Skills Training or Occupational Therapy for Persistent Schizophrenia

To the Editor: It was with dismay that I read the article by Robert Paul Liberman, M.D., and colleagues (1). Occupational therapists have worked in the mental health system for over 75 years, and many of the current psychiatric rehabilitation practice models incorporate occupational therapy theory and practice. It was therefore a matter of great concern to read about research that questioned the efficacy of psychosocial occupational therapy. I believe there are several flaws in the research design and the article that should be acknowledged.

With no apparent literature or references, the authors state that occupational therapy treatment “[consists of] expressive art and crafts and recreational activities [used to] build self-esteem and productivity.” While these media are used in occupational therapy programs, they are not the only media used. In a 1997 survey of 243 occupational therapists practicing in mental health, the following interventions were regularly used by more than 50% of those responding: training in daily living skills (62%), assertiveness training (64%), behavior management (58%), coping skills (56%), self-awareness exercises (60%), social skills training (74%), and time management (66%) (unpublished American Occupational Therapy Association Mental Health Special Interest Section Survey of Mental Health Practitioners, 1997).

It is unclear when the authors’ research occurred. They mention that the program began in 1981 but not when the study was conducted. There have been significant changes in mental health service delivery since 1981—e.g., managed care, more effective psychotropic medications—which have affected modalities used by occupational therapists.

While I applaud the study of the efficacy of interventions with people with persistent mental illness and Dr. Liberman’s significant contributions, it does not seem appropriate to evaluate the whole of occupational therapy by only one of its modalities. While constructive and expressive activities are a part of occupational therapy, according to the American Occupational Therapy Association’s Practice Guidelines for Adults With Schizophrenia (2), occupational therapy “uses activities which are meaningful and relevant to the clients to improve functional performance…facilitate the client’s engagement in the desired performance area… and experience success and gain confidence in his or her performance abilities.” Occupational therapy “emphasizes…development of skills, environmental or task adaptations, compensatory strategies, and family/caregiver training to support function in desired and needed roles in activities of daily living, work and other productive activities and leisure” (2).

Occupational therapy continues to have significant value to individuals with serious mental illness in helping them adapt to their disability and recover their ability to function. As members of a profession and association, occupational therapists continue to be concerned about the outcome of our services to individuals across the continuum of life. A recent study demonstrated the positive effect of occupational therapy on a variety of measures of social functioning and mental and physical well-being (3). It is my hope that research will continue to explore efficacious interventions without encouraging inappropriate bias toward any of the disciplines that have the skills and technology to benefit individuals with serious mental illness. Please contact me if you or your readers would like more information about occupational therapy.