DBBB

Doing-Being-Becoming-Belonging Framework (DBBB)

The Doing-Being-Becoming framework was first proposed by Ann Allart Wilcock in 1998 as “a simple way to talk about occupation that appears to appeal to a wide range of people” (Wilcock, 1999, p. 1). Wilcock provided the following descriptions for the framework’s three dimensions: 


In 2004, Karen Whalley Hammell proposed to additionally include Belonging as a fourth dimension, stating “this incorporates the sense of affirmation that one’s life has value for others as well as for oneself” (p. 302). Expanding on work from Rebeiro et al. (2001), Hammell described belonging as “the necessary contribution of social interaction, mutual support and friendship, and the sense of being included, to occupational performance and life satisfaction” (p. 302). Wilcock (2007) later included “belonging” as a fourth dimension in her subsequent work, and a review of the literature demonstrates a general acceptance of this now four-dimensional framework by the OT community. As such, this resource references its evolved form: the Doing-Being-Becoming-Belonging (DBBB) framework.

Figure. One visualization of the Doing-Being-Becoming-Belonging Framework and relationship between occupation and identity.

References. (Christiansen, 1999; Hammell, 2004; Wilcock, 1999; Wilcock, 2007)

Graphic by OTpall using Canva Pro (2023).

Serious illness often initiates a wave of far-reaching changes across a client’s life. The waves may start as ripples with a range of appointments, lifestyle changes, and/or treatments. As the disease progresses, however, it changes what the client is capable of doing, the manner in which they are doing it, and for how long or often they can do it. Decline in functional capacity, fatigue, pain, bodily changes, side effects of surgeries or chemotherapy, precautions/contraindications - these are but a few examples of physical limitations imposed by serious illness that prevent the doing of occupation. Emotional, mental, and spiritual symptoms of living with serious illness also impact the doing of occupation. Depression and anxiety, existential distress, and grief are not uncommon. Cherished roles and routines may become less accessible. For example, a parent may no longer be able to lift their child, or a decline in fine motor control may affect a sketch artist’s quality of work. Clients may experience challenges with occupations that, before their illness, enabled them to be themselves and feel fulfilled. And some of these occupations may be integral to their sense of belonging. Using the previous examples, the parent may feel like they are less a part of their family, and the sketch artist may begin withdrawing from their local art community. OT practice claims a holistic ethos (American Occupational Therapy Association, 2020) and practitioners should anticipate addressing all aspects of their clients who live with serious illness, not just physical limitations.


Becoming will be addressed separately for how it is uniquely processed by those living with serious illness. Using Wilcock’s (1999) definition, “becoming” imbues “a sense of future … growth and potential” (p. 1) into the experience of being. Serious illness, however, brings an uncertainty about the future that may be accompanied by complex emotions and existential worry, especially if the prognosis is terminal. A recent study about cancer survivorship by Martin et al. (2023) argues that “becoming” may even be an unwelcome experience by some clients. Making accommodations to daily life in response to effects of cancer “changed who [participants] became” and “knocked [participants] off their pathway” (p. 286), with some additionally describing themselves as becoming “someone different … as angry, annoyed, abrupt, and nasty” (p. 286). Participants in the study also described positive emotions in relation to who they had become due to cancer, such as resiliency, inner strength, and an ability to overcome fears, as well as a reprioritization of what is most important in life. Regardless of the stage of their disease or the breadth of their functional capacity, clients may continue to seek growth and development. OT practitioners can facilitate becoming by assisting clients in reprioritizing occupational engagement, collaboratively developing new or different ways to engage in occupation, and providing caregiver education that promotes respectful consideration of the client’s priorities and involves caregivers to the client-directed degree.


OT practitioners can use this framework to ground their conceptualization of occupation as not just activities or actions but as something that contributes to a sense of identity and feeling human (Christiansen, 1999). Serious illness may deprive clients of their right to occupation and, subsequently, their right to feel whole and fulfilled as themselves and as human beings. As the specialists in human occupation, OT is especially (and uniquely) equipped to facilitate engagement or re-engagement in occupation for seriously ill clients. As members of a rehabilitation-minded profession, OT practitioners often struggle to conceptualize their role in hospice or palliative care and may experience a sense of futility or crisis in professional identity when working with clients who are not expected to rehabilitate (Bye, 1998; Hammill et al., 2014; Mills & Payne, 2015). Using DBBB, OT practitioners can focus on engagement in meaningful occupation and facilitating achievement of personalized, client-directed goals. Although this shifts the focus of practice away from improving functional capacity or graduating a client off of rehabilitative services, it allows for utilization of the full scope of OT practice and providing truly client-centered care to a population that frequently experiences decreased access to occupation and loss of autonomy.

References

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 1-87. https://doi.org/10.5014/ajot.2020.74S2001 

Bye, R. A. (1998). When clients are dying: Occupational therapists' perspectives. Occupational Therapy Journal of Research, 18(1), 3-24. https://doi.org/10.1177/153944929801800101 

Christiansen. (1999). Defining lives: Occupation as identity: An essay on competence, coherence, and the creation of meaning - The 1999 Eleanor Clarke Slagle lecture. American Journal of Occupational Therapy, 53(6), 547–558. https://doi.org/10.5014/ajot.53.6.547 

Hammell, K. W. (2004). Dimensions of meaning in the occupations of daily life. Canadian Journal of Occupational Therapy, 71(5), 296–305. https://doi.org/10.1177/000841740407100509

Hammill, K., Bye, R., & Cook, C. (2014). Occupational therapy for people living with a life-limiting illness: A thematic review. British Journal of Occupational Therapy, 77(11), 582-589. https://doi.org/10.4276/030802214X14151078348594 

Martin, E., Hocking, C., & Sandham, M. (2023). Doing, being, becoming, and belonging: Experiences transitioning from bowel cancer patient to survivor. Journal of Occupational Science, 30(2), 277–290. https://doi.org/10.1080/14427591.2020.1827017 

Mills, K., & Payne, A. (2015). Enabling occupation at the end of life: A literature review. Palliative & Supportive Care, 13(6), 1755-1769. https://doi.org/10.1017/S1478951515000772 

Rebeiro, K. L., Day, D. G., Semeniuk, B., O’Brien, M. C., & Wilson, B. (2001). Northern Initiative for Social Action: An occupation-based mental health program. American Journal of Occupational Therapy, 55(5), 493-500. https://doi.org/10.5014/ajot.55.5.493 

Wilcock, A. A. (1999). Reflections on doing, being and becoming. Australian Occupational Therapy Journal, 46(1), 1–11. https://doi.org/10.1046/j.1440-1630.1999.00174.x 

Wilcock, A. A. (2007). Occupation and health: Are they one and the same? Journal of Occupational Science, 14(1), 3–8. https://doi.org/10.1080/14427591.2007.9686577 

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