Skills Training or Occupational Therapy for Persistent Schizophrenia

To the Editor: It is with great interest that I read the article by Robert Paul Liberman, M.D., and colleagues. As an occupational therapist concerned with the functional abilities of patients with chronic disorders, I am well aware of the need to attend to skills acquisition. I was not surprised that the subjects who received skills training, as compared to those receiving “expressive, artistic, and recreational activities,” fared significantly better in domains associated with social skills development and retention.

However, the authors made several assumptions that were not only inadequately delineated but clearly erroneous. These assumptions misrepresented the conceptual and operational definitions of the variables and the practice of occupational therapy and led to flawed methodology and conclusions.

Dr. Liberman and associates began their article by defining occupational therapy as “expressive arts and crafts and recreational activities…through which therapists build self-esteem and productivity” (p. 1087). This definition, and the subsequent study’s conclusion, is deceiving. Inherent in occupational therapy practice is occupation, which is synonymous neither with arts and crafts nor with activities. Occupation reflects the participation in tasks and roles that allow for productivity within a personally relevant context, such as self-care/maintenance, work, or leisure. Modalities used within occupation are regularly subjected to a complex process of activity analysis in order to determine and monitor their therapeutic potential. This includes attention to specific skills that support adequate role function and skills that fall within the physical, cognitive, perceptual, psychological, and social arenas. Although some occupational therapists may occasionally use the types of activities described by Dr. Liberman and colleagues, many do not. Most occupational therapists who work with individuals with persistent forms of schizophrenia may address the psychological issues that affect performance, but they primarily structure assessments and treatment programs along a rehabilitative model oriented toward the development and maintenance of social and living skills.

The authors’ second assumption suggests that social skills training is distinct from occupational therapy. Attention to social skills is and always has been a critical component of occupational therapy practice. In fact, one of the study’s social skills module trainers was an occupational therapist. This research was more appropriately a study of expressive craft and art activities versus social skills training; it was not a study of the effectiveness of one group of mental health professionals versus another, as misstated by the authors.

Finally, the study’s design assumes that “expressive art and crafts and recreational activities” oriented toward self-esteem facilitate the building of social skills. Fundamental to any research assumption is evidence, either empirical or theoretical, as to why such an assumption is appropriate. The authors failed to provide evidence indicating that these activities are appropriate modalities for social skills development. Interventions that focus on the psychological arena are very different from interventions that focus on rehabilitation and should be viewed through distinct lenses. The authors clearly neglected to make this distinction and consequently never defended the appropriateness of the independent variables.

In summary, social skills training, which is vital to the reintegration of clients with schizophrenia into the community, is an essential component of occupational therapy assessment and intervention. Expressive, artistic, and recreational activities, while not central to the development of social/living skills, are also not synonymous with the practice of occupational therapy.