Introduction

Schizophrenia is one of the most insidious, slowly progressive and disabling of the mental disorders. It seems to attack by producing severe disability during the potentially most creative and productive years of a person’s life (Kaplan & Sadock 2000).

In recent years, treatment for schizophrenia has greatly improved, and the effects of medication are less disabling. Some sufferers of schizophrenia only experience one episode and are able to control the illness for the rest of their lives, the majority will experience a relapse of symptoms within two years, many will never be free of symptoms, and a minority will remain resistant to treatment (Sheffield Mind Ltd 2009).

The stigma of schizophrenia still exists nationwide and is particularly strong in undeveloped and Third World countries. This fact seriously impacts on the rehabilitation of the person with schizophrenia and makes the reintegration of the person back into community life and work difficult. Lesunyane (2010) describes the difficulty for people with a serious mental illness to retain and maintain their roles in the community and the impact that stigma has on trying to reintegrate. The film industry has had both a negative and positive impact on the community’s understanding and stigma of schizophrenia. It is the author’s opinion that the film ‘One Flew Over the Cuckoo’s Nest’ made in 1964 had a serious and lasting impact on people’s understanding of mental illness, even though it was made so long ago. Recent movies such as ‘The Beautiful Mind’ and ‘The Musician’, it is hoped, have helped to generate a more positive view of the illness.

Persons with schizophrenia are often extraordinarily intelligent and creative people who become seriously demoralised when they realise the impact that the illness can have on their lives. Schizophrenia involves dysfunction in one or more major areas of functioning, for example, interpersonal relationships, work, education and self-care (DSM-5) (American Psychiatric Association (APA) 2013). Cognitive functioning is also often affected, and changes in the ability to interpret situations and to make sense of experiences are often present. Bejerholm and Eklund (2007) presented an excellent research paper on occupational engagement in persons with schizophrenia, which should be perused by all occupational therapists who intend treating a person with this disorder. The research is based on occupational engagement which ‘describes the extent to which a person has a balanced rhythm of activity and rest, a variety and range of meaningful occupations and routines, and the ability to move around in society and interact socially, implying that occupational engagement occurs over time’ (Bejerholm & Eklund 2007, p. 21). Concepts of ‘enabling occupation’ are inherent in the Canadian Model of Occupational Performance and Engagement (Polatajko et al. 2007). This chapter is based on this theory.

The illness of schizophrenia

The cause of schizophrenia is not yet fully understood, but there are many indications that several factors play a part. These are heredity, disposition or vulnerability, infections, damage to brain tissue and excessive stress.

Dopamine levels are affected, and normal brain function is disrupted. However, ‘with the advent of the serotonin-dopamine antagonists, many persons with severe illnesses have their symptoms controlled enough to make them candidates for rehabilitation’ (Meninger in Kaplan & Sadock 2000, p. 3193).

The full description and classification of the illness of schizophrenia can be found in:

• The Diagnostic and Statistical Manual of Mental Disorders, DSM-5 (APA 2013)
  
• Kaplan and Sadock’s Pocket Handbook of Clinical Psychiatry (2010)
  
• The ICD-10 Classification of Mental and Behavioural Disorders (World Health Organisation 1992)

It is important to note that several key changes have been made to the category of schizophrenia in the DSM-5 (APA 2013). The diagnostic criteria no longer identify subgroups. The reader should familiarise himself/herself with the details of the specifiers related to the diagnosis of schizophrenia and closely related disorders.

There are some important features of schizophrenia that should be highlighted in order to fully understand the focus of intervention of the occupational therapist:

• Schizophrenia is primarily a disorganisation of thinking which can result in grossly disorganised behaviour, including inappropriate sexual behaviour, silliness and argumentativeness and a deterioration of activities of daily living (ADL) skills such as unusual dress and a lack of hygiene. Perception, motor activity and changes in affect are also present.
  
• Symptoms of schizophrenia can be divided into:
  
  
  
  • – Positive symptoms: delusions, hallucinations, disorganised thinking and grossly disorganised or abnormal behaviour (including catatonia)
    
  • – Negative symptoms: reduced emotional expression, alogia, anhedonia, asociality and avolition (APA 2013)
  
  
• Other symptoms of concern to the occupational therapists include:
  
  
  
  • – Lack of interest in eating (delusions may be an interfering factor).
    
  • – Abnormalities of psychomotor activity, for example, pacing, rocking and psychomotor retardation. There are often motor abnormalities such as grimacing and posturing, odd mannerisms and stereotyped behaviour.
    
  • – Concentration, attention and memory difficulties.
    
  • – Poor psychosocial functioning.
    
  • – Depersonalisation and derealisation.
    
  • – Somatic concerns, for example, digestive or weight problems.
    
  • – Anxieties and phobias.
    
  • – Hallucinations which are often ‘responsible for profound dysfunction in all aspects of daily life. Such patients find it difficult to engage in meaningful tasks or relationships. For some patients, hallucinations are problematic only in certain situations or at specific times, such as when they are alone or in a stressful situation’ (Kelkar 2002, p. 1).
    
  • – Suicide. 10% of people with schizophrenia succeed at suicide and 20–40% make an attempt. Again, it is often related to delusions or hallucinations (Sheffield Mind Ltd 2009).
    
  • – Non-compliance with treatment, the most serious of which is non-compliance with medication. This is often related to delusional thinking.

Occupational therapy theory

If one looks at the aforementioned symptoms of schizophrenia, the various theoretical models of occupational performance and engagement come to mind, that is, Bejerholm and Eklund (2004, 2006), Christansen (2005), Kielhofner (2002) and Law et al. (1998). Gardner (in Creek 2002, p. 230) states that ‘within these models cognition is seen as a performance component or skill which contributes, along with many other performance components, to a person’s ability to function competently, and to their own satisfaction, in a given occupational area’. Cognitive skills and the impact on function are the primary focus of treatment by occupational therapists with the person with schizophrenia.

It is achieved by purposeful activity which is the cornerstone and the major tool of intervention in occupational therapy. An individual with the illness of schizophrenia may have an impaired capacity for the performance of purposeful activity due to changes in cognitive functioning (Creek 1998). These changes ‘decrease the ability to interpret and make sense of experiences that may result in a sense of detachment and ability to reflect, which is part of the occupational engagement process’ (Bejerholm & Eklund 2007, p. 22). Models such as the Person–Environment Occupational Performance Model (Christansen & Baum 1997) also identify those factors contributing to self-identity which might be missing and thereby influence both well-being and occupational performance.

Linking to theories on the performance of purposeful activity is the research undertaken by a South African, du Toit in 1983 (de Witt 2005 in Crouch & Alers). She intimates that creative capacity varies from one individual to another and is influenced by factors such as intelligence, personality structure, mental health, environmental factors and security. du Toit describes volition as being central to creative theory, and this is pivotal in the illness of schizophrenia. du Toit describes volition as motivation and action. The motivational component represents the energy source for occupational behaviour, and this motivation governs action. It is known that one of the central aspects of schizophrenia is loss of volition. This is the link and the critical axis at which change can occur through the occupational therapy process. Casteleijn (2010) and Casteleijn and Graham (2012) have developed this theory in their work on developing an outcome measure for occupational therapy in mental health settings. The Activity Participation Outcome Measure (APOM) has been designed in empirical research and is a reliable assessment emanating from du Toit’s theory.

Snowdon et al. in Creek (2002, p. 337) discuss the Stress-Vulnerability Model in detail in which it is suggested that ‘Current research is investigating a number of areas which may be indicated in the aetiology of schizophrenia’. They suggest that there is a vulnerability which predisposes schizophrenia which is environmentally based such as life stresses inherent in factors such as changing roles, poor coping mechanisms and stressed family relationships. See the ‘Secondary Psychosocial Disabilities Model’ (Snowdon et al. in Creek 2002, p. 338). The authors are attempting to link the psychopathology and clinical features of schizophrenia with the theory and practice of occupational therapy in order to provide the best possible treatment for a person with this condition. They intimate that ‘The validity of the stress-vulnerability model continues to be strengthened as clinical evidence is amassed to support its explanation of the phenomenon of schizophrenia’ (Snowdon et al. in Creek 2002, p. 339).

The theories of Lorna Jean King (1974), occupational therapist, should not be forgotten. She hypothesised that schizophrenic patients show defects in proprioceptive mechanisms which result in a lack of sensory integration. King has discussed the vestibular component of proprioceptive feedback being underactive and under-reactive in the person with schizophrenia in its role in the sensory integration process. This person may therefore exhibit an apparent gross motor or motor planning problem resulting in lack of perceptual constancy, poor body image and fatigue, which often causes postural patterns. She based her ideas on those of Ayres (1971) and Ayres and Mailloux (1983). King further developed her ideas in 1987 in relation to autistic adults (Mailloux 1987).

During the 1970–1990 period, sensory integration therapy was conducted with chronic patients with schizophrenia with good results. However, these results were not sufficiently empirically proven, and research funding in the USA related to sensory integration in psychiatry was diverted from schizophrenia focused to Autistic Spectrum Disorder (ASD) focused.

Treatment of schizophrenia

Many guidelines are provided in the literature on the general treatment of schizophrenia both at an institutional level and in the community. NHS Choices (2010) discusses what they consider to be ‘good care for schizophrenia’. The National Institute for Health and Clinical Excellence (NICE) has produced good guidelines for how people who have schizophrenia should be cared for such as:

• Developing a supportive relationship with patients and carers
  
• Taking into account the needs of the patient’s family or carers and providing information
  
• Ensuring people have an assessment by the multidisciplinary team, etc.

Many of these guidelines incorporate the skills of an occupational therapist (NHS Choices 2010, p. 1).

With the advances in psychotropic medicine, there has been a trend internationally to move chronic schizophrenia patients out of the institutions into the community. In the community setting, facilities for clients with schizophrenia are far from adequate throughout the world, but a real attempt to accommodate them in their home context is being made. Primary health-care clinics are administering chronic medicines from the clinics and to the home base. Schizophrenia clients are followed up on a regular basis; however, some clients do slip through the system. Support groups can be an effective medium to normalise their behaviour within the community context.

Medication in the form of a new generation of neuroleptics makes it possible today to alleviate the negative symptoms of schizophrenia and in doing so opens the door for the person with this illness to rehabilitation. With the correct approach to the treatment of schizophrenia, many of those afflicted are able to live as normal a life as possible in the community. Treatment can be hospital based or community based depending on the severity of the first episode and also on the treatment facilities available. Wherever treatment takes place, occupational therapy is a vital part of the holistic approach to rehabilitation.

Elpers (in Kaplan & Sadock 2000, p. 3190) states that with schizophrenia ‘psychosocial rehabilitation goals can range from complete restoration of function to limited improvement in the patient’s ability to handle self care’. Elpers believes that today all persons with schizophrenia do or will need rehabilitation and this focus is essentially on the person’s remaining capacities, not the residual symptoms. This emphasises the person’s individuality, his/her responsibility and sense of self-reliance rather than the residual symptoms, illness and dependency.

‘An essential ingredient of rehabilitation is hope’ (Elpers in Kaplan & Sadock 2000, p. 3193), and this hope must be transferred to the client with schizophrenia and his/her family.

Occupational therapy intervention

Psychosocial occupational therapy is concerned with helping persons with schizophrenia to recover. It is also about a person becoming occupied with experiences of events that are real, instead of being occupied with their chaotic thoughts and delusions. (Bejerholm & Eklund 2007). Purposeful activity which involves a person with schizophrenia in occupational engagement is a central part of occupational therapy intervention.