chez les
personnes ayant ou non une maladie mentale grave

Dulce María Romero-Ayuso , Abel Toledano-González,

Mercedes Pinilla-Cerezo, Óscar Sánchez-Rodríguez,
José Joaquín García-Arenas, José Matías Triviño-Juárez ,
and Araceli Ortíz-Rubio

Key words: Emotional self-regulation; Occupational pattern; Occupational therapy; Psychiatry; Time allocation.

Mots clés : Autorégulation émotionnelle ; ergothérapie ; patron occupationnel ; psychiatrie ; répartition du temps.

Abstract
Background. Serious mental illness affects daily functioning, including occupational balance. Purpose. This study aims to com-
pare occupational balance and emotional regulation between people with serious mental illness and the healthy population and to
examine the relationship between occupational balance and emotional regulation. Method. A cross-sectional study was per-
formed. Occupational balance and emotional regulation were measured using the Occupational Balance Questionnaire and
the Emotional Regulation Questionnaire, respectively. A multivariate analysis (analysis of covariance) was conducted.
Findings. The sample consisted of 112 individuals, divided into two groups: the serious mental illness group (n = 55); and
the healthy group (n = 57). People with serious mental illness reported lower occupational balance and lower cognitive reap-
praisal than the healthy population. Furthermore, the higher cognitive reappraisal, the higher the occupational balance, and
the higher the expressive suppression, the lower the occupational balance. Conclusion. The results provide preliminary evi-
dence of the relationship between occupational balance and emotional regulation.

Résumé
Description. Les maladies mentaux graves affectent le fonctionnement quotidien, y compris l’équilibre occupationnel. But.
Cette étude vise à comparer l’équilibre occupationnel et la régulation émotionnelle entre les personnes ayant une maladie men-
tale grave et celles n’en ayant pas, et à examiner la relation entre l’équilibre occupationnel et la régulation émotionnelle.
Méthodologie. Une étude transversale a été réalisée. L’équilibre occupationnel et la régulation émotionnelle ont été
mesurés à l’aide du Questionnaire de l’équilibre occupationnel (OBQ-E) et du Questionnaire de régulation émotionnelle
(ERQ), respectivement. Une analyse de la covariance a été réalisée. Résultats. L’échantillon était composé de 112 personnes,
divisées en deux groupes : celles ayant une maladie mentale grave (n = 55) et les personnes en santé (n = 57). Les personnes
ayant une maladie mentale grave ont rapporté un équilibre occupationnel inférieur et une réévaluation cognitive inférieure
par rapport à la population en santé. En outre, plus la réévaluation cognitive est élevée, plus l’équilibre occupationnel est

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Universidad de
Granada. Vicerrectorado de Responsabilidad Social, Igualdad e Inclusión, Programa 45. Impulso de investigación en materia.

Corresponding author: Dulce María Romero-Ayuso, Department of Physical Therapy, Occupational Therapy Division, Faculty of Health Sciences, University of
Granada. Avenida de la Ilustración n° 60, 18016 Granada, Spain. Email: [email protected]
Canadian Journal of Occupational Therapy 91(1) 101

élevé. Plus la suppression expressive est élevée, plus l’équilibre occupationnel est faible. Conclusion. Ces résultats fournissent
des données préliminaires sur la relation entre l’équilibre occupationnel et la régulation émotionnelle.

S
erious mental illness, such as schizophrenia, bipolar dis- based on one’s own and others’ emotions, facilitating social
order, and schizoaffective disorder, often results in con- adaptation and social functioning, controlling negative emo-
sequences such as a deteriorated quality of life, an tions, and focusing on pleasurable ones (Mayer et al., 2008).
impoverished everyday life with few meaningful activities, There are two main types of strategies for emotional regulation:
reduced work capacity, risks of cardiovascular problems, and (1) cognitive reappraisal and (2) expressive suppression (Gross
increased mortality. Thus, a serious mental illness is noted to & John, 2003). Cognitive reappraisal can be defined as the
have significant repercussions in numerous areas of life func- mental change that occurs prior to the generation of the
tioning including independent living, employment, and inter- emotion and that consequently modifies its emotional impact
personal skills (McCormick et al., 2022). on the situation (e.g., when we receive news that disappoints
Well-being is associated with their every occupation, par- us or that we did not expect, new arguments are contemplated
ticularly how individuals perceive the meaning, values, and sat- that allow us to approach the situation in a different way). On
isfaction linked with those occupations (Eklund et al., 2017). the other hand, expressive suppression involves inhibiting the
People with a diagnosis of severe mental illness often show dif- expression of emotions after the emotional response has been
ficulties in engaging in different occupations, such as work, generated (e.g., when someone tells us news we don’t like,
leisure, and personal care, affecting their occupational balance keeping a poker face even when we feel very sad or angry)
(Backman, 2004). Different authors have suggested the need (Gross & John, 2003). Despite the relevance of emotional reg-
and the interest to study in-depth the occupational balance in ulation in people with severe mental illness and the decrease in
people with serious mental illness. The balance between the dif- self-care, work, and social participation activities, to date, to the
ferent occupations that compose people’s daily lives, that is, best of the authors’ knowledge, they have not been found
work, personal care, rest, leisure, and play, has been considered studies that relate occupational balance and emotional regula-
vital since occupational therapy was founded (Backman, 2004; tion in people with severe mental illness or healthy people.
Eklund & Argentzell, 2016). The aim of this study was to analyze perceptions of occu-
The use of time in a harmonious and rhythmic way is a core pational balance and emotional regulation in people with
concept underlying the theory and practice of occupational serious mental illness compared to the healthy population.
therapy, an important concept since the beginning of the profes- Additionally, this study aimed to find out if emotional regula-
sion (Meyer, 1977): “The whole of human organization has its tion can be related to occupational balance in people with
shape in a kind of rhythm. (…) the big four – work and play and serious mental illness. Based on the current status quo of the lit-
rest and sleep, which our organism must be able to balance erature, we hypothesized that: (1) people with severe mental
even under difficulty” (p. 641). Nowadays, occupational illness will report lower occupational balance and emotional
balance might be defined as “the individual’s perception of self-regulation than the healthy population, (2) people who
having the right amount of occupations and the right variation show greater occupational balance will show better emotional
between occupations” (Wagman et al., 2012). There are previ- self-regulation, with greater cognitive reappraisal and expres-
ous studies which showed that being under-occupied is a sive suppression; (3) age and gender moderate the relationship
problem for individuals with serious mental illness people and between occupational balance and emotional self-regulation,
that they could better control their anger when they showed such that younger age and female gender are associated with
occupational balance and they felt competent (Leufstadius better occupational balance, less expressive suppression and
et al., 2009). greater use of cognitive reappraisal. Understanding the relation-
Promoting participation and social inclusion is one of the ship between occupational balance and emotional self-
challenges in mental health rehabilitation and it is a fundamen- regulation might help to establish appropriate intervention
tal part of occupational therapy. The lack of participation in strategies in mental health programs.
social activities in people with severe mental illness has been
linked to a deficit in social cognition, especially in the process-
ing of emotions, perception, recognition, and regulation of emo- Method
tions. This deficit in social cognition makes it difficult to
understand social situations and predict the behaviour and Study Design
intentions of other people (Barrios et al., 2018). These difficul- An observational cross-sectional study was performed. The
ties persist after clinical remission in more than half of the study is reported using EQUATOR network recommendations
people with mental health illness (Pinna et al., 2013). Thus, for observational studies (STROBE, STrengthening the
emotional regulation could be related to participation in differ- Reporting of OBservational studies in Epidemiology)
ent social activities. In this sense, emotional regulation refers to (Vandenbroucke et al., 2014). Ethics approval was obtained
the ability to control and show emotions according to each sit- from the relevant University Human Research Ethics
uation, being able to initiate, and maintain an emotional state, Committee and was conducted following the last version of

Revue canadienne d’ergothérapie

102 Romero-Ayuso et al.

the Helsinki Declaration. All participants agreed to participate (Carpenter et al., 2020; Klodnick et al., 2014). Considering
and gave their informed consent before completing the that in the European Union, in 2020, the average age of
questionnaires. young people leaving the parental household was 26.5 years
(EUROSTAT, 2020), age was dichotomized into two catego-
ries (18–27 years; ≥ 28 years).
Participants
Two occupational therapists recruited all participants using con-
venience sampling (Hernández et al., 2010). People with mental Occupational Balance Questionnaire
illness were recruited from two public community mental health Occupational balance was measured with the Spanish version
centers and healthy people through advertisements at a univer- of the Occupational Balance Questionnaire (OBQ-E)
sity in Spain. All participants had to be between 18 and 65 years (Peral-Gómez et al., 2022). This has been described as an ade-
old and all subjects participated voluntarily. Prior to inclusion, quate questionnaire to register occupational balance in the
participants were asked to fill in a health questionnaire to verify Spanish population. This questionnaire focuses on a person’s
that they did not suffer from any other illness. The eligibility experience of her /his amount and variation of occupations in
criteria for the serious mental illness group were as follows: everyday life (Wagman et al., 2021). It consists of 13 questions
being an adult patient, who is diagnosed with mental illness measured on a six-point Likert scale from 0 “strongly disagree”
using the DSM-5 criteria; and skills to read and write indepen- to 5 “strongly agree.” The rating of the instrument can be
dently. People with mental illness who were illiterate or had any assessed at the level of the individual item or as a summed
chronic comorbid physical or neurological disease (e.g., cardio- total score (ranging between 0 and 65; the higher score, the
pulmonary disease, lupus) were excluded from the study. In better occupational balance). OBQ-E has good internal consis-
addition, everyone had to have the ability to write and read tency with a Cronbach’s alpha value of 0.87 (Peral-Gómez
independently. In each centre, the occupational therapist et al., 2022).
informed the participants about the aims of the study, the meth-
odology, its duration, that their participation was voluntary, as
well as the possibility of leaving the study at any time if they so Emotion Regulation Questionnaire
wished and without any explanation. It was explained to them Emotional regulation was assessed with the Spanish version of
that their participation did not affect their treatment in any the Emotion Regulation Questionnaire (ERQ) (Marco et al.,
way and the study was independent of it. Once this information 2021). It is a 10-item measure with two subscales evaluating
was received, people with mental illness decided whether they the perception of the use of cognitive reappraisal (six items)
wanted to participate or not. Those people who gave written and expressive suppression (four items) to regulate emotions.
informed consent were contacted by the research team to These two factors have been shown to operate independently
have an appointment for the study. In the case of the healthy of each other. Items are rated on a 7-point Likert-type response
sample, they were initially recruited by advertisements at scale from 1 “strongly disagree” to 7 “strongly agree.” An
the university indicating that if they were interested in partici- example of items from the cognitive reappraisal and expressive
pating, they should contact the main researcher by email. suppression subscale respectively are: “When I’m faced with a
Once the informed consent was signed, the questionnaires stressful situation, I make myself think about it in a way that
were completed. helps me stay calm,” and “I control my emotions by not express-
ing them.” Higher scores on each scale indicate greater use of
the corresponding emotional regulation strategy. The reliability
Data Collection of the scale was good, with a Cronbach’s alpha value of 0.93.
The evaluation was performed in one session, lasting 1 h. The
answers of the included participants were collected in writing
on an electronic form developed for this study. The question- Data Analysis
naire was self-administered. In the case of the people with Sociodemographic characteristics (gender, range of age, and
mental illness, a 4th-grade Occupational Therapy student educational level) were described using absolute and percent-
trained in the administration of both questionnaires performed age values. To detect the differences between the two groups
the evaluation and supervised the process while they completed (serious mental illness group and healthy group) in the distribu-
it. None of the participants had received financial incentive for tion of gender, age-range and educational level, it was per-
participating in the study. A total of two patient-reported formed Pearson’s χ2 test or Fisher’s exact test when the
outcome measures were completed by the participants to regis- expected values in any of the cells of the contingency table
ter occupational balance and emotional regulation. Gender and were below five (Sánchez Villegas et al., 2006).
profession were collected using a survey. Other demographic Normal distribution was checked for occupational balance,
data collected was age, because of its importance in the incor- emotional regulation, cognitive reappraisal, and expressive
poration into the labour market, in turn related to economic suppression using the Kolmogorov–Smirnov test. As these
independence and emancipation, aspects that could have a sig- variables followed a non-normal distribution (Kolmogorov–
nificant impact on the occupational balance in adulthood Smirnov’s test p-value < .05), median and interquartile range

Canadian Journal of Occupational Therapy

Canadian Journal of Occupational Therapy 91(1) 103

(IQR) were used for their description. According to the number treatment. Regarding the healthy group, it was composed of
of items in the ERQ and the sample size of this study, the inter- 57 people (Table 1).
nal consistency of the scale can be considered moderate for a The reliability of ERQ was good, with a Cronbach’s alpha
Cronbach’s alpha value > 0.75, good if > 0.80, and excellent value of 0.82, and for the OBQ-E it was excellent, with a
if > 0.85. In the case of the OBQ-E, given that it has 13 items, Cronbach’s alpha value of 0.92. There were statistically signifi-
and the sample size, the internal consistency can be considered cant differences between the two groups in age (χ2 = 21.584;
moderate for a Cronbach’s alpha value > 0.80, good if > 0.85 df = 1; p < .001), gender (χ2 = 35.489; df = 1; p < .001), and
and excellent if > 0.90 (Ponterotto & Ruckdeschel, 2007). To educational level (χ2 = 13.369; df = 1; p = .001) (Table 1).
analyze the differences in occupational balance, emotional reg- Non-normal distribution was followed by occupational
ulation, cognitive reappraisal, and expressive suppression balance (Kolmogorov–Smirnov test = 0.084 df = 112; p =
between the two groups, the Mann–Whitney U-Test was .048), emotional regulation (Kolmogorov–Smirnov test =
used. To know the differences between groups in percentages 0.153 df = 112; p < .001), cognitive reappraisal (Kolmogorov–
of answers for each item of the OBQ-E, Pearson’s χ2 test or Smirnov test = 0.091 df = 112; p = .023), and expressive
Fisher’s exact test was conducted when the expected values suppression (Kolmogorov–Smirnov test = 0.121 df = 112; p <
in any of the cells of the contingency table were below five .001). The healthy group showed statistically significant higher
(Sánchez Villegas et al., 2006). scores in occupational balance (Mann–Whitney U-test =
The analysis of the association between two categorical 1132.5; p = .011), and in cognitive reappraisal (Mann–
variables was conducted using Spearman’s correlation coeffi- Whitney U-test = 867; p < .001), and as well as a slightly signif-
cient. An analysis of covariance (ANCOVA) with OBQ-E icant lower score in expressive suppression (Mann–Whitney
was conducted, including those variables that showed a signifi- U-test = 1240.5; p = .057) (Table 2).
cant correlation controlling for age, gender, educational level, When analyzing the answers between the comparison
and group. Statistical significance was set at p < .05. The anal- groups for each item of the OBQ-E, differences were observed
ysis was performed with IBM Statistical Package for Social in three of them. Serious mental illness group, compared to
Sciences software (IBM Corp. Published 2012. IBM SPSS healthy group, perceived that they had fewer meaningful occu-
Statistics for Windows, Version 28.0 Armonk, NY). pations (Fisher’s exact test = 17.279; df = 5; p = .004), a
lower balance between doing things alone/with others
(Fisher’s exact test = 13.504; df = 5; p = .019), and a
greater disagreement with having enough to do during a
Results regular week (Fisher`s exact test = 28.120; df = 5; p < .001)
A total of 65 people with serious mental illness from the (Table 3).
Vocational Rehabilitation Centre were invited to participate, Regarding the correlation analyses, occupational balance
of whom 22 service users agreed to participate. Of the 95 showed a statistically significant positive relationship with cog-
patients from the psychosocial rehabilitation center, a total of nitive reappraisal (rs = .365; p < .001) and a negative relation-
37 volunteered/consented to participate, of which four were ship with expressive suppression (rs = −.332; p < .001)
ineligible due to exclusion criteria (two of them had obesity (Table 4).
and hypertension, one patient had heart disease, and another After controlling for age, gender, educational level, and
patient had psoriasis and uncontrolled thyroid disease), group, the results of the ANCOVA showed that, for every one-
leaving a total of 33 participants from this setting. The 55 point increase in expressive suppression, the total OBQ-E score
patients were in clinical follow-up and with pharmacological decreases by an average of 0.70 points (p < .001); and for every

Table 1
Characteristic of the Participants Included in the Study (n = 112)

Healthy
Serious mental illness (n = 55) (n = 57) χ2 p-value

Gender 35.489 <.001*

Male 37 (67.3%) 7 (12.3%)
Women 18 (32.7%) 50 (87.7%)
Range of age 21.584 <.001*
23–27 years old 5 (9.1%) 28 (49.1%)
≥28 years old 50 (90.9%) 29 (50.9%)
Educational level 13.369 .001**
Primary education 10 (18.2%) 0 (0%)
Secondary education 42 (76.4%) 48 (84.2%)
University education 3 (5.5.%) 9 (15.8%)

*χ2 = Pearson’s Chi-square test; ** Fisher’s exact test.

Revue canadienne d’ergothérapie

104 Romero-Ayuso et al.

Table 2
Differences in Occupational Balance and Emotional Regulation by Groups

Serious mental illness Healthy

(n = 55) (n = 57)
Median (IQR) Median (IQR) Mann–Whitney U-test p-value

OBQ-E 30 (20–41) 39 (30.5–47) 1132.5 .011

ERQ 44 (36–48) 45 (39–51) 1397.5 .322
Expressive suppression 19 (12–22) 15 (9–20) 1240.5 .057
Cognitive reappraisal 25 (20–29) 31 (27–35) 867 <.001
OBQ-E = Occupational Balance Questionnaire; ERQ = Emotion Regulation Questionnaire.

one-point increase in cognitive reappraisal, the total OBQ-E (Kielhofner, 2007) emphasizing one’s qualitative perspective
increases by an average of 0.47 points (p = .002) (Table 5). about the relevance of one’s occupations (Crist et al., 2000).
This point of view is consistent with the results obtained by a
previous study in which the healthy group showed greater
Discussion enjoyment, competence, and relevance from occupations than
people who had mental health problems. Furthermore, the
Differences in Occupational Balance healthy group became more aware of the relevance of play/
The first aim of this study was to analyze the perceptions of leisure and its relationship with their well-being (Crist et al.,
occupational balance in people with serious mental illness 2000). Moreover, other studies have shown a relationship
and to study if there were differences by group. The results of between occupational balance and emotional well-being
our study support our first hypothesis, which states that (Eklund & Argentzell, 2016). Consistent with our findings,
people with serious mental illness reported lower occupational people with severe mental illness reported having lower occu-
balance than the healthy population. The cut-off points set for pational balance. Considering the results of the previous
the OBQ-E for the general population (Peral-Gómez et al., authors, occupational therapy interventions that promote occu-
2022) are also consistent with these results. Previous studies pational balance and awareness of it, could help generate
have shown that lack of occupation is a problem for people greater well-being in people with serious mental illness.
with mental illness (Bejerholm & Björkman, 2011) which Furthermore, it has been suggested that one of the most impor-
may have an impact on their quality of life (Wagman et al., tant challenges for occupational therapists is to understand the
2021). In addition, these results could be related to the findings meaning that activities have for the client and their impact on
of other studies that showed occupational engagement facili- the reconstruction of their occupational identity, through
tates the reduction of negative symptoms in people with engagement in different occupations (Crist et al., 2000). Other
serious mental illness (Bejerholm & Björkman, 2011) and it authors have mentioned that this important task should start
has even been found that participation in social activities by helping people with mental illness understand their partici-
helps in reducing delusions (Myin-Germeys et al., 2001). pation in occupations in a harmonious way (Eklund &
Our findings showed that people with severe mental illness Argentzell, 2016) fostering their sense of competence, belong-
perceived their occupations as less meaningful. These findings ing, enjoyment and autonomy (Crist et al., 2000). In this sense,
support previous literature showing that this population is char- it has been described that people with severe mental illness tend
acterized by low participation in significant occupations and to consider meaningful activities those activities that are pleas-
maintains low occupational engagement (Bejerholm & ant and allow them to enjoy and to be in connection and interact
Björkman, 2011). Similar results have been reported in other with other people and their environment, productive activities
studies, showing that people with schizophrenia participated that lead to the development of a sense of competence, activities
in significantly fewer activities than healthy people that allow them to have routines and develop projects as well as
(Lipskaya-Velikovsky et al., 2015) and with impoverished activities involved with personal and health care.
daily life with few meaningful occupations and a sedentary On the other hand, our findings showed statistically signifi-
style (Eklund et al., 2017). Also, other authors with the cant differences for “the balance between doing things alone
Spanish population showed differences in occupational satis- with others.” It has been indicated that people with mental
faction when comparing people with mental illness and the illness are characterized by being under-occupied, which
healthy population using another useful instrument to assess affects their recovery and well-being (Eklund & Argentzell,
occupational balance and satisfaction with occupations 2016). It has been pointed out that there is a cultural and
(SDO-OB) (Vidaña-Moya et al., 2020). In community mental gender pattern in the occupational balance, in such a way that
health intervention programs, beyond the distribution of time people who have children perceive that they perform a higher
in self-care, work, leisure, rest, etc., it has been suggested that number of activities in their daily life, such as occurs with
a broader perspective, of temporal adaptation, should be taken women who assume more responsibilities in raising children

Canadian Journal of Occupational Therapy

 Table 3
Differences in Occupational Balance (OBQ-E) Between Healthy and Serious Mental Illness

Serious mental illness (n = 55) Healthy (n = 57)

SD D SgD SgA A SA SD D SgD SgA A SA

Items n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) p-value

1. Balance between doing things for 9 (16.4) 9 (16.4) 11 (20) 13 (23.6) 7 (12.7) 6 (10.9) 6 (10.5) 9 (15.8) 9 (15.8) 13 (22.8) 14 (24.6) 6 (10.5) .685*
others/for oneself
2. Perceiving one’s occupations as 2 (3.6) 6 (10.9) 5 (9.1) 22 (40) 14 (25.5) 6 (10.9) 2 (3.5) 1 (1.8) 0 (0) 14 (24.6) 25 (43.9) 15 (26.3) .004**
Canadian Journal of Occupational Therapy 91(1)

meaningful
3. Time for doing things wanted 3 (5.5) 7 (12.7) 5 (9.1) 21 (38.2) 13 (23.6) 6 (10.9) 2 (3.5) 3 (5.3) 3 (5.3) 17 (29.8) 21 (36.8) 11 (19.3) .302**
4. Balance between work, home, 3 (5.5) 16 (29.1) 12 (21.8) 15 (27.3) 6 (10.9) 3 (5.5) 5 (8.8) 5 (8.8) 11 (19.3) 22 (38.6) 10 (17.5) 4 (7) .120**
family, leisure, rest, and sleep
5. Balance between doing things 9 (16.4) 11 (20) 16 (29.1) 8 (14.5) 7 (12.7) 4 (7.3) 3 (5.3) 4 (7) 12 (21.1) 15 (26.3) 17 (29.8) 6 (10.5) .019**
alone/with others
6. Having sufficient to do during a 8 (14.5) 8 (14.5) 14 (25.5) 7 (12.7) 11 (20) 7 (12.7) 0 (0) 1 (1.8) 6 (10.5) 6 (10.5) 22 (38.6) 22 (38.6) <.001**
regular week
7. Have sufficient time for doing 5 (9.1) 4 (7.3) 12 (21.8) 10 (18.2) 16 (29.1) 8 (14.5) 4 (7) 9 (15.8) 14 (24.6) 11 (19.3) 12 (21.1) 7 (12.3) .725**
obligatory occupations
8. Balance between physical, social, 8 (14.5) 14 (25.5) 14 (25.5) 11 (20) 5 (9.1) 3 (5.5) 6 (10.5) 11 (19.3) 12 (21.1) 17 (29.8) 9 (15.8) 2 (3.5) .640**
mental, and restful occupations
9. Satisfaction with how time is spent 7 (12.7) 13 (23.6) 11 (20) 12 (21.8) 9 (16.4) 3 (5.5) 4 (7) 10 (17.5) 16 (28.1) 9 (15.8) 16 (28.1) 2 (3.5) .455**
in everyday life
10. Satisfaction with the number of 8 (14.5) 8 (14.5) 16 (29.1) 14 (25.5) 6 (10.9) 3 (5.5) 3 (5.3) 7 (12.3) 13 (22.8) 16 (28.1) 15 (26.3) 3 (5.3) .252**
activities during a regular week
11. Balance between obligatory/ 10 (18.2) 8 (14.5) 14 (25.5) 15 (27.3) 6 (10.9) 2 (3.6) 3 (5.3) 8 (14) 12 (21.1) 14 (24.6) 14 (24.6) 6 (10.5) .104**
voluntary occupations
12. Balance between energy-giving/ 11 (20) 16 (29.1) 13 (23.6) 9 (16.4) 2 (3.6) 4 (7.3) 4 (7) 11 (19.3) 15 (26.3) 16 (28.1) 8 (14) 3 (5.3) .075**
energy-taking activities
13. Satisfaction with time spent in 3 (5.5) 6 (10.9) 14 (25.5) 15 (27.3) 10 (18.2) 7 (12.7) 7 (12.3) 10 (17.5) 13 (22.8) 10 (17.5) 11 (19.3) 6 (10.5) .589**
rest, recovery, and sleep
SD = strongly disagree; D = disagree; SgD = slightly disagree; A = agree; SgA = slightly agree; SA = strongly agree. Categorical variables are expressed as a percentage; n = population size. *χ2 = Pearson’s
Chi- square test; ** Fisher’s exact test.

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105
106 Romero-Ayuso et al.

and in household chores. This pattern could be related to less Our research is consistent with other author’s results, which
participation in work and leisure activities, where spaces are suggest that people with severe mental illness should be encour-
shared and where they interact with other people (Eklund & aged to find a balance between occupations and rest (Eklund &
Argentzell, 2016). These differences are greater in the popula- Sandlund, 2014) even if they do not have a job, providing oppor-
tion with mental illness, in which a lower socio-labour integra- tunities to be active and break the pattern of being under-occupied
tion has been reported, associated with the stigma of mental (Eklund & Argentzell, 2016).
illness and the difficulty for employers to understand it.
Likewise, the lack of balance between doing things alone or
with others may be related to the well-being perceived by Differences in Expressive Suppression and
some patients with mental illness when doing things alone, Cognitive Reappraisal
such as walking (Jivanjee et al., 2008). Our first aim also included analyzing the perceptions about
Moreover, our results showed that the serious mental emotional regulation in people with serious mental illness and
illness group, in comparison to the healthy group, reported a studying if there were differences when compared with the
greater disagreement with “having sufficient to do during a healthy group. Related to emotional regulation in people with
regular week,” that is, they perceived to be under-occupied, serious mental illness, one of the key symptoms is reduced emo-
been these differences statistically significant. The under- tional experience, understood as emotional withdrawal, passive
occupation or lack of occupation is another key element in social withdrawal, active social avoidance, or social withdrawal
the occupational balance in people with mental illness that coin- (Al-Halabí et al., 2016; Silberstein et al., 2018). In the serious
cides with the findings of a previous research (Eklund & mental illness group, compared to the healthy group, we
Argentzell, 2016). It is interesting to mention that when it has found a statistically significant lower cognitive reappraisal
been compared over-occupied versus under-occupied users, and a higher expressive suppression, although in this case the
the occupational balance is greater in the last. This has been difference was marginally significant. Poor emotional aware-
explained because, in the case of people with serious mental ness can lead to difficulties in identifying and describing feel-
illness, the mere fact of having a job does not mean having more ings, with fewer social contacts (Kimhy et al. 2012). In
occupational balance if the job is not flexible enough to adapt to people with mental illness, it has been observed that they use
the evolution of their disease (Eklund & Argentzell, 2016). emotional suppression to a greater extent, related to poor
social functioning, compared to cognitive reappraisal, which
allows modifying the way in which they think about a certain
Table 4
Correlations Between Occupational Balance and Emotional Regulation
event to alter its emotional impact and it is more related to a
positive emotion and general feelings of well-being.
Cognitive Expressive
OBQ-E EQR reappraisal suppression
Relationship Between Occupational Balance and
OBQ-E —
EQR .096 — Emotional Regulation
Cognitive .365** .761** — The second hypothesis of our research was that people with
reappraisal greater occupational balance would show better emotional self-
Expressive −.332** .557** −.004 — regulation, with greater cognitive reappraisal and expressive
suppression
suppression. In this sense, this study partially confirms it. Our
OBQ-E = Occupational Balance Questionnaire; ERQ = Emotion Regulation findings showed that the higher cognitive reappraisal, the
Questionnaire. higher occupational balance, and the higher expressive suppres-
** The correlation is significant at the .001 level (two-tailed). sion, the lower occupational balance. According to Kimhy et al.

Table 5
Multivariate Model (ANCOVA) of Occupational Balance Adjusted for Age, Gender, Cognitive Reappraisal, and Expressive Suppression

95% Confidence interval

Variable β SE t p-value Lower limit Upper limit

Intercept 24.74 12.31 2.010 .047 0.33 49.14

Cognitive reappraisal 0.47 0.15 3.167 .002 0.18 0.76
Expressive suppression −0.70 0.19 −3.724 <.001 −1.07 −0.33
Age 2.59 2.90 0.895 .373 −3.15 8.34
Gender 1.21 2.96 0.408 .684 −4.66 7.08
Educational level 0.16 2.87 0.054 .957 −5.52 5.84
Group (reference: Healthy) −2.21 3.62 −.611 .542 −9.39 4.97

Adjusted R2 = .18.

Canadian Journal of Occupational Therapy

Canadian Journal of Occupational Therapy 91(1) 107

(Kimhy et al., 2012), less suppression and a greater cognitive It would be of interest to conduct longitudinal studies to estab-
reappraisal have been associated with better social functioning lish causal relationships and to verify whether interventions in
in people with serious mental illness. Other studies have shown people with severe mental illness that try to increase group
that people with mental illness who use suppression as an emo- activities manage to improve their social participation and occu-
tional regulation strategy, showed greater negative emotions, a pational balance. Fourth, nowadays, there are two instruments
reduction in positive emotions, a decrease in social interaction available for use in the Spanish population: the SOD-EO and
in their daily life (Moran & Kring, 2018) and fewer prosocial the OBQ-E. SOD-EO assess satisfaction with occupations and
activities (Lopes et al., 2005). Likewise, it has been indicated occupational balance in the Spanish population with mental
that greater use of suppression is associated with poorer illness (Vidaña-Moya et al., 2020). OBQ-E is validated in the
social functioning, lower quality of friendships, lower interper- Spanish population but not in mental health. However, the
sonal sensitivity, fewer prosocial activities, and more social use of the OBQ-E could be justified by wanting to compare
conflict in young adults (Kimhy et al., 2012). people with and without mental illness and because the
Our findings could have implications for the clinical prac- OBQ-E has normative data that also allows a better assessment
tice. The assessment of occupational balance in people with of the results (Peral-Gómez et al., 2022).
serious mental illness could help occupational therapists to opti-
mize the design of therapeutic approaches for this population.
Occupational Therapy intervention in patients with serious Conclusions
mental illness should give opportunities for these people to People with serious mental illness reported a lower occupa-
get involved and engage in occupations that are meaningful. tional balance compared to healthy people. Furthermore, our
On the other hand, implementing programs that include mean- findings showed that the higher cognitive reappraisal, the
ingful occupations and that allow these people to improve their higher occupational balance, and the higher expressive suppres-
cognitive reappraisal, could improve their occupational sion, the lower occupational balance. These findings give rea-
balance. Negative emotions can trigger psychotic symptoms, sonable support to the idea that patients with severe mental
which makes it even more relevant for them to learn effective illness can benefit from occupational therapy intervention
regulation strategies (Grezellschak et al., 2015). In addition, it based on meaningful occupations, especially those required
has been found that people with schizophrenia can modulate an interaction with others and with the environmental and not
their emotional regulation following explicit instructions only the number of activities.
(Moran & Kring, 2018). The development of emotional skills
in outpatients could be crucial for their recovery since it has
been observed that the improving of social cognition, such as Key Messages
empathy and emotional understanding skills are good predictors • People with serious mental illness had significantly lower
of treatment success (Rus-Calafell et al., 2013). In addition, the occupational balance concerning meaningful occupations,
results suggest that it could be relevant to promote occupational the balance between doing things alone/with others, and
balance and involvement in social occupations that encourage having sufficient to do during regular work.
these patients to relate to others and their environment. It may • The higher cognitive reappraisal, the higher occupational
be of interest to consider the most important social occupations balance, and the higher expressive suppression, the lower
for each person (i.e., team sports, dance), extending participa- occupational balance.
tion beyond the therapeutic intervention, such as weekends. • Patients with severe mental illness can benefit from occupa-
In addition, incorporating interventions aimed to improve tional therapy intervention based on meaningful occupa-
time management to avoid, for example, procrastination, tions, especially those requiring interaction with others
excess or deficiency of some type of specific occupation, and with the environment and not only the number of
could allow the gradual development of a viable, regular and activities.
sustainable occupational pattern, and help prepare for discharge
(Holmefur et al., 2019, 2021).
ORCID iDs
Dulce María Romero-Ayuso https://orcid.org/0000-0002-2479-
Limitations 8913
Our study has several limitations. First, the selection of patients José Matías Triviño-Juárez https://orcid.org/0000-0002-0988-3191
was conducted by means of a non-probabilistic convenience
sampling. This might limit the extrapolation of the results,
although the usefulness of this method has been demonstrated
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Physiotherapy, Faculty of Health Science, University of
coefficient alpha and a reliability matrix for estimating adequacy
Granada, Granada, Spain; with Mind, Brain and Behavior
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Granada, Spain and Instituto de Investigación Biosanitaria
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schizophrenia: A preliminary study. Schizophrenia Research, Castilla-La Mancha, Talavera de la Reina, Spain.
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assessments of social cognitive ability, and everyday outcomes.
José Joaquín García-Arenas is affiliated with Servicio
Schizophrenia Research, 199, 75–82. https://doi.org/10.1016/j.
Murciano de Salud, Mental Health Center, Lorca, Spain.
schres.2018.04.015
Vandenbroucke, J. P., von Elm, E., Altman, D. G., Gøtzsche, P. C., José Matías Triviño-Juárez is affiliated with Department of
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Egger, M., & STROBE Initiative. (2014). Strengthening the report- 18016 Granada, Spain.
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Explanation and elaboration. International Journal of Surgery Araceli Ortiz Rubio is affiliated with Department of
(London, England), 12(12), 1500–1524. https://doi.org/10.1016/j. Physiotherapy, Faculty of Health Sciience, University of
ijsu.2014.07.014 Granada, Granada, Spain.

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