OCCUPATIONAL THERAPY - JULY, 1986
Appendix 1. Occupational Therapy, Horton Hospital Rebabilitation Unit, March 1984
Timetable of activities regularly available for treatment pro-
grammes (others added as and when needed/possible).
Where appropriate, groups are classified as catering for high,
medium or low performance: HP, MP, LP; or high, medium or
low dependency: HD, MD, LD.
Social skills: Two groups, one HP and one MPILP.
Drama games: Three groups, one HP, one MP and one LP.
Projective art, cookery, homecare and laundry: Catering separ-
ately for HD, MD and LD.
Self-care: Separate groups for men and women.
Community orientation
Woodwork
Gardening
Word games
Newspaperlcurrent affairs
Clerical work: Including typing, printing, duplicating and general
clerical skills.
Graphics: Two groups.
Part 2: Social Skills Training
Long-stay hospitalized schizophrenic patients exhibit multiple social skills deficits. Doubts have
been expressed about the effectiveness of social skills training for them, and also about the
possibility of achieving generalization of skills. Part 2 of this article describes the setting-up of
groups with such patients, the selection of group members and the content of the programmes.
INTRODUCTION
In the not-so-distant past, the term 'social skills' was used to
encompass skills in a wide range of functions of everyday life,
from home management to personal hygiene. Approaches to
training or retraining in these skills have been equally varied.
In its precise form, social skills training relates to skills of
interpersonal communication and employs a systematic ap-
proach to assisting change. Wilkinson and Carter! define the
activities involved as assessing problems and designing, manag-
in~ and running programmes. They also point out that, with the
Wide range of problems which may be tackled in this way and
th~ va~ation in the categories of people involved, only general
guidelines and some selected examples can be offered in a
handbook such as theirs and it has to be largely left to
individual organizers to design programmes to suit their
members' specific needs.
Social skiDstraining for schizophrenic patients
Brady' reviewed the controlled clinical outcome of social
skills training in a number of psychiatric populations, including
psychiatric inpatients, and pointed out that, with this group in
particular, more research is needed to determine its effective-
ness. Brady? also pointed out that a difficulty facing anyone
undertaking such a study is that the residual skills deficits in
schizophrenics following their acute and often prolonged illness
are multiple. All aspects of social functioning are often
impaired - personal care and basic living as well as communi-
cation skills - and the necessity of relearning this range of
skills concurrently poses problems in undertaking a controlled
study. The controlled study undertaken at Horton Hospital!
compared the use of different methods of reinforcement of
desired behaviours. Many of these behaviours fall within the
range of communication skills.
Generalization
Liberman et al" stated that generalization should not be
assumed to be an automatic by-product of behavioural
treatment, and demonstrated in their study that successful
outcome was greatly assisted by planned follow-up and mainte-
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229
Literacy groups: Two groups. The main aim of Group 1 is to
as~ss the level of ability of each member to discover (a) potential
which may be able to be developed and/or utilized in other
groups, and (b) needs which may be met by Group 2. The aim of
Group 2 is to meet the needs identified in Group 1 by, firstly,
~ttempting to identify the cause of the difficulty (for example
intellectual, educational, eyesight and hearing).
Quizzes
Word games
Discussions
Sports and games
Music and movement
Music group: For example, percussion.
Music appreciation
Projects: A daily session with flexibility to meet changing patient
needs and to enable a wide a variety of ideas and skills (in both
patients and staff) to be exercised, without constant changes in
the basic programme structure.
nance of consistent reinforcement. In their study patients
transferred from hospital to community, and systematic treat-
ment programmes were coordinated between a state hospital
ward and a community-based day hospital; in this way,
behaviours learned in the first situation were transfered to the
second.
Rating scales
The social behaviour rating scale (SBRS)5 is a 5-point scale
with 15. items. The first 3 items concern eye contact, facial
expression and posture, and the other 12 all refer to aspects of
verbal communication. The highest rating is placed at either
left or right in random sequence, to minimize rater tendency to
link the rating of one item with that of the next.
SOCIAL SKILLS GROUPS AT HORTON
HOSPITAL
In the rehabilitation unit of the occupational therapy
depa~ment of Horton Hospital, a social skills group was
estabhshed as a key part of the repertoire of activities available
for individual treatment programmes for long-stay schizo-
phrenic patients involved in the 3-year research project." The
group was set up by a senior psychologist, with the head
occupational therapist and two occupational therapy helpers as
co-therapi~ts. Subsequently, a second group was added, and
later a thud. Towards the end of the research period the
psychologist left the team temporarily. A senior occupational
therapist joined the unit and the occupational therapy staff
continued running the groups. It would not have been possible
or indeed appropriate to isolate these groups for controlled
study, but as one of the interventions used in the main study it
may be considered to have contributed to the overall outcome.
Unlike the Liberman et al" study, concern was with the very
earliest stages of social rehabilitation. Discharge from hospital
was a possible long-term aim, but the immediate goal was to
improve communication skills with particular emphasis on
aiding generalization of learned behaviours to situations
outside the groups.
230 OCCUPATIONAL THERAPY -
The situations considered initially were:
(a) Within the hospital, with hospital staff in wards and
departments, the hospital shop and the patients' bank, and
with other patients at mealtimes and in work and leisure
situations; progressing to
(b) Outside the hospital, with local bus drivers and shopkeep-
ers, and members of the general public in a cafe or bus
queue, and so on.
lt is generally accepted that schizophrenics are unlikely to
achieve and maintain a very sophisticated level of social
interaction, and so we were initially considering skills which
were essential in the above situations. The extent to which
goals beyond this point could be set would depend upon the
progress of group members.
SELECTION OF GROUP MEMBERS
The first group was drawn exclusively from behaviour
therapy project wards. All project patients attending the
occupational therapy department and one attending the
hospital industrial workshop were rated, using the SBRS.
Using these baseline scores, patients from the token economy
ward were matched with those receiving social reinforcement
only, and a balanced selection made of four men and four
women.
When the second and third groups were selected, patients
from other than behaviour therapy wards were included, which
allowed a wider range of choice. One limitation existed,
however, in that males predominated among patients of
approximately matched needs. This level was redressed in the
groups finally selected by the predominance of female staff
(there was only one male staff member in the unit).
In the selection of all three groups it was considered that too
great a variation of skills would be against the interest of those
at the extremes of the range and of the progress of the group as
a whole, but that some variation would facilitate modelling
among group members.
IDENTIFYING NEEDS
The SBRS ratings showed that baseline communication skills
were higher in the first group than in the other two. This being
so, members of the first group were more actively motivated to
improve these skills. With the other groups this motivation was
less apparent. Members of the first group were able to identify,
and with encouragement to verbalize, the problems they
experienced in their daily lives; for example, difficulty in asking
nursing staff for items such as razor blades, towels and clean
clothes, or to see the doctor; enquiring about bus destinations,
fares and timetables, asking for assistance in a shop, and
exchanging goods in a shop.
The personal difficulties of the members of the other two
groups were often unperceived by themselves or, possibly, they
did not wish to acknowledge them. Their problems were
usually essentially the same, but staff observation and exten-
sive prompting were needed to bring them to the fore.
TARGET SETTING
In the early stages all targets were simple and basic, for
example, asking the ward staff for toilet items. The first group
progressed steadily through these targets to others such as
asking for goods in the hospital shop, followed by shopping in
town, asking directions, conversing in cafes and shops and
planning journeys farther afield. This progress was made on
suggestions received from the patients themselves, who showed
insight into their difficulties. The other two groups spent much
longer on the basics, only moving on slowly and, again, with
considerable prompting.
STAFFING OF GROUPS
Key therapist: It was considered important that there should
be a key therapist who attended every group session. In the
first group, this was the senior psychologist. In the other two
groups, the role was shared by the head and senior occupational
therapists.
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JULY, 1986
A high staff/patient ratio (an average of one staff to two
patients) was maintained in each group for several reasons:
(a) As these groups were regarded as learning situations for
staff, it was important that every member of the staff of the
unit, and some of the ward nursing staff, should have the
opportunity of participating
(b) The observation opportunities offered by this group
experience facilitated prompting of generalization of learned
behaviour outside the groups
(c) Consistency of staffing is vital, and by adopting an
overlapping rota system this consistency could be main-
tained in spite of the inevitable leave, sickness and staff
changes
(d) We felt it important for these patients to have the
opportunity of experiencing active communication with
others and participating in a group which was 'successful'.
Staff participation as group members and their brief but
varied input facilitated the flow of the group, and the high
staff/patient ratio allowed modelling and the prompting of
individuals to be discreet.
CONTENT OF SESSIONAL PROGRAMMES
Every session opened with practice in introducing others.
Each person introduced himself and one other, for example, 'I
am Peter and on my left is Margaret.' To this was added some
simple observation about that person, such as 'She is wearing a
blue dress.' Many variations were used. Sometimes there were
visitors to be introduced. It was many weeks before the group
members all remembered each other's names. Introductions
continued to be enjoyed and were therefore retained as a
regular part of the programme.
Explanation (preferred to 'instruction')
As each activity in the programme was introduced, explana-
tions were given by the therapist or co-therapist as to exactly
what was expected. The explanation was repeated whenever
necessary.
Modelling
Modelling occurred continuously in the groups by both staff
and patients. Staff sought consciously to model desired
behaviour throughout, and more specifically in introductions to
role play.
Roleplay
Exercises in role play occurred in each session. Group
members were encouraged to talk about any communication
difficulties they had experienced. Role play exercises were set
up to rehearse these problem behaviours. Introductory model-
ling was presented by either staff or patients or by both
together.
Reinforcement
Performance of desired behaviour in the group was reinforced
immediately with attention and praise and by favourable
reactions from all group members. Token reinforcement was
never given in these groups because it was considered that it
would interrupt the flow of the group.
Feedback
Extensive use was made of feedback from both staff and
patients. Group members expressed how they felt and how
they perceived each other's performances. Staff gave positive
feedback to encourage continuation and development of
desired behaviour.
Homework
Assignments followed on from role play. Behaviour rehearsed
in the group was tried out in the reality of ward or department
life or visits outside the hospital. Some difficulty was exper-
ienced in remembering the assignment or in finding an
opportunity to carry it out. Sometimes the unresponsive
attitude of others created a problem. The first group was more
consistent in carrying out homework assignments successfully
than the other two. However, these difficulties only served to
underline the needs of the group members to achieve new
behaviour patterns in order to be able to function adequately
and to emphasize the value of perseverance.
 OCCUPATIONAL THERAPY -
INTER-STAFF FEEDBACK AND
EVALUATION
At the end of each session subjective assessments were made
of each patient's response and progress. The level of, for
example, staff support and prompting was discussed, the aim
being to keep these at levels at which they assisted the
performance of group members and the 'flow' of the group,
whilst allowing each person to progress at his own pace and in
accordance with established individual treatment targets.
COMPARISON OF GROUPS
Members of the first group progressed more rapidly than
members of the other two groups. This could be attributed to
one or all of a number of variables. It is not possible to isolate
the effects of any individual variable, but it is interesting to
note them.
The key therapist of the first group was a clinical psychologist.
- She brought her particular professional skills to the group.
- A psychologist works as an individual clinician within a
profession with a philosophy of firm commitment to
establishing and adhering to treatment priorities. In the
occupational therapy profession, on the other hand, there
often tends to be a many faceted approach which brings
conflicting demands. In this instance, and particularly when
a number of staff are involved, not all of them professionally
qualified, it is more difficult to follow clear and consistent
priorities.
Group members: Patient members of the first group were
exclusively research project patients. Their whole programme
inside and outside the department was planned along beha-
viour therapy lines. Multidisciplinary interaction facilitated
awareness of the aims of the group and practice of learned
skills. Group members also brought to the group skills learned
in other parts of their programme.
Part 3: Staff of an Occupational Therapy Unit as
Part of a Multidisciplinary Behaviour Therapy Team
An approach to the multidisciplinary staffing of a behaviour therapy project carried out with long-
stay mentally ill patients is described. Financial and recruiting constraints allowed little scope for
selection or appointment of 'special' staff. A solution was sought in in-service training for staff
already in post, some of whom were not professionally qualified and practically all of whom had
no previous experience in behaviour therapy.
INTRODUCTION
'Old long-stay' schizophrenic patients make up the majority
of the population in our large mental illness hospitals and
working with them requires a specialist approach. All too
often, however, this is not appreciated, and it is extremely
difficult to recruit staff of suitable calibre and in large enough
numbers. 'Cures' are comparatively few and results slow to
emerge. Young energetic staff seeking a wide range of
experience seldom remain in one post long enough to see any
significant progress. Professionally trained staff are therefore
often reluctant to apply for posts where the work is with long-
stay patients.
There appear to be two possible approaches to this problem.
The first is to set up specialized treatment units in the hope of
attracting a high calibre of trained staff. The second is to make
the best possible use of staff in post, whether trained or
untrained, and to offer in-service training opportunities in the
special treatment to be undertaken. The ideal approach would
seem to be a combination of these two.
The use of 'paraprofessional' staff
In the United States, Paul and Lenz' were faced with the
problem that 70% of staff in public mental institutions were not.
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JULY, 1986 231
Co-therapists: The introduction of a larger number of co-
therapists was made to all groups at the same time. It did not
appear to inhibit progress of the first group, and even when
those who had worked with group 1 worked together with
group 2 or 3 they found it markedly more difficult to facilitate
participation and progress.
CONCLUSION
Group members were rated before and after each block of
sessions, using the SBRS. These ratings showed improvement
in every case. In addition to improved ratings, a steady
improvement in social skills in all settings was observed over
the four relevant years (1980-1984). Some patients were
discharged, and others were leading fuller lives in the hospital
and making greater use of opportunities to extend their
experience of life outside hospital through, for example, days
out, holidays and visits to town. It is not possible to attribute
the improvement to anyone particular intervention because
many were used concurrently, but we do feel that specific social
skills training has played, and will continue to play, a very
important part.
References
1. Wilkinson J, Carter S. Social skills training manual. Chichester:
John Wiley, 1982.
2. Brady JP. Social skills training for psychiatric patients II. Am J
Psychiatry 1984; 141: 491-8.
3. Drouet VM. Behaviour modification research project: occupational
therapy involvement. Br J Occup Ther 1983; 46(5): 137-40.
4. Liberman RP, McCann J, Wallace CJ. Generalization of behaviour
therapy with psychotics. Br J Psychiatry 1976; 129: 490-6.
5. Shepherd G. The social behaviour rating scale (SBRS): studies in the
assessment and treatment ofsocial difficulties in long-term psychiatric
patients. PhD thesis. London: Institute of Psychiatry, 1984.
professionally qualified. It was felt that, although there was
some justification in the assertion that they were employed as
cheaper substitutes, many played a valuable part in treating
patients and that it was therefore justifiable that they should be
helped to gain as high a level of expertise as possible. In-service
training was carried out in behaviour therapy, and the results
judged to be of benefit to all concerned.
In Britain, occupational therapy helper training courses offer
general basic introductions to a number of fields, sometimes
including behavioural methods, but if these staff are to be
involved in specialist treatment they need more specific
training. Here, as in America, there are critics of any scheme
which 'waters down' professionalism, but there are also
champions of the viewpoint that the professions will be helped
rather than hindered by augmenting their numbers with
paraprofessionals who have received in-service training in one
particular speciality. Milne and Mason/ carried out an evalua-
tion of occupational therapy helpers as behaviour therapists
working with long-stay psychiatric patients. Evidence is pro-
vided of their effectiveness and efficiency.
Training for all staff
Milne and Mason? also quote Freud's definition of a 'quack'
as being 'anyone who undertakes a treatment without possess-