Meal Preparation: Comparing Treatment

Approaches to Increase Acquisition of Skills

for Adults With Schizophrenic Disorders
Erica Zielinski Grimm, Jennifer Sturtevant Meus, Catana Brown, S. Megan Exley,
Susan Hartman, Carole Hays, Terence Manner
key words: schizophrenia, meal preparation, occupational therapy

Abstract

This pilot study was conducted to determine whether an occupational therapy intervention
using an acquisitional frame of reference with a psychoeducational component resulted in
greater functional outcomes in the improvement of meal preparation for adult clients with
schizophrenic disorders than an intervention framed solely by acquisition. Eight participants
who met the inclusion criteria and were randomly assigned to the control group or the experi-
mental group completed the study. Occupational performance in this area was assessed before
and after treatment by administering relevant portions of the Performance Assessment of Self-
Care Skills. Analysis of data suggests a significant change in one of three areas evaluated. All
participants’ “level of independence” improved, indicating that clients required less assistance
after occupational therapy intervention; however, the findings did not indicate that the acquisi-
tion plus psychoeducation resulted in better outcomes than acquisition alone.

D
uring the 1960s, society became concerned
with the quality of life of individuals who
were perceived as severely disabled as a
result of illness, disease, or symptoms of the same
(Neistadt & Marques, 1984), including patients with
psychiatric disorders. As a result, patients were
discharged from hospitals in mass numbers, a trend
called “deinstitutionalization.” As patients were
discharged with no place to go, they eventually re-
entered other institutions, such as nursing homes
and group homes, a trend called “transinstitution-
alization” (Gale, 2006, transinstitutionalization sec-
tion). Consequently, there are substantially fewer
individuals receiving long-term psychiatric hospi-
talization. For this reason, there is a need to create,
sustain, and improve community-based housing
and services to enable individuals with serious men-
tal illness to live and participate in the community
context. However, there remains a population of
patients who, for various reasons, still require long-
term hospitalization, often because of the severity of
their illness.
According to Carson, Butcher, and Mineka (1998),
people with schizophrenia may have many psycho-
logical impairments, including “peculiarities in ac-
tion, thinking, perception, feeling, sense of self, and

Erica Zielinski Grimm, MOT, OTR/L, is Chair of OT Research Committee, Terence Manner, OTR/L, is Lead Occupational
Therapist, and Carole Hays, MA, OTR/L, FAOTA, is retired Director of Rehabilitation Services, Springfield Hospital Center,
Sykesville, Maryland. Jennifer Sturtevant Meus, MSOT, OTR/L, is Occupational Therapist, Rehabilitation Services, Inc., Laurel,
Maryland. Susan Hartman, MOT, OTR/L, is Clinical Assistant Professor, Towson University, Towson, Maryland. Catana Brown,
PhD, OTR, FAOTA, is Associate Professor, School of Occupational Therapy, Touro University Nevada, Henderson, Nevada.
S. Megan Exley, MOT, OTR/L, is Occupational Therapist, Landmark Home Health Care, Pittsburgh, Pennsylvania.
Originally submitted June 13, 2007. Accepted for publication April 7, 2008. Posted online December 19, 2008.
Address correspondence to Erica Zielinski Grimm at egrimm@dhmh.state.md.us.
This manuscript was accepted under the editorship of Helene J. Polatajko, PhD, OT(C), OT Reg. (Ont.), FCAOT.
doi: 10.3928/15394492-20090914-02

148 OTJR: Occupation, Participation and Health

manner of relating to others” (p. 443). Although the
specific deficits related to schizophrenia vary from
one individual to the next, dysfunctions often occur
in “perception, inferential thinking, language, com-
munication, behavioral monitoring, affect, fluency
and productivity of thought and speech, hedonic ca-
pacity, volition and drive, and attention” (American
Psychiatric Association [APA], 2000, p. 299).
Schizoaffective disorder is a psychiatric diagnosis
that includes the characteristic symptoms of schizo-
phrenia and a concurrent “period of either a Major
Depressive Disorder, a Manic Episode, or a Mixed
Episode” (APA, 2000, p. 323). People diagnosed as
having either illness exhibit psychotic symptoms
for a significant period, therefore affecting the set of
skill areas previously mentioned (APA, 2000). The
Diagnostic and Statistical Manual of Mental Disorders,
fourth edition, text revision (APA, 2000), adds that
such a diagnosis is determined not only by the speci-
fied signs and symptoms, but also by “the recognition
of a constellation of signs and symptoms associated
with impaired occupational or social functioning”
(p. 299). To improve the occupational and social
functioning of individuals with schizophrenic disor-
ders, it is important to assess their specific strengths
and problem areas and the overall effect of these on
occupational performance.
Most individuals who receive treatment at inpa-
tient psychiatric facilities would prefer to live in the
community independently. Although independent
living is the ultimate goal for both clients and pro-
viders, it is not always possible to safely discharge
a person into the community independently. These
individuals may require varying levels of assistance
from a variety of service providers to achieve suc-
cessful community living. Instrumental activities of
daily living (IADLs) are defined in the Occupational
Therapy Practice Framework (American Occupa-
tional Therapy Association, 2002) as “activities that
are oriented toward interacting with the environ-
ment and are often complex—generally optional in
nature (i.e., may be delegated to another)” (p. 620).
Meal preparation, including cleanup, is an IADL
that few published studies have investigated. This
IADL is important for community living.
There is little research determining the most ef-
fective methods for improving IADLs, and there are
even fewer references in the literature specifically
investigating improvement of meal preparation. In
the literature reviewed, one study was found that
focused on the context of a cooking intervention.
This study involved adults with schizophrenia and
addressed the influence of context during the in-
tervention, specifically home versus clinic. The re-
Fall 2009, Volume 29, Number 4
sults showed no significant difference in new skill
development when comparing the home and the
clinic (Duncombe, 2004). Further review uncovered
a study that measured the efficacy of a meal prepa-
ration intervention that used cognitive–perceptual
information processing theory for adults with brain
injury. This pilot study showed significant improve-
ment in meal preparation skills based on a treatment
protocol that included descriptions of the structure,
grading, and cuing (Neistadt, 1994). Finally, a quali-
tative study performed with clients in acute inpatient
units at a mental health facility found cooking to be
a meaningful and productive experience. This article
did not address skill outcomes, only clients’ attitudes
toward baking (Haley & McKay, 2004). Based on the
available body of literature, our pilot study was cre-
ated to compare two treatment approaches that aim
to improve meal preparation skills for people with
schizophrenia.
Researchers hypothesized that presenting infor-
mation in a psychoeducational format, in addition
to the action–consequence feedback intervention
guided by an acquisitional frame of reference, would
result in greater improvement in meal preparation
skills in patients with schizophrenic disorders than
would occur with the use of an acquisitional ap-
proach alone. The participants in the experimental
group received the combined intervention, whereas
the participants in the control group received inter-
vention guided solely by an acquisitional frame of
reference. Researchers proposed that adding a psy-
choeducational component would present a vari-
ety of methods to deliver necessary knowledge for
performing meal preparation skills, thus providing
more opportunities for new skill acquisition.
Acquisitional frames of reference are frequently
the favored approach of psychosocial occupational
therapists. According to Anne Cronin Mosey (1986),
in an acquisitional approach, activities are viewed as
“entities to be learned” rather than a means to teach
underlying skills (p. 443). Also, environment is seen
as being the key influence on behavior. Therefore,
the focus of intervention is the activity to be learned
within as natural a context as possible. For example,
to help a client learn to cook, a therapist would use
the occupation of cooking itself as the method for
teaching the skill. This frame of reference guides
occupational therapy intervention, including meal
preparation groups, and is considered “treatment
as usual” at the state psychiatric hospital in which
the research was conducted; therefore, this approach
was chosen to guide clinical reasoning for both the
control group and the experimental group.
The psychoeducational approach, as defined by
149
Cara and McRae (2005), is “an aspect of the thera-
peutic process in which change is brought about by
learning or through education usually about a psy-
chological topic. There is a clear objective to teach
specific information or techniques” (p. 731). The term
“psychoeducation” is used across healthcare disci-
plines to describe a method of teaching a variety of
subjects, including illness, recovery, and functional
living skills. These teaching and learning techniques
are also commonly used by occupational therapists,
in a group context, to teach independent living skills.
Methods may include, but are not limited to, lecture,
hands-on skill training, role-playing, and demonstra-
tion. For this study, the psychoeducational approach
was used in conjunction with the acquisitional frame
of reference with the experimental group.
Method
Participants
Potential study participants were identified
through diagnostic records of patients being treat-
ed in programs other than the Acute Care Services
program. The Health Information Services Depart-
ment provided the initial demographic data so that
researchers could establish which patients met the
stated inclusion criteria and to determine eligibil-
ity. Inclusion criteria included receiving treatment
at Springfield Hospital Center, in Sykesville, Mary-
land, for a minimum of 6 months. Further, to be in-
cluded in the study, individuals had to be diagnosed
as having a subtype of schizophrenia or schizoaf-
fective disorder. After a list of potential participants
who met the stated inclusion criteria was compiled,
a record abstract form approved by the Maryland
Department of Health and the Mental Hygiene In-
ternal Review Board was used to extract further data
about the identified individuals.
Researchers used the record abstract to note de-
mographic information and also as a tool to identify
exclusionary criteria. Individuals who had demon-
strated dangerous, aggressive, or assaultive behav-
iors (requiring a documented need for restraint or
seclusion) within the past 2 months were excluded
from the study. In addition, individuals with serious
physical limitations were excluded to decrease con-
founding variables that might affect meal prepara-
tion. Researchers also considered individuals’ native
language and their ability to comprehend English be-
cause the verbal components of intervention would
be provided in English and the experimental group
would consist of much verbal interaction as a funda-
mental characteristic of psychoeducation; only three
individuals were excluded based on a language bar-
rier. Researchers also excluded any individuals who
150
had been diagnosed as having cognitive disorders
or dementia because these conditions would inhibit
their ability to learn new skills. Finally, individuals
with Axis II diagnoses were excluded to further fo-
cus the study.
Researchers contacted 64 individuals who met the
stated criteria to generate participant interest in the
study, which included the opportunity to take part
in a “cooking group.” Twenty-one individuals gave
consent to participate in the research study and were
randomly assigned to one of five groups; however,
six individuals dropped out before the preinterven-
tion phase. Four individuals refused preintervention
evaluations on more than one occasion and changed
their minds about participating in the research study.
The other two individuals had begun experiencing
increased signs and symptoms of their psychiatric
illness, and their treatment teams concluded that
participation in the study would be contraindicated.
Symptoms included, but were not limited to, avo-
lition, increase in paranoia, anhedonia, and lack of
insight into the need to develop the skill area. Katz,
Fleming, Keren, Lightbody, and Hartman-Maeir
(2002) stated, “From a clinical perspective, lack of
awareness is considered an impeding factor in the
rehabilitation process. Individuals who are unaware
of their abilities may not actively engage in thera-
peutic activities” (p. 283). Therefore, 15 individuals
participated in the pilot study, 5 in the control group
and 10 in the experimental group.
Instrument
The assessment tool used for pretest–posttest
measures was the Performance Assessment of Self-
Care Skills (PASS) (Rogers & Holm, 1989). The PASS
tool provides informative data about performance of
daily living skills. There are two versions available,
one for the clinic and one for the home. The version
used in this study was the PASS-Clinic. The PASS
tool provides quantitative scores for functional sta-
tus to establish a baseline and to determine whether
there is a change at discharge.
The PASS tool was designed to assess adults with
a variety of diagnoses, including arthritis, demen-
tia, depression, schizophrenia, and stroke. Twenty-
six functional tasks are evaluated and broken down
into three categories: functional mobility (MOB-5),
personal self-care (ADL-3), and instrumental activi-
ties of daily living (IADL-18). The PASS tool is a cri-
terion-referenced assessment tool that can be used
as a whole or divided into the individual tasks and
assessed separately, allowing for evaluation of the
most relevant skill performance areas. This study
focused on the following five skill areas listed in
OTJR: Occupation, Participation and Health
the PASS tool: (1) Home Maintenance—Sweeping,
(2) Meal Preparation—Oven Use, (3) Meal Prepara-
tion—Stovetop Use, (4) Meal Preparation—Use of
Sharp Utensils, and (5) Light Housework—Cleanup
after Meal Preparation. Scoring is quantitative and
evaluates the level of assistance needed in the fol-
lowing areas: independence, safety, and adequacy.
Validity and reliability evidence exists to support the
use of the PASS-Clinic (Holm & Rogers, 2008).
Procedure
Three weeks before the intervention, participants
in both the control and experimental groups were
assessed using the PASS-Clinic tool to establish
baseline data. An occupational therapist and an oc-
cupational therapy assistant team completed the as-
sessments within a 3-week period before the initia-
tion of the first intervention session. Therapist teams
leading intervention sessions were separate from
those who completed the assessments. After random
assignment of participants, five groups were created,
with three participants in three groups, four partici-
pants in one group, and two participants in the last
group. Group leaders were not informed of the spe-
cifics of the experimental and control interventions
and were not informed whether they were leading
“experimental groups” or “control groups.”
Experimental group leaders were given protocols
and recipes for each of the 10 sessions. These pro-
tocols detailed an area of meal preparation that the
group would focus on and a suggested method of
conducting the psychoeducational component (i.e.,
a script, activities, and methods). Protocols also in-
cluded a list breaking down the recipes into four
groups of tasks to rotate among participants. This
allowed each participant an opportunity to perform
the different tasks associated with meal preparation.
Therapists were expected to use protocols as a guide
while exercising clinical judgment as they would
in any therapeutic intervention. Protocols included
the following ten topics: (1) kitchen orientation; (2)
kitchen safety and first aid; (3) food handling and
safe use of utensils; (4) oven and stovetop use; (5)
reading recipes; (6) microwave use and time man-
agement; (7) cooking terms; (8) measuring; (9) clean-
up and food storage; and (10) table manners.
Therapists leading the control group were given
the same 10 recipes as the experimental group lead-
ers, but were asked to provide “treatment as usual.”
Both experimental and control intervention sessions
were conducted for a maximum of 2 hours and oc-
curred within a 12-week period. Depending on
participant attendance, therapists facilitated either
group or individual sessions. Although not all par-
Fall 2009, Volume 29, Number 4
ticipants received intervention for all 10 sessions,
because of refusals or unforeseen conflicts, all eight
final participants received intervention for a mini-
mum of six sessions.
Postintervention assessments were conducted
within a 3-week period after the conclusion of all
study intervention sessions. The same occupational
therapy practitioner teams that conducted the pre-
intervention assessments performed postinterven-
tion assessments with seven of eight participants.
Because of a scheduling conflict, one participant was
assessed only by the occupational therapist to stay
within the parameters of assessing the participants
within 3 weeks postintervention.
Results
The final study participants included six men and
two women, with a mean age of 43.88 years. The dis-
tribution of these participants was four in the control
group and four in the experimental group. The con-
trol group consisted of two women and two men,
with a mean age of 52.75 years. Two participants
were white and two were African American. One
participant had a second-grade education, one had a
12th-grade education, and two had completed some
college. The experimental group consisted of four
men, with a mean age of 35 years. Three participants
were white and one was Korean. One participant
had a ninth-grade education, one had a 12th-grade
education, one had received a general equivalency
diploma, and one had completed some college.
A univariate analysis of variance (ANOVA) was
conducted to determine whether there was a differ-
ence between the two groups on the posttest when
the pretest was entered as a covariate on the PASS
outcomes of independence and level of assistance
needed. Two separate analyses were conducted, one
analyzing the mean scores for level of independence
on tasks 19, 23, 24, 25, and 26 of the PASS tool, and
the other analyzing the highest level of assistance
required. Mean scores are shown in the table. For
level of independence, a high score indicated greater
independence. For level of assistance, a high score
indicated that more assistance was required.
The ANOVA indicated that there was no signifi-
cant difference between the two groups in terms
of independence or level of assistance at posttest.
However, both groups were combined and a paired
samples t test was conducted for both outcomes. In
this analysis, there was a significant improvement
from pretest to posttest in level of independence
when both groups were combined (t = 3.07, df = 7,
p = .018). There was no significant improvement in
151
 Table
Mean Scores for Independence and Level of Assistance (Standard Deviation)
Independence
Variable Pretest
Acquisition 2.31 (0.60)
Acquisition and psychoeducation 2.18 (0.22)
Combined groups 2.24 (0.43)
level of assistance required from pretest to posttest (t
= 0.92, df = 7, p = .388). These results indicate that the
level of independence did improve for both groups,
but psychoeducation did not result in additional im-
provements.
Discussion
Given the study results, it is evident that skill devel-
opment, guided by traditional occupational therapy
interventions, occurred in both groups. However, be-
cause of the small sample size, the study was not pow-
ered sufficiently, which may have resulted in a Type
II error. Therefore, although the interaction effect was
not statistically significant, the small sample size made
it difficult to detect a difference. Thus, it is unclear
whether the psychoeducational component provided
any advantage in skill improvement in the experimen-
tal group. Several challenges arose limiting sample size,
such as individuals who qualified for the study but, for
various reasons, declined to participate when initially
approached by researchers. Other individuals who ini-
tially agreed to participate in the study later refused or
were unable to participate in the required minimum of
six sessions. A sample size large enough to determine
statistical significance would better determine whether
change might be attributed to the independent variable
of psychoeducation.
As stated in the Results section, the control group
was older and had a 2:2 female-to-male ratio. In ad-
dition to age, the stereotype of traditional gender
roles may have been a factor in the level of improve-
ment seen in the control group because this group
contained two women who may have had more
opportunities to participate in meal preparation. It
should also be noted that one male participant in the
control group had engaged in cooking on a profes-
sional level, having been employed as a chef before
hospitalization. These variables may have influ-
enced the results by creating a higher baseline mea-
sure, thus leaving less room for improvement than
in the experimental group.
Future researchers could attempt to increase the
152
Independence Assistance Assistance
Posttest Pretest Posttest
2.51 (0.43) 5.50 (2.65) 5.75 (3.77)
2.41 (0.34) 7.25 (2.90) 5.75 (1.30)
2.46 (0.36) 6.38 (2.70) 5.75 (2.60)
sample size by generating a multisite participant
pool, including inpatient, outpatient, and commu-
nity-based mental health residential facilities. Ex-
panding the study to different settings could create
another variable for generalizability of the results
found; however, outcomes could be statistically ana-
lyzed to differentiate results from each setting and
the data compared.
This strategy of implementing the study could
also be completed on a one-to-one basis at multiple
centers and could provide a more manageable way
for therapists to implement intervention and collect
data. Researchers found that the pilot study groups
varied in attendance and number, and therapists
sometimes provided individual intervention. Pro-
viding intervention on an individual basis may also
be more contextually appropriate because people
do not often cook in groups. It would also allow for
more client-centered therapy because the occupa-
tional therapist can focus more closely on the needs
of the individual participant and create consistency
in the implementation of the study intervention.
Conclusion
The data show that occupational therapy inter-
vention improves meal preparation skills in the
specified population of adults with schizophrenia
and is a valuable tool to prepare clients for discharge
into the community. However, it cannot be statisti-
cally determined whether the addition of a psycho-
educational component produces greater skill acqui-
sition than occurs when the therapy intervention is
“treatment as usual,” based on the traditionally used
acquisitional frame of reference. The information
is most relevant to therapists working in inpatient
psychiatric hospitals, but future research could de-
termine the generalizability of the findings to outpa-
tient settings.
Acknowledgments
Contributions to this study were made by: Stephanie
Adami, MOT, OTR/L, Jennifer Jackowski, OTR/L, Jen-
OTJR: Occupation, Participation and Health
nifer Caple, OTR/L, Michelle Smith, OTR/L, and An-
nette Thompson, MS, OTR/L, The Occupational Therapy
Department at Springfield Hospital Center, Sykesville,
Maryland; and Bonnie Smith, Director of Health Infor-
mation Services, Springfield Hospital Center, Sykesville,
Maryland. Presented at the 26th Annual Maryland Oc-
cupational Therapy Association Conference, Catonsville,
Maryland, November 3, 2006.
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