Reasons for participating in occupational therapy groups: Perceptions of adult psychiatric inpatients and occupational therapists

Transcription

1 CJOT m VOLUME 59 NO 5 ISABELLA POLIMENI-WALKER KEITH G. WILSON ROBIN JEWERS Reasons for participating in occupational therapy groups: Perceptions of adult psychiatric inpatients and occupational therapists KEY WORDS Activity groups Occupational therapy in psychiatry Patient education Isabella Polimeni-Walker, B.M.R., O.T., is an Occupational Therapist II working in adult inpatient psychiatry at the Health Sciences Centre, 820 Sherbrook Street, Winnipeg, Manitoba, R3A 1 R9. Keith G. Wilson, Ph.D., is now at the Rehabilitation Centre, Ottawa, Ontario. He was formerly the Coordinator of Research and Evaluation at the Health Sciences Centre, Department of Psychiatry, Winnipeg, Manitoba. Robin Jewers, B.M.R., O.T., was an Occupational Therapist II at the Health Sciences Centre, Winnipeg, Manitoba working in adult inpatient psychiatry. Presently, she is a Senior Occupational Therapist in Child and Adolescent Psychiatry at St. Boniface General Hospital, Winnipeg, Manitoba. ABSTRACT Little is known about the attitudes of psychiatric patients towards the specific role of occupational therapy within the overall context of hospital-based treatment. The present study examined this issue by asking 102 adult psychiatric inpatients to indicate their reasons for participating in an occupational therapy group programme, and comparing their responses to those of 31 occupational therapists. Both groups gave high ratings to "reasons for participation" that were related to the achievement of positive therapeutic outcomes, although therapists rated these items significantly higher. The patients, on the other hand, gave higher ratings than therapists to items related to escaping the hospital routine (e.g., "to decrease boredom"), and to achieving "secondary gains" (e.g., to get passes to leave the hospital). The results emphasize the importance of preparing patients for pa rticipation in therapy groups in order to enhance the therapeutic value of these experiences. RÉSUMÉ On possède peu d'information sur ce que pensent les patients psychiatriques de l'ergothérapie dans le contexte global des soins hospitaliers. Cette étude porte sur 102 adultes hospitalisés en psychiatrie à qui on a demandé de donner les raisons à l'origine de leur participation à un programme de groupe en ergothérapie. Leurs réponses ont ensuite été comparées à celles fournies par 31 ergthérapeutes. Les deux groupes ont donné un score élevé aux "raisons de participation" reliées à la réalisation de résultats thérapeutiques positifs, bien que les ergothérapeutes aient donné à ces éléments une évaluation significativement plus élevée. Les patients, par contre, ont attribué des scores plus élevés que les ergothérapeutes aux aspects reliés au fait d'échapper à la routine de l'hôpital (ex. pour diminuer l'ennui) et pour réaliser des "gains secondaires" (ex. l'obtention de permis de sortie de l'hôpital). Les résultats démontrent l'importance de préparer les patients à participer aux groupes de traitement afin d'augmenter la valeur thérapeutique de ces expériences DÉCEMBRE 1992

2 GOT VOLUME 59 NO 5 Occupational therapists who work with adult psychiatric inpatients often provide therapy groups to teach independent living skills and promote self-awareness. Such groups include a combination of task-oriented activities, didactic teaching, and role-playing. Although these methods are now well-established within those inpatient psychiatric services that offer occupational therapy programmes, they depart from a traditional "medical model" of hospital-based care. As a result, several authors have noted that the goals and methods of occupational therapy must often be reviewed with both patients and hospital staff in order to clarify the role of occupational therapy services in relation to other components of inpatient treatment (Bloomer, 1978; Holm, 1983; Locker & Dunt, 1978; Snelling & Walker, 1978). With busy inpatient programmes, however, it can be difficult to find the time and resources to combine comprehensive patient preparation while still maintaining a primary emphasis on the provision of direct service. As a result, the Occupational Therapy Department at the Winnipeg Health Sciences Centre undertook a trial of a "blanket" referral system. This system was implemented in order to allow occupational therapists to treat patients without requiring individual referrals from the attending physicians. Rather, the department adopted a policy of encouraging all but aggressive or floridly psychotic patients to participate in all aspects of the occupational therapy programme. The goal of the blanket referral system was to enable occupational therapists to assess each patient's functional performance in a variety of areas. The groups were typically general enough in nature that they would be of some potential therapeutic benefit to most patients. A further advantage of the system was that it offered optimal flexibility for quickly incorporating new patients into occupational therapy. Despite these advantages, however, the blanket referral system also presented some corresponding drawbacks. Because of the sho rt time lag between a patient's admission to hospital and subsequent entry into occupational therapy groups, therapists did not always have the opportunity to meet with patients prior to their pa rticipation in groups; the decision to include a patient in groups was often made informally in consultation with clinical team members. In some cases, this practice precluded an individual meeting with the patient to provide a thorough orientation to the specific goals and methods of occupational therapy. As a result, it was not always clear that the patients fully appreciated the therapeutic function that the groups were intended to provide. Similar problems have been addressed by Peloquin (1988) in a recent discussion of the impo rtance of preparing patients for pa rticipation in occupational therapy programmes. Because occupational therapists use activity as a therapeutic modality, they run a risk that their services will be misunderstood. Too often, in the absence of an explicit orientation procedure, it is left to the patient to infer the therapeutic purpose of a given activity. In this regard, psychiatric inpatients may represent one population for whom the rationale and purpose of occupational therapy groups are particularly unclear. Hence, their reasons for pa rticipation in these groups may reflect a range of perceived needs and interests, which are not necessarily related to the therapeutic function that the groups attempt to serve. Given this overriding set of concerns, the present study was undertaken to evaluate the role of occupational therapy groups from the patient's point of view. The study comprised one component of a programme evaluation of the blanket referral system. Two basic issues were addressed. Firstly, we were interested in examining the patients' general perceptions of occupational therapy groups, particularly with regard to identifying their basic reasons for participating. Secondly, we attempted to determine the extent to which their reasons for pa rticipation overlap with those that occupational therapists themselves consider to be most important from a clinical standpoint. Hence, the goals of the study were: to obtain a better perspective on the factors that motivate adult psychiatric inpatients to attend occupational therapy groups and to determine the extent to which their reasons reflect an appreciation of the therapeutic function of these groups. It was intended that the results of the study would provide the occupational therapy staff with an overview of the patients' perceptions of their programme, and perhaps offer some specific areas in which the patients might benefit from a more explicit orientation. METHOD Subjects "Reasons for Pa rticipation" inventories were distributed to 127 adult psychiatric inpatients at the Health Sciences Centre in Winnipeg, Manitoba who had attended at least three occupational therapy groups. The occupational therapy groups focused on a variety of topics such as meal preparation and planning, assertiveness, stress management, vocational training, self-awareness, and leisure skills. Each of the patients was given a diagnosis by an attending psychiatrist, based on criteria specified in Diagnostic and Statistical Manual (third edition - revised) of the American Psychiatric Association (1987). Twenty-five (19.7%) patients had been diagnosed with schizophrenia, 53 (41.7%) with mood disorders, 10 (7.9%) with eating disorders, and 39 (30.7%) with a range of other diagnoses. There were 44 males and 83 females, with an average age of 36 years. DECEMBER

3 CJOT VOLUME 59 NO 5 Instrument The "Reasons for Participation" inventory was developed for use in the study by the occupational therapy staff. It included a list of 32 items, each of which referred to a specific reason for participating in the occupational therapy programme. In the absence of a specific theory to guide item construction, the pool of items was selected on the basis of sampling a wide range of possible reasons. Some of these were based on clinicians' opinions of the therapeutic gains that can be achieved through pa rticipation in occupational therapy groups. Others were generated on the basis of anecdotal reports from patients. This procedure ensured that the inventory would not be biased towards the inclusion of only those items that reflected favourably on the therapeutic value of the groups. In fact, many of the reasons for participation that were gathered from the patients for inclusion in the inventory had little to do with the therapeutic aspects of the programme but rather pertained to the role of occupational therapy groups in the overall context of ward life. The patient was asked to indicate the importance of each reason as a determinant of his/her own pa rticipation, by circling a number on a 7-point scale ranging from "Very Unimportant" to "Very Impo rtant." Procedure Inventories were given to each patient who attended at least three occupational therapy groups, regardless of their specific focus. This criterion was introduced in order to ensure that each patient had some minimal familiarity with occupational therapy services in general. However, individual patients could meet this criterion in various ways (e.g., by attending three sessions on one topic, or by attending single sessions addressed to different topics). Thus, all participating patients were involved with the occupational therapy programme, but they varied with regard to the specific group experiences to which they had been exposed. The patients were asked to take the questionnaire back to their rooms to fill out, and the instructions emphasized that the form was to be completed anonymously. In order to maximize the validity of the responses, completed forms were returned to ward personnel who were not involved in the occupational therapy programmes. One hundred and two questionnaires were returned, for an overall response rate of 80.3%. In order to compare the patients' responses with those of occupational therapists themselves, the inventory was also distributed to a group of 31 occupational therapists at a single group testing session. The occupational therapist group included individuals working in a variety of settings within the affiliated hospitals of the Winnipeg Health Sciences Centre, and was not restricted to those whose primary assignments were in psychiatry. For the occupational therapists, the scale instructions were revised to state, "In your clinical opinion, how important is each of the reasons listed?" RESULTS Average Ratings The average ratings given by the patients and by the occupational therapists to each of the 32 items are shown in Table 1. The items are ordered according to the patients' mean response ratings (e.g., ranging from the most highly rated to the lowest rated). The patients' and therapists' ratings for each item were then compared using a series of t-tests. For items on which the groups differed significantly, the resulting t-ratios and significance levels are also given in Table 1. Positive t- ratios indicate that the patients gave higher mean ratings than occupational therapists, while negative t- ratios indicate higher mean ratings for the therapists. As shown in Table 1, the items given the highest ratings by patients were "To decrease boredom" and "To avoid sitting around doing nothing." Other highly rated reasons had to do with achieving positive therapeutic gains as a result of the group experience (e.g., "To enhance self-confidence," "To feel productive"). Patients and therapists differed in their ratings on 12 of the 32 items. The patients' ratings were higher on 10 of the 12, suggesting a general tendency for the patients to view a range of different reasons as being important factors in their motivation to participate in the groups. It should be noted, however, that many of the reasons acknowledged by the patients were rated by the therapists as being relatively unimportant therapeutically. In order to identify more globally the underlying dimensions on which the patients and therapists differed, an additional series of analyses was undertaken. Principal Components Analysis The item pool from the patients' questionnaires was subjected to a principal components factor analysis (with varimax rotation) in order to reduce the number of items to a few superordinate dimensions. With conventional criteria (i.e., eigenvalues > 1.0), the scale was factorially complex, generating a total of 7 factors from the 32 items. However, the last three factors to be extracted comprised only one or two unique items each. In addition, each of these latter factors explained less than 5% of the variability in scores. Hence, for the present purposes, the focus of subsequent analyses was on the first four factors. The items making up these statistically derived "subscales" are shown in Table 2. This table also gives the factor loading for each item, the coefficient alpha estimate of internal consistency for the subscale as a whole, and the percentage of variance accounted for 242 DÉCEMBRE 1992

4 CJOT VOLUME 59 NO 5 Table 1 Reasons for Participation in O.T. Groups Ranked by Order of Importance Mean Ratings Item Patients Therapists t-ratio 13. To decrease boredom 24. To avoid sitting around doing nothing 12. To enhance my self-confidence ** +4.90** * 17. To feel productive NS 19. To learn how to cope more effectively NS 6. To improve my concentration NS 11. To help ease my way back into the community NS 5. To have fun NS 14. To learn how to be a better problem-solver NS 20. To be with other people NS 18. To get off the ward fora while * * 10. To help others NS 32. To improve my physical health NS 15. To get feedback from others about my abilities and behaviour NS 23. To talk to other people in the same boat as myself NS 8. To learn new skills I never knew before NS 4. To improve how I get along with people in social situations * * 3. To get a chance to be creative NS 21. To work out my problems NS 25. To relax NS 16. To practice old skills NS 7. To make new friends NS 28. To prove to people that I can be discharged soon ** 1. To distract myself from my problems NS 31. To improve my chances of getting or keeping a job NS 2. To work on crafts * * 27. To get passes to leave the hospital * * 29. To please other people who expect me to come ** 26. To have people show me the right and wrong ways to do things NS 9. To play games ** 30. To avoid having to say I don't want to come * * 23. To get the staff to stop bothering me * Note: t-ratios that are marked with a single asterisk (*) are significant at p <.05 while those marked with double asterisks (**) are significant at.a <.01. DECEMBER

5 CJOT VOLUME 59 NO 5 Table 2 Subscales Derived from Principal Components Analysis of Patients' Ratings Factor 1 Therapeutic Gains Factor 3 Factor Loading Secondary Gains Factor Loading To learn how to cope more effectively To enhance my self-confidence To help ease my way back into the community To work out my problems To improve how I get along with people in social situations To feel productive To learn how to be a better problem-solver To improve my concentration coefficient alpha =.92 variance explained = 40.7% Factor 2 Socialization To have fun To make new friends To help others To practice old skills.82 To get staff to stop bothering me.79 To get passes to leave the hospital.78 To prove to people that I can be discharged soon.78 To avoid having to say I don't want to come coefficient alpha = variance explained = 5.7% Factor 4.58 Escaping Hospital Routine To avoid sitting around doing nothing To get off the ward for a while To decrease boredom coefficient alpha =.77 variance explained = 5.6% Note: These subscales are based on principal components for which the observed eigenvalue was > 1.0 and which also accounted for > 5% of the variance in responses. An item was selected for a particular subscale if its factor loading was >.50 on that factor and <.40 on the others. by that factor. In order to be considered as providing an acceptable measure of the construct underlying a given factor, an individual item was required to have a loading >.50 on that factor, and <.40 on the others. Together, the four factors explained 61.2% of the variance across items in the "Reasons for Pa rticipation" scale. The first factor was made up of eight items that reflected "Therapeutic Gains" as impo rtant reasons for participating in occupational therapy groups. The second factor comprised four items, and seemed to be related to the use of the groups for "Socialization." The third factor also contained four items, all of which were related to the use of the groups as a means of obtaining a desired end. These items seemed to reflect "Secondary Gains" rather than the recognition of any value inherent in the groups themselves. Finally, the last factor was made up of three items that pertained to participation in the groups as a means of "Escaping Hospital Routine." Between-Groups Comparisons For each patient, a score was obtained for each scale by taking the average rating that the patients gave to the scale items (because there were different numbers of items on the different scales, the mean rating across items was computed, rather than simple sums). These mean item ratings are shown in Table 3. Corresponding scale scores were also obtained for each occupational therapist, and the two groups were then compared in a series of t-tests. Because of occasional missing data points, which necessitated dropping some subjects from some analyses, the degrees of freedom for the different statistical tests varied slightly. Nevertheless, significant differences were observed between the patients and occupational therapists on three of the four scales. The occupational therapists considered "Therapeutic Gains" to be more important reasons for pa rticipation than did the patients, t(124) = -2.45, p =.016. The patients, 244 DÉCEMBRE 1992

6 CJOT VOLUME 59 NO 5 Table 3 Mean Item Ratings of the Reasons for Participation Subscales Patient Occupational Therapist Scale Ratings Ratings t-value 1. Therapeutic Gains * (1.52) (0.85) 2. Socialization (1.53) (0.94) 3. Secondary Gains ** (1.76) (1.25) 4. Escaping Hospital Routine ** (1.46) (1.57) Note: t-values marked with a single asterisk (*) are significant at p <.05, while those marked with a double asterisk (**) are significant at p <.01. Standard deviations are given in brackets. however, obtained higher scores on the "Secondary Gains" t(123) = 3.84, p <.001, and "Escaping Hospital Routine," t(128) = 5.72, p <.001 subscales. Finally, the two groups obtained comparable scores in their ratings of items reflecting "Socialization" as a salient reason for participating in occupational therapy groups, t(127) = 0.20, p >.10. Within-Groups Comparisons It was also instructive to compare responses across the four subscales within the patient and therapist groups separately. This allowed for an examination of the relative impo rtance of the different factors for each group of respondents. For the patients, the two most highly rated scales, "Therapeutic Gains" and "Escaping Hospital Routine", did not differ significantly from one another, t(93) = -1.17, p >.10, although both had higher mean item ratings than either the "Socialization" or "Secondary Gains" scales ("Therapeutic Gains" vs. "Socialization," t(93) = 2.19, p <.05; "Therapeutic Gains" vs. "Secondary Gains," t(91) = 6.32, p <.001; "Escaping Hospital Routine" vs. "Socialization," t(95) = 3.18, p <.01, "Escaping Hospital Routine" vs. "Secondary Gains," t(91) = 7.77, p <.001). In addition, "Socialization" items received higher mean ratings than did the "Secondary Gains" items, t(92) = 5.35, p <.001). For the occupational therapists, a somewhat different pattern emerged. "Therapeutic Gains" were rated significantly more highly than were items in any of the other scales, t(29) = 6.91, 6.56, and for comparisons with "Socialization," "Escaping Hospital Routine," and "Secondary Gains" scales, respectively, all ps <.001. The "Socialization" items received the next highest ratings, with mean values that were significantly higher than those of the "Escaping Hospital Routine," t(30) = 4.42, p <.001, and "Secondary Gains" scales, t(30) = 7.67, p <.001. Finally, the occupational therapists also gave higher ratings to the "Escaping Hospital Routine" items than to the items reflecting "Secondary Gains," t(30) = 3.72, p =.001. DISCUSSION The results of the present study indicate that patients choose to participate in occupational therapy groups for a variety of reasons, not all of which are considered by occupational therapists themselves to be important from a clinical perspective. The major area of discrepancy seems to be in the patients' use of activity programmes as a means of relieving the tedium of their hospitalizations. In fact, patients considered "Escaping Hospital Routine" to be as impo rtant for their participation as the possibility of achieving significant "Therapeutic Gains." This finding stands in marked contrast to the results that were obtained with the occupational therapists, and it is particularly well' illustrated in the examination of the ratings that were given to the individual items. For the patients, the two most highly rated reasons for pa rticipation in activity groups were, "To decrease boredom," and "To avoid sitting around doing nothing." Apparently, in the absence of alternative ward activities, the occupational therapy groups offer patients the opportunity to do something with their day. These results are comparable to those of Burton (1984) who found that most patients in an acute psychiatric unit attended occupational therapy for diversional reasons. The finding that diversion, or "Escaping Hospital Routine," emerges as a strong reason for participation on occupational therapy groups can be interpreted from two perspectives. On the one hand, diversion can be viewed as a positive benefit of the groups, since they offer the patients an impo rtant source of structured social activity, and may prevent them from ruminating about their problems (Barton & Scheer, 1975; Coviensky & Buckley, 1986; Hayes, 1989). In this context, it is important to note that there is nothing wrong with lessening the patients' boredom. On the DECEMBER

7 CJOT VOLUME 59 NO 5 other hand, when patients view the relief of boredom as the most important reason for participating in occupational therapy groups, one must question whether they are deriving the optimal benefits of the therapy. Despite the generally high ratings that were given to the "Escaping Hospital Routine" items, it was clear that the therapeutic value of the groups was also appreciated by the patients. That is, reasons for pa rticipation that reflected the potential for "Therapeutic Gains" were also given high ratings. It should be noted in this context that "Escaping Hospital Routine" is not mutually exclusive with an interest in achieving "Therapeutic Gains;" even patients who find ward routines to be particularly dull may consider the activity groups to be both stimulating diversion and valuable therapy. However, the patients' ratings of "Therapeutic Gains" items were still significantly lower than those of the occupational therapists. For the latter respondents, "Therapeutic Gains" stood out as being the most salient reasons for participation in the activity programme whereas for the patients, these items were rated as being about comparable to the diversional function of the groups. A third factor that was extracted for the principal components analysis pertained to the social aspects of the occupational therapy programme. Both the patients and occupational therapists had similar views of the importance of this area. Although the social aspects of occupational therapy are apparently not the central feature for either patients or staff, they are still valued relatively highly by both groups. Finally, participation in occupational therapy groups, at least for some patients, appears to be motivated to a degree by the desire to prove to others that one is deserving of discharge, passes, or other privileges. It should be noted that the items reflecting the use of the programme to achieve such "Secondary Gains" received ratings that were significantly lower than items in all other categories. Hence, the general importance of these reasons for participating in occupational therapy appears to be considerably less than the importance of diversional, therapeutic, and social reasons. Furthermore, it is perhaps quite appropriate that patients might attempt to demonstrate their progress by joining in any available ward activities. Nevertheless, the instrumental use of the groups to achieve "Secondary Gains" appears to be an area whose importance may be underestimated by occupational therapists. CONCLUSION In summary, the present study was able to: provide preliminary evidence as to the range of reasons that motivate adult psychiatric patients to participate in occupational therapy groups; identify the relative importance of different types of reasons; and examine some of the similarities and differences between patients and occupational therapists themselves. Perhaps the most striking finding is that "Escaping Hospital Routine" emerged as being as strong a factor as "Therapeutic Gains" for motivating patients' attendance at occupational therapy groups. Although the goals of a psychiatric hospitalization are not primarily recreational, a concern that arises from the survey is that the patients may perceive themselves as not having enough to do. With a population that can be characterized by emotional difficulties and low morale, there is a risk that understimulation during the hospital admission may have a negative impact on the process of recovery. Increasing the availability of other ward activities to such patients might help to meet their needs for diversion and social interaction, and allow occupational therapy groups to deliver the other therapeutic benefits that they are intended to provide. To some extent, this finding may reflect an inherent drawback of the blanket referral system that was in place at the Health Sciences Centre at the time the study was conducted. Because new patients were constantly being introduced into the group setting, there were limited opportunities to offer an individualized and explicit introduction to the rationale and goals of occupational therapy. As a result, many patients may not have developed a complete understanding of the therapeutic potential of the groups, and instead came to view their purpose as primarily recreational and diversional. To circumvent this potential problem, the occupational therapy department has now replaced blanket referrals with individual referrals. This prevents patients from participating in occupational therapy groups before they have completed an initial interview. During the interview, information is communicated about the relevance of occupational therapy within the context of the patient's overall treatment. Following Kaplan (1985) and Peloquin (1988), the interviews are geared to the patient's understanding of his or her current difficulties. As these authors have suggested, in order for patients to understand fully the purposes of occupational therapy, it may be important to orient them more systematically to what those purposes are. Otherwise, patients may attend the occupational therapy programme for a variety of reasons that we are only beginning to appreciate. Finally, it is important to note some of the limitations of the present study. Although the "Reasons for Participation" inventory was able to provide valuable preliminary information about patients' perceptions of the occupational therapy programme, it requires further psychometric refinement before it can be recommended for more general use. It would be important 246 DÉCEMBRE 1992

8 CJOT. VOLUME 59 NO 5 to determine the stability of the four primary factors over time, and across populations that include nonpsychiatric patients. The potentially confounding influences of social desirability demand characteristics and response-set biases should also be examined more extensively in the future. It would also be of interest to determine the extent to which scores on the inventory are related to other patient behaviours, such as patients' perceptions of the groups, their level of participation in the groups, and their satisfaction with occupational therapy as a component of hospital treatment. Finally, it would be valuable to examine ratings postdischarge, when the patients may have a more distant perspective on their hospitalizations and the boredom of ward life is no longer an immediate concern. The present results have emerged from a study that was exploratory in nature, but from them have arisen a number of important avenues for future research. REFERENCES American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd edition - revised). Washington, D.C.: Author. Barton, G.M., & Scheer, N. (1975). A measurement of attitudes about an activity program. American Journal of Occupational Therapy, 29, Bloomer, J.S. (1978). The consumer of therapy in mental health. American Journal of Occupational Therapy, 32, Burton, L. (1984). Introducing the concept of occupational therapy to patients in an acute psychiatric unit. British Journal of Occupational Therapy, 47, Coviensky, M., & Buckley, V.C. (1986). Day activities programming: Serving the severely impaired chronic client. Occupational Therapy in Mental Health, 6, Hayes, R. (1989). Occupational therapy in the treatment of schizophrenia. Occupational Therapy in Mental Health, 9, Holm, M.B. (1983). Video as a medium in occupational therapy. American Journal of Occupational Therapy, 37, Kaplan, S.H. (1985). Patient education techniques used at burn centres. American Journal of Occupational Therapy, 39, Locker, D., & Dunt, D. (1978). Theoretical and methodological issues in sociological studies of consumer satisfaction with medical care. Social Science in Medicine, 12, Peloquin, S.M. (1988). Linking purpose to procedure during interactions with patients. American Journal of Occupational Therapy, 42, Snelling, E., & Walker, F. (1978). Patient satisfaction with facilities at an acute admission psychiatric unit. New Zealand Medical Journal, 87, ACKNOWLEDGEMENTS We would like to thank occupational therapists Ed Ziesmann, Cynthia M. Puttaert, Karin Chanas, Sharon Eadie and Marlene Stern for their assistance and support in this study. We would also like to acknowledge the contribution of Mr. Kuldip Maini, who provided statistical consultation. A presentation based on this work was given at the Canadian Association of Occupational Therapists Conference on June 2, 1989 in Winnipeg, Manitoba. DECEMBER