The International Journal of Psychosocial Rehabilitation
 

Efficacy of occupational therapy with supportive techniques on
Social and Occupational Functioning among person with schizophrenia

Upendra Singh* Sweta** Dr. Manisha Kiran***

*Consultant Psychiatric Social Worker, DMHP Rohtas, (District Hospital, SASARAM) Bihar, 

** Consultant Clinical Psychologist DMHP, Mirzapur, (District Hospital Mirzapur), U.P., 

*** Associate Professor & Head, Dept of PSW, RINPAS, Kanke Ranchi





Citation:
Singh U, Sweta, & Kiran M (2017)  Efficacy of occupational therapy with supportive techniques
on Social and Occupational Functioning among person with schizophrenia
 
International Journal of Psychosocial Rehabilitation. Vol 21 (1) 67-74



Address for correspondence: Upendra Singh, Consultant Psychiatric Social Worker, Sadar Hospital, Sasaram, Bihar, India. Email: upendrasingh.aims@gmail.com

Abstract
Background: It is well understood that psychotherapy attempts to alleviate emotional suffering and to enhance personality adjustment through planned psychosocial interventions. But it is unfortunate that much of the emphasis has been placed on the ill effects of psychotic disorders like schizophrenia and thus researches are concerned with destructive pathological effects and ignores the fact that constructive regenerative influences may be present. No matter how much victimized an individual with schizophrenia be by his symptoms, he is always capable of some determinate learning under encouraging circumstances. Many opportunities exist in the environment of individuals suffering with schizophrenia that lead them to implement a corrective influence on their life. Unfortunately, individuals with schizophrenia do not take advantage of them because they may be unaware of their potential, or because he distorts their meaning. Thus, the study used occupational therapy and supportive techniques to help individuals with schizophrenia in recognizing their potentials and utilizing resources in the environment to help adjust in their daily life.
Aim: Aim of the study was to assess efficacy of occupational therapy with supportive technique on socio-occupational functioning among persons with schizophrenia.
Methodology: It was a hospital based study in which pre and post with control group design was used. To select the sample purposive sampling technique was used in this study.
Results: Result showed that participants of the experimental group after receiving occupational therapy with supportive technique had significant improvement in their socio-occupational functioning.
Conclusion: Occupational therapy when complemented with techniques of supportive therapy helps individuals with schizophrenia to restore to an adaptive equilibrium in their life.

KEY WORDS: Functioning, Social, Occupational, Schizophrenia, Supportive Techniques


Introduction:

Basic objective of Psychosocial-rehabilitation is to reduce the harmful effect of psychiatric disorder on the sufferers socio-occupational functioning and life skills. Psychosocial rehabilitation is a multidimensional therapeutic effort which requires active participation of patient and professionals, e.g. mental health professionals, occupational therapists, policy makers, judiciaries, social activist and most importantly patients and their key caregivers. Psychosocial rehabilitation is a comprehensive approach that includes numerous therapeutic ingredients such as emphasis on medication compliance, optimistic staff involvement with high degree of motivation, supportive social environment for the patients, and provision of basic needs for decent housing.

Psychosocial-rehabilitation as stated above thus could play very efficient role in resolving the impairments any individual faces because of psychiatric illnesses like schizophrenia. Schizophrenia is a type of psychiatric illness which hampers individuals’ social, personal and occupational functioning. Individual with schizophrenia is not able to perform proper functioning even if there is complete remission. Schizophrenia is characterized by sever impairments in thought process, decision making process, ability to initiate, regulate and experience emotions and in executing responses towards daily interpersonal interactions. Schizophrenic patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment. Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and grooming. Impairment in vocational skills due to long term illness, frequent hospitalization and continuous antipsychotics develops negative self image and low self esteem in individuals with schizophrenia. Schizophrenia affects individuals’ social and occupational functioning adversely.

Occupational Therapy
Occupational therapy is the art and science of helping people do the day-to-day activities that are important to them despite impairment, disability or handicap. The World Federation of Occupational Therapists defines occupational therapy as a profession concerned with promoting health and well-being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Thus, occupational unit in a psychiatric set up is an effective place where an individual with schizophrenia could learn how to initiate, take a decision, and especially how to respond to interpersonal interactions. The primary goal of occupational therapy (OT) is to enable people with schizophrenia to participate in the activities of everyday life. Activities in OT provide opportunities to experiment with ways of relating, connecting and communicating (Fidler & Velde, 1999). Occupational therapists achieve this outcome by enhancing the individual's ability to participate, by modifying the environment, adapting the activity to better support participation and/or facilitating physical or mental rehabilitation to maximize functional performance (Quiroga, 1995). Occupational therapy focuses on social and occupational skills, which may be absent or underdeveloped due to the illness.  Occupational therapy operates on the principle of rehabilitation which focuses on getting the clients whole life back and not just managing his symptoms. When a person becomes ill, it is helpful for others to focus on their strengths and not dwell on their mental illness.

Supportive Therapy
Supportive therapy is used when the personality has been severely damaged during the formative years so that there is little on which to build, the objective may be to stabilize the individual through supportive measures. Supportive therapy is effective when due to psychotic reactions individual may be unable to tolerate the anxieties of exploration and challenge. Supportive therapy is an adjunctive form of treatment during re-educative and reconstructive therapy. Thus, where coping strategies of the ego starts to fail, as impact of long term psychotic symptoms, extension of support becomes very necessary. Role of supportive techniques are to help enhance individual’s self esteem, quality of life, social skills, and interpersonal relations; and thus, improving the individuals social and occupation functioning.
Supportive psychotherapy has been developed as an approach to address the long-term difficulties of patients with chronic diseases and complaints (Fenton, 2000). The techniques of the approach are rehabilitative (Frank, 1982), emphasizing adjustment and coping with ongoing difficulties. They are compatible with a recovery philosophy of ‘learning how to live, and how to live well, with enduring symptoms and vulnerabilities’ (Roberts & Wolfson, 2006).

The therapeutic techniques of supportive psychotherapy are as follows:

-A style of communication characterized by emphatic validation, praise and advice, and gentle confrontation
-Environmental interventions (e.g. health promotion, enabling access to community resources and support)
-Psycho education (including identifying and managing early warning signs of relapse)
-Improving self-awareness (e.g. of defences) and developing coping/adaptive strategies to promote a sense of agency, control and self-management

A needs-adapted approach: perhaps an emphasis on fostering personal growth, separation and individuation; or a focus on maintenance, preventing deterioration and weathering relapses.

Methodology
The study was approved by the ethical committee of the hospital. This was a hospital based quasi experimental research in which pre and post with control group design was used. Two stage sampling was used first stage participants (with screening) were selected purposively and in the second stage systematic random technique was used for creating experimental and control groups. Individuals diagnosed with schizophrenia according to ICD-10, DCR (1992) at inpatient department of RINPAS, between the ages of 20 to 45 years, only male patients who were educated up to 5th standard were selected for the study. Once participant gave inform consent in written he was included in the study. Individuals diagnosed with schizophrenia having severe physical illness, any organic illness or history of substance dependence was excluded from the study. 58 patients were selected through purposive sampling technique from RINPAS in-patient department (male section) and were assessed through a semi-structured interview using the Self prepared motivational analysis checklist; patients scoring more than 20 were selected for the research. Out of 58 patients 40 patients scored more than 20 on the self prepared motivational analysis checklist. A list of 40 patients was prepared and every 2nd patient was selected for the study. 20 participants selected after systematic random sampling was then divided into experimental and control group randomly. Once the sampling was over necessary tools; structured socio-demographic and clinical data sheet and Socio-occupational functioning scale (SOFS; Saraswat, et. al, 2006) were administered on the participants for baseline assessment. Then their daily living activities, ward activities and occupational unit functioning was monitored according to the therapeutic package. They were monitored to attained occupational therapy unit daily. Experimental group received special package of supportive techniques with occupational therapy, whereas, control group received the regular occupational therapy activities. Both groups were provided same duration of training period at occupation therapy unit. At the end of termination post assessment of both the groups was done.
Result

Table 1: Comparison of socio demographic variables of participants from experimental and control group

Variable

Experimental

Control

Mann

Whitney U

Z

p

Mean

Sd

Mean

Sd

Age

31.00

7.46

31.60

7.53

47.50

.190

.849

Duration of

illness

5.95

3.45

5.80

3.48

48.00

.153

.879

No. of

Hospitalization

1.40

.699

1.20

.422

44.00

.600

.549

 

 

 

 

 

Table 1 shows no significant difference between the two groups when compared on socio-demographical variables.

 

Table 2: Comparison of socio demographic variables between experimental and control group

Variables

Experimental Group

N-10(%)

Control Group

N-10(%)

χ2

df

p

Education

.476

3

1.00

Primary Education

4(40)

3(30)

Secondary Education

4(40)

4(40)

Higher S. Education

1(10)

1(10)

Graduation

1(10)

2(20)

Occupation

4.00

4

1.00

Farmer

4(40)

2(20)

Business

2(20)

1(10)

Daily Labour

NIL

2(20)

Unemployed

2(20)

4(40)

Student

2(20)

1(10)

Family Type

.000

1

4.00

Nuclear

6(60)

6(60)

Joint

4(40)

4(40)

Domicile

.952

1

3.00

Rural

8(80)

6(60)

Urban

2(20)

4(40)

 



The table 2 shows that there had been no significant difference between the groups on the above socio-demographical variables. Further showing that, every participant had been educated at least till 5thstd and most of them had been educated up to secondary standards. An average number of participants had been working and were employed. Most participants shared semi-urban background and were living in a nuclear family.

Table 3: Comparison of Baseline Assessment Scores on Socio Occupational Functioning Scale (SOFS)

Variable

Mean

U

Z

p

Experimental

Group(N=10)

Control

Group(N=10)

Bathing and grooming

10.50

10.50

50.00

.000

1.000

Clothing and dressing

9.75

11.25

42.50

.640

.522

Eating, feeding and diet

10.00

11.00

45.00

.483

.661

Neatness and maintenances

10.00

11.00

45.00

.503

.615

Conversational skills

11.50

09.50

40.00

1.09

.276

Social appropriateness  /politeness

10.50

10.50

50.00

.000

1.000

Social engagement

10.50

10.50

50.00

.000

1.000

Money management

10.50

10.50

50.00

.000

1.000

Orientation/mobility

11.00

10.00

35.00

.610

.542

Instrumental social skills

10.00

11.00

45.00

.503

.615

Recreation/leisure

10.00

11.00

45.00

.438

.661

Work

11.50

09.50

50.00

1.09

.276

Respect for property

10.00

11.50

40.00

.610

.542

Independence/responsibility

11.50

10.50

45.00

.000

1.000



Table 3 shows comparison of baseline scores of experimental and controlled group on SOFS. SOFS assessed the socio occupational functioning level of the participants. Scores on SOFS shows that socio occupational functioning of participants from both the groups was very poor. Result shows high deficit in the domains of SOFS i.e., self care and activities of daily living, communication and interpersonal relations, instrumental living skills and work. No significant deference was found between the experimental and control group.

 
Table 4: Comparison of Post Assessment Scores on SOFS

Variable

Experimental

group

Control

Group

U

Z

p

Bathing and grooming

8.50

12.50

30.00

2.179

.029**

Clothing and dressing

6.50

14.50

10.00

3.559

.000#

Eating, feeding and diet

6.85

14.15

13.50

3.201

.001#

Neatness and maintenances

6.30

14.70

8.00

3.523

.000#

Conversational skills

6.30

14.70

8.00

3.523

.000#

Social  appropriateness

/politeness

6.50

14.50

10.00

3.559

.000#

Social engagement

6.20

14.80

7.00

3.539

.000#

Money management

7.90

13.10

24.00

2.439

.015*

Orientation/mobility

9.00

12.00

35.00

1.831

.067**

Instrumental social skills

9.50

11.50

40.00

1.453

.146

Recreation/leisure

7.50

13.50

20.00

2.690

.007*

Work

9.50

11.50

40.00

1.453

.146

Respect for property

10.05

10.95

45.00

.449

.654

Independence/responsibility

5.58

15.15

3.50

3.696

.000#

Table 4 shows the scores obtained by the participants on SOFS, after 2months of therapeutic sessions. Result indicates significant difference between the scores of experimental and control groups on domains of SOFS i.e. self care and activities of daily living, communication and interpersonal relations, instrumental living skills and work.

Discussion
Schizophrenia is a psychiatric diagnosis that describes a mental disorder characterized by abnormalities in the perception or expression of reality. Many of these individuals have problems that diminish their ability to function in the community and they often become socially isolated (Halford & Hayes, 1995). They also have problems to perform activities in daily life (Boronow, 1986; Henry & Coster, 1996). Cognitive impairments, neurobehavioral deficits and social dysfuctiong have been found to limit these individuals’ performance of daily activities (APA, 1994).

Occupational therapy (OT) is considered to be the most essential treatment for rehabilitation and mainstreaming of individuals with schizophrenia. The goal of occupational therapy is to enable people with schizophrenia to participate in the activities of everyday life. Supportive therapy helps them to learn activities which are important for individual’s daily living and helpful for interpersonal relationship.

The present study is an attempt in this direction. A few of researches have been carried out in the west regarding occupational therapy and supportive techniques to improve individuals’ social and occupational functioning, however there is a lack of research in this area in the Indian context.

The study comprised of twenty male participants randomly divided into experimental and control groups. It was a hospital based study. Pre and post with control group design was used. The participants received the therapeutic package for 2months.

Discussion of therapeutic module
Two therapeutic modules were used where experimental group was introduced with both; occupational therapy unit and supportive therapy, while control group only had occupational therapy.

Initial phase was to establish therapeutic alliance with the participants followed by psycho education to them. Participants in the middle phase received different techniques of supportive therapy while they attended OT unit. Initially participants were introduced to life balance skills training where they learned the importance of maintaining personal hygiene daily. They learned to develop activity scheduling and following them, thus maintaining their daily living activities and helping them manage household activities on their own. Following this they learned the communication skills like eye contact, loudness and pitch of voice, approaching people, initiating conversation.

Participants of controlled group were then helped to understand the role of OT unit in their treatment. They were explained the importance of occupational training and were monitor and helped to attend occupational therapy unit daily. Supportive techniques i.e. guidance and encouragement; praising & incentives were imparted to the participants of the experimental group while they were monitored in the OT unit daily.

Working in the OT unit participants started to gain self confidence yet was confused how to analyze problems at work, take decisions, become assertive, dealing with symptoms of illness. Thus, with supportive techniques; reassurance, rationalization and reforming participants develop a framework for delivering, generating and balancing solutions for effective solution to problems while working in OT unit.

Further anticipatory guidance (rehearsal) was used to help participants of experimental group in reducing and preventing anxiety and fears related to work. Participants of experimental group were helped through expanding their awareness about maintaining work skills and that it could help prevent frequent relapses.
At the termination phase participants were explained that as the set goal of the therapeutic module has been achieved the sessions were terminated while taking concern from the participants. Participants were assured that even if the intervention was terminated they would be helped as required in future.

Discussion of statistical analysis
Statistical analyses of the quantitative scores were done using Statistical Package for Social Sciences (SPSS for Windows version 16.0). The χ2 test was used to compare the difference between the two groups on the discrete and categorical socio-demographic variables i.e., education, occupation, family type and domicile. Mann-Whitney U-test was used to compare differences between two independent groups with dependent variable that was continuous, but not normally distributed.

Discussion of result
Results indicate that there had been no significant difference between the groups on the socio-demographical variables i.e., age, education, duration of illness, occupation, family type, domicile, marital status, duration of marriage. Thus, the participants of the experimental and controlled group were matched pairs.

Baseline assessment on SOFS of both the group indicates that participants were not regular in maintaining their personal hygiene and bodily care. They had problem in maintaining dressing properly and their regular eating habit (food intake, preparation of simple meal). Sores reveal that participants were poor at maintaining their livening area and at household tasks. They showed poor conversational skills like inability to initiate and terminate conversation, maintaining non-verbal cues and paralinguistic skills. Participants had problem in maintaining close and stable relationships, also had problems in developing relationships outside immediate family with poor ability to provide and receive social support. Results indicate poor instrumental living skills like understanding social rules, approaching a person (doctor, shopkeeper) directly or through telecommunications. Participants showed inability to maintain their behaviour at their respective work place i.e., they had problem in spending time in structured and meaningful way. Participants avowed an inability to take care of self and others on their own.

After two months of therapeutic package and supervision at OT unit of the hospital it was found that the scores obtained by the participants of controlled group showed significant difference with that of experimental group on SOFS. Participants of controlled group were better at taking self care i.e., were regular at maintain personal hygiene, had better sense of dressing and grooming, and took interest in maintain their living area and helping at household tasks. Participants of controlled group showed an improved pattern in their conversational skills, they were able to initiate and terminate a conversation, were able to enter an ongoing conversation, started to maintain eye contact, use social distance in a conversation, took interest in maintaining their pitch and loudness of voice etc. Result also indicates that they were able to maintain social relationships and gain social support; they developed ability as how to approach people in the community and get their works done. At present participants of the controlled group were able to maintain household works on their own and were able to take care of themselves and even others on their own.

Conclusion
The study concludes that individuals with schizophrenia might presume that their symptoms are actually an escape from responsibilities in life. But engaging themselves in social activities, externalizing interests, hobbies, working in groups, physical exercise, hygiene and recreation; they could actually find relief from their symptomatic preoccupations. Thus, occupational therapy re-educates individuals with schizophrenia to deliberately make efforts to readjustment. Occupational therapy when complemented with techniques of supportive therapy helps individuals with schizophrenia to restore to an adaptive equilibrium in their life
.



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