Dr. Liberman Replies

To the Editor: My colleagues and I appreciate being edified by the many letters that we have received regarding the broad scope of psychosocial occupational therapy, but we would find even more informative the actual use of specific occupational therapy modalities that are currently in use at a representative sample of psychiatric facilities. The unpublished 1997 survey from which Jeanette Bair, M.B.A., O.T., F.A.O.T.A., extracts self-reports may confuse the interventions used with the goals of the interventions; for example, at many psychiatric facilities, expressive arts and crafts as interventions are viewed as vehicles for improving cognitive capacities, daily living skills, coping skills, self-awareness, time management, and social skills. Until more reliable data are published, we will continue to use our personal observations from more than three decades of visits to hundreds of mental health facilities to assert that expressive arts and crafts are the modal form of psychosocial occupational therapy being used with psychiatric patients. We were pleased to see support for our findings from a recent evaluation by occupational therapists of 6 weeks of art therapy, which found no impact on the social skills of persons with chronic schizophrenia (1).

At the same time, we are cognizant of the wide range of modalities—including social skills training—used by occupational therapists to improve self-care and vocational, social, and independent living skills. We trust that the concerns raised by those occupational therapists who have written letters to the editor (Ms. Bair, Franklin Stein, Ph.D., O.T.R./L., F.A.O.T.A., and others) will lead to a broader utilization of skills training techniques by occupational therapists. It is important for the future of psychiatric occupational therapy that empirically validated and replicable techniques are introduced into the field.

The intent of the study was not to compare the entire practice of occupational therapy with skills training. Rather, the study was designed to contrast a single modality—skills training—with an equally frequent, interpersonally delivered treatment that was credible and representative of the practice of many occupational therapists. Given the limitations of the study’s design and procedures, it would be reductionistic for any reader to conclude that occupational therapy as a discipline, with a rich array of complex treatments, is less effective than a limited application of modularized skills training.

The question by Sadako Vargas, Ed.D., O.T.R., regarding the educational backgrounds of the therapists can be answered simply: the paraprofessionals who led the skills training groups had associate’s degrees with a minimum of 10 years working with the mentally ill and 2 years of using the modules. One of the trainers was a registered occupational therapist who had 3 years of experience using the modules. Paraprofessionals and nonprofessionals have been shown to be effective in teaching social and independent living skills to individuals with serious and persisting mental disorders, by using the modules, in various field studies in the United States and overseas (2–4). None of the skills trainers designed or supervised the training procedures. All dependent measures were administered before random assignment to the treatment conditions, and the mixed-model repeated measures analysis of covariance controlled for any baseline cohort differences. In summary, we encourage the development, refinement, and empirical validation of interventions conducted by occupational therapists for improving the social, vocational, and independent living skills of persons with disabling forms of mental disorders. We hope that our study has contributed to this impetus, which will greatly benefit the clinical outcomes of our patients.