Effectiveness of Occupational Goal Intervention
for Clients With Schizophrenia
KEY WORDS
 activities of daily living
 comparative effectiveness research
 executive function
 goals
 schizophrenia
Noomi Katz, PhD, OTR, is Director, Research Institute
for Health and Medical Professions, Ono Academic
College, 32 HaHaroshet Street, Or Yehuda 60375, Israel,
and Professor Emeritus, School of Occupational Therapy,
Hebrew University, Jerusalem, Israel; noomi.katz@
gmail.com
Navah Keren, is Lecturer, School of Occupational
Therapy, Hebrew University, Jerusalem, Israel, and
Director, Occupational Therapy Department, Kaplan
Medical Center, Rechovot, Israel.
The American Journal of Occupational Therapy
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Noomi Katz, Navah Keren
OBJECTIVE. The effectiveness of Occupational Goal Intervention (OGI) in clients with schizophrenia was
compared with that of the Frontal Executive Program and a control group.
METHOD. We used a quasi-experimental design with 18 adult participants ages 2038 who were randomly
assigned to three groups. Testing was performed before treatment, after treatment, and at 6-mo follow-up
(Time 2). Instruments assessed executive functions (EFs) and activity and participation. Participants re-
ceived 18 treatment sessions over a period of 68 wk.
RESULTS. We found no significant differences among the groups on pretestposttest change; however, we
did find significant differences within groups before and after intervention and moderate to high effect sizes.
The OGI group showed relative improvement on all measures of EF and activity and participation. Most
participants achievements were maintained at Time 2.
CONCLUSIONS. Results provide initial support for the OGIs effectiveness for clients with schizophrenia.
Further studies are needed to verify these initial findings.
Katz, N., & Keren, N. (2011). Effectiveness of occupational goal intervention for clients with schizophrenia. American
Journal of Occupational Therapy, 65, 287296. doi: 10.5014/ajot.2011.001347
E xecutive functions (EFs) are considered essential elements in nonroutine
situations and in performance of complicated or new tasks that require
coordination among subprocesses to achieve a specific goal (Burgess & Simons,
2005; Burgess et al., 2006). EF deficits can affect the ability to initiate, to plan,
to inhibit inadequate responses, and to monitor and modify different aspects of
performance (Lezak, Howieson, Loring, Hannay, & Fischer, 2004). The lit-
erature has shown that clients with schizophrenia experience deficits in EFs,
characterized by difficulties in mental flexibility, working memory, initiating
and performing tasks (planning, shifting, and regulation), and solving novel
and conflicting problems in complicated and unfamiliar situations (Barch,
2005; Green, Kern, Braff, & Mintz, 2000). In addition, adaptive functioning in
everyday life is well known to be impaired in clients with schizophrenia
(Semkovska, Bedard, Godbout, Limoge, & Stip, 2004).
Cognitive treatment of clients with schizophrenia is discussed in various
programs that differ with respect to their theoretical basis, methods, goals, and
outcomes. The remedial, or process-oriented, approach consists of direct re-
training or restoration of impaired core areas of cognitive skills. This treat-
ment method targets the underlying mechanisms that may cause the deficit
(Delahunty & Morice, 1993, 1996; Medalia & Freilich, 2008; Medalia &
Richardson, 2005; Wykes, Newton, et al., 2007; Wykes, Reeder, et al., 2007).
The strategy approach teaches clients to use their assets to achieve successful
performance and gradually improve their underlying cognitive deficits (Katz &
Hartman-Maeir, 2005; Toglia, 2005). An example of such an intervention
program is Goal Management Training (GMT), developed by Levine and
colleagues (2000). This program was used with people with traumatic brain
287
 injury (Levine et al., 2000) and was more recently elab-
orated on and used with healthy elderly people (Levine
et al., 2007). This program is the basis of the OGI
program.
Wykes and colleagues (2007) series of studies with
schizophrenic populations used a cognitive remediation
therapy approach that is the same as the Frontal Execu-
tive Program (FEP) used in this study. It demonstrated
an advantage for cognitive remediation compared with
standard occupational therapy care. In these studies, both
groups improved after intervention, but the improvement
of the study group that received cognitive therapy was
greater than that of the control group in executive
measures such as working memory and cognitive flexi-
bility, and memory improvement predicted improvement
in social functioning (Wykes, Reeder, et al., 2007). Those
achievements were durable 6 mo after the cessation of
therapy.
Medalia, Revheim, and Casey (2002) demonstrated
that participants in a problem-solving group improved to
a greater extent in problem solving than did those in
memory skills training or control groups. The effects of
remediation persisted for 4 wk after training. This finding
was also confirmed by Hodge et al. (2010) using the NEAR
computer program by Medalia and Freilich (2008), who
showed the same results. Other studies, however, have in-
dicated that few differential treatment effects were found
on cognitionneurocognition in favor of the study group
that received cognitive training versus a control group that
received supportive therapy (Hogarty, Greenwald, & Eack,
2006). In previous studies, the outcome measures that
were tested varied. Some studies tested treatment effects on
executivecognitive functions themselves (Hodge et al.,
2010), and others referred to self-image, social cognition
(Hogarty et al., 2006), or social adaptation and work
functioning (Bell, Bryson, & Wexler, 2003; Hadas-Lidor,
Katz, Tyano, & Weizman, 2001).
In this study, we examined the effectiveness of a struc-
tured strategy learning intervention program based on
GMT but developed in occupational therapy, the Oc-
cupational Goal Intervention (OGI; Keren, Gal,
Dagan, Yakoel, & Katz, 2008). The OGI targets clients
with schizophrenia who have EF deficits that affect daily
activities and participation in the community. We ex-
amined changes at the end of the intervention program
and 6 mo later, at follow-up. We further compared the
OGI with the FEP, a remedial approach using mainly
paper-and-pencil tasks, and a control group treated with
an activity training approach (ATA) specifically in skill
training and without a focus on EFs (Mairs & Bradshaw,
2004; Zielinski Grimm et al., 2009).
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We expected that the OGI approach that combines
work on EFs in daily tasks would be the most effective in
both outcome categories, namely EF and activity and
participation. Moreover, we expected that the FEP would
be similarly effective for the formal EF measures but less so
with respect to activity and participation outcomes. Both
were assumed to be more effective than the ATA used with
the control group. Moreover, we expected that all par-
ticipants would maintain their gains from the end of the
intervention period to follow-up.
Method
Research Design
The study followed a quasi-experimental design with ran-
dom assignment and pretest, posttest, and 6-mo follow-up
data collection time periods.
Participants
Thirty-seven clients met the study criteria and consented
to participate in the study. Nineteen dropped out after
initial testing (a few refused to continue with the program;
most were discharged before starting the program as a
result of shortened lengths of hospitalization). Using a
two-sample t test with a Bonferroni correction, we found
no significant differences on any of the measures between
the two subgroups that completed the baseline assessment
at Time 0 (T0). These findings support the studys in-
ternal validity.
The study sample consisted of 18 adult participants
ages 2238 (mean [M ] 5 30, standard deviation [SD] 5 8)
diagnosed with schizophrenia according to the Di-
agnostic and Statistical Manual of Mental Disorders (4th
ed., text rev.; American Psychiatric Association, 2000) by
the treating physician, who also administered the Positive
and Negative Symptoms Scale to assess severity of psy-
chiatric symptoms (Kay & Opler, 1987). All participants
were in a day treatment program at Kaplan Medical
Center in Rehovot, Israel. The participants were randomly
assigned to one of three groups: two study groups (OGI
and FEP) and a control group (ATA). Each group in-
cluded 6 participants.
Inclusion criteria included diagnosis of schizophrenia
or schizoaffective disorder, deficits in at least one of the EF
measures (see the assessments used), and age between 20
and 55 yr. Participants were excluded if they had another
neurological disease or severe physical illness, addictions,
or severe cognitive deficits, based on a screening using the
Standard Progressive Matrices (Raven, Raven, & Court,
2000). Participants who obtained Grade 5 intellectually
May/June 2011, Volume 65, Number 3
 impaired, a score that lies at or below the 5th percentile Behavioral Assessment of the Dysexecutive Syndrome.
for the age group on the Standard Progressive Matrices, The Behavioral Assessment of the Dysexecutive Syn-
were excluded from the study. Demographic information drome (BADS; Wilson, Alderman, Burgess, Emslie &
and illness data for the three groups are presented in Evans, 1996) consists of six subtests measuring various
Table 1. No significant differences were found among the aspects of EFs. The profile scores of each subtest range
groups on any of the variables. from 0 to 4, and the total profile score ranges from 0 to
24. The entire test was performed before treatment (at
Instruments: EF Measures T0). The Zoo Map subtest, measuring planning and
adherence to rules (score range 5 04), was used at the
All instruments used in the study are validated measures
end of the treatment (Time 1 [T1]) and at 6 mo follow-
used with the current population.
up (Time 2 [T2]). The test battery has established re-
Wisconsin Card Sorting Test. We used computerized ver-
liability and validity in the population with schizophrenia
sion 4 of the Wisconsin Card Sorting Test (WCST; Heaton,
(Evans, Chua, McKenna, & Wilson, 1997; Katz, Tadmor,
Chelune, Talley, Kay, & Curtiss, 1993) for cognitive
Felzen, & Hartman-Maeir, 2007a; Norris & Tate, 2000).
flexibility, using 128 cards (two sets). We used scoring of
The Zoo Map is foremost a measure of planning with
number of categories achieved among six possible catego-
good validity data on its own, and we therefore used it
ries in each set and the number of perseverative errors
as an outcome measure on its own (Norris & Tate, 2000).
(more errors reflected low EF). Extensive research has been
Executive Functions Performance Test. The Executive
done on the use of the WCST in schizophrenia. The
Functions Performance Test (EFPT; Baum, Morrison,
WCST was used only in the screening stage for EFs.
Hahn, & Edwards, 2003) is a performance test that ex-
Wechsler Adult Intelligence ScaleDigit Span Forward
and Backward. The Wechsler Adult Intelligence Scale, amines the execution of four instrumental activities of
3rd edition (WAISIII; Wechsler, 1998) is a validated daily living (IADLs) essential for self-maintenance and
instrument with standards in various countries. The Digit independent living: simple cooking, telephone use,
Span is a subtest of the WAISIII Performance scale that medication management, and bill payment. In all tasks,
assesses working memory and attention. The range is 030; the EFPT assesses a persons ability to adhere to these five
higher scores reflect better performance. components of EFs: initiation of a task, execution of
a task, organization, sequencing, judgment and safety,
and completion of a task. The level of cueing necessary to
Table 1. Demographic Characteristics of the Three Study Groups support task performance is recorded; thus, the score
reflects the participants capacity for EF during perfor-
OGI FEP ATA
Characteristic (n 5 6) (n 5 6) (n 5 6) mance of everyday tasks. Score range is 742; higher
Gender, n scores reflect a need for greater cueing, indicating more
Male 2 5 5 severe EF deficits (Baum et al., 2008; Katz et al., 2007b).
Female 4 1 1
Marital status, n Instruments: Activity and Participation
Single 6 4 3 Outcome Measures
Married 1 3
Divorced 1
Routine Task InventoryExpanded. The Routine Task
Employment, n InventoryExpanded (RTI2E; Katz, 2006) is a functional
Employed 1 1 evaluation that assesses the degree to which routine task
Unemployed 5 5 6 behaviors are restricted. It is based on the observation of
Residence, n basic activities of daily living (ADLs), IADLs, communi-
Independent 1 6 6
cation, and work readiness. The instrument was translated
Living with families (parents) 5
Age, yr; M (SD ) 30.0 (8.8) 29.0 (9.4) 31.0 (8.3)
and researched with various populations in different coun-
Education, yr; M (SD ) 11.8 (0.4) 12.0 (0.4) 11.7 (1.5) tries (see Katz, 2006, for research summary). The RTI2E
Clinical characteristics: PANSS symptoms, M (SD ) provides summary scores or means in each of the four
Positive 21.6 (12.7) 24.3 (9.04) 35.6 (9.1) areas, and higher scores indicate more independent
Negative 22.8 (5.5) 30.0 (10.0) 28.2 (6.04) functioning. The RTI is an activity outcome measure.
Total score 87.0 (24) 98.8 (24.21) 121.0 (17.8)
Activity Card Sort. The Activity Card Sort (ACS; Baum
Age of onset (yr) 21.8 (2.0) 24.1 (4.4) 22.6 (1.63)
& Edwards, 2008) measures the percentage of activities
Note. 5 not applicable; ATA 5 activity training approach; FEP 5 Frontal
Executive Program; M 5 mean; PANSS 5 Positive and Negative Symptoms retained by an individual as an indicator of occupational
Scale; OGI 5 Occupational Goal Intervention; SD 5 standard deviation. engagement. Construct validity of the Israeli ACS (Katz &

The American Journal of Occupational Therapy 289

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 Hartman-Maeir, 2001) has been demonstrated by its
ability to differentiate activity levels of different age
and diagnostic groups (Katz, Karpin, Lak, Furman, &
Hartman-Maeir, 2003). Factor analysis revealed the
structure of the four areas included in the ACS: IADLs
and three leisure areas; scoring indicates percentage of
level of activities retained (Baum et al., 2008; Katz et al.,
2003).
Reintegration to Normal Living Index. The Reintegra-
tion to Normal Living Index (RNL; Wood-Dauphinee,
Opzoomer, Williams, Marchand, & Spitzer, 1988) is a
questionnaire that assesses global functional status and
measures the clients perception of his or her capabilities
in areas such as participation in leisure and social ac-
tivities, mobility, and interaction with others and family
members. The measure includes 11 items; scores range
from 11 to 55, with low scores indicating better in-
tegration. The RNL is well known and has been used in
many studies (Pang, Eng, & Miller, 2007). The ACS and
RNL are participation outcome measures.
Intervention Methods
Occupational Goals Intervention. The OGI program
focuses on strategy learning using activities and everyday
tasks. The steps of the program followed GMT but with
a focus at the beginning on the individual choice of
meaningful activities and at the end on debriefing of the
activity performance (see Table 2). The treatment process
emphasized the use of functional activities in three main
domains: (1) food preparation; (2) money management;
and (3) reading, writing, and using computers for in-
formation seeking. However, the functional domain was
adapted to each clients choices and needs when the client
preferred to work on other activity domains. The as-
sumption is that the learned thinking process is trans-
ferred to any other occupational performance domains
(Toglia, 2005).
Frontal/Executive Program. The FEP intervention
includes specific training for neurocognitive rehabilitation
based on a process-specific approach. The FEP consists of
three modulescognitive shift, working memory, and
planningthat target flexibility and working memory and
planning deficits in a graded fashion. Most of the training
components are paper-and-pencil tasks, and some use
construction exercises. The program was translated when
necessary with the authors permission.
Activity Training Approach. The ATA, in different
variations, is used in mental health programs (Mairs &
Bradshaw, 2004; Zielinski Grimm et al., 2009) that
emphasize teaching activity-specific routines. In this
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Table 2. Stages of the Occupational Goals Intervention Program
Stage Steps of the Program
1 Stop and think!
 Orienting and alerting to task
 Initial discussion of interests and tasks the
individual wants to work on; raises awareness of
individual meaningful activities that will direct
the choice of tasks
2 Define the main task.
 Define the specific goal. This stage includes
choice, definition, and goal setting.
3 List and partition goal into subgoals.
 Setting the steps to achieve the goal
 Recording the process, steps, and required
material
 Estimating duration of performance
4 Learn steps.
 Encoding and retention, say the process by
heart (the subgoals)
 Perform the task
5 Monitor.
 Check and evaluate the outcome and the process.
 Compare the outcome with the goal definition.
 What kind of problems and difficulties did you
meet or encounter?
 What factors promoted or interrupted goal achievement
(task completion)? Are there alternative ways to carry
out the task?
approach, the client is trained to carry out specific tasks that
he or she needs or wants to do and to practice their per-
formance so they become habitual.
Procedure
The participants were randomly assigned by order of their
admission to one of three groups: two study groups and
one control group. Each group consisted of 6 participants.
Testing was performed at three points in time: before
treatment (T0), at the end of treatment (T1), and at 6-mo
follow-up (T2). Navah Keren did all of the testing, and
three experienced occupational therapists, who were trained
by Keren, performed the treatments for each group. The
participants of all three groups underwent a total of 18
individual treatment sessions, in which two or three 1- to
1.5-hr meetings were held weekly over a period of 68 wk.
Follow-up testing was performed 6 mo after the program
ended.
The study was approved by the Hospital Human
Rights Committee as required and participants signed
informed consent.
Data Analysis
Data were analyzed using SPSS Version 12 (SPSS Inc.,
Chicago, IL). To compare the differences achieved between
T0 to T1 among the three treatment groups, we performed
KruskalWallis nonparametric statistics followed by Wil-
coxon pairwise post hoc analysis. Next, we analyzed
treatment effectiveness within each group with Wilcoxon
May/June 2011, Volume 65, Number 3
 signed-rank tests for the significance of the difference from
T0 to T1 and performed calculation of effect size of the
differences (which is based on the means and standard
deviations of the groups compared) using Cohens d
(Cohen, 1988).
To further study the change within each group, we
performed relative improvement analysis, expressed by the
actual improvement divided by the potential improve-
ment (Heinemann, Roth, Cichowski, & Bett, 1987;
Shah, Vanclay, & Cooper, 1990). The equation is cal-
culated as follows:
posttesting 2 pretesting
maximal possible score 2 pretesting
This measure provides a value from 0 to 1.0, such that
0 represents no improvement between the two assessment
times and a score of 1 represents the maximal progress
possible.
Results
Treatment Effectiveness Among the Groups
Comparison of the differences from T0 to T1 among
the three study groups showed no significant differences
for the EF measures and only one significant result
among the participation outcomes (RNL family, x2[2] 5
6.78, n 5 18, p 5 .034). The analysis showed that the
source of difference was between the OGI group (mean
rank 5 13.75) and the ATA group (mean rank 5 5.83),
with the OGI group having the higher scores. The FEP
group (mean rank 5 8.92) fell between the other two
groups.
Treatment Effectiveness Within Each Group
Descriptive data on all measures according to the three
study groups are presented in Table 3.
EF Measures. On all tests, all groups mean increased
at T1 except for Digit Span in the ATA group that had the
exact mean performance at both times (see Table 3). The
Zoo Map subtest showed a significant difference for the
OGI group (z 5 2.23, p 5 .026, d 5 1.98); for the FEP
group, the difference approached significance (z 5 1.89,
p 5 .059, d 5 0.97); and no significant difference was
found for the ATA control group. The Digit Span test
showed a significant difference for the FEP group (z 5
2.04, p 5 .041, d 5 0.72) and a nonsignificant difference
for the OGI. The EFPT test showed significant differences
for all groups (for the OGI, FEP, and ATA, respectively,
zs 5 2.21, 2.20, and 2.21; ps 5 .027, .028, and .027; ds 5
0.39, 1.15, and 0.91). Effect sizes ranged from moderate
The American Journal of Occupational Therapy
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to high (0.391.98) for all comparisons, effect sizes were
higher for the Zoo Map, and the highest mean gain was
for the OGI group.
Activity and Participation Outcomes. On all tests, all
groups mean increased at T1. For the RTI2E (IADL),
a significant difference was indicated only for the OGI
group (z 5 2.20, p 5 .028, d 5 0.30), and no significant
differences were found for the FEP and ATA groups.
However, the RTI2E (communication) showed no sig-
nificant difference for the OGI and FEP groups and
a significant difference for the ATA group at posttreat-
ment (z 5 2.02, p 5 .043, d 5 0.51). No significant
differences were found for any of the three groups for
RTI2E (work readiness). The ACS demonstrated a sig-
nificant difference for the OGI and ATA groups (zs 5
1.99 and 2.02, respectively, ps 5 .046, ds 5 0.78 and
0.64) and nonsignificant differences for the FEP group.
The RNL client questionnaire showed a significant dif-
ference for the FEP group (z 5 2.03, p 5 .042, d 5
0.49), and no significant difference for the OGI and ATA
groups, even though the OGI group showed a higher
mean increase (z 5 1.68, p < .09). However, the RNL
caregiver perspective showed a significant difference for
the OGI group (z 5 2.02, p 5 .043, d 5 1.86) and the
FEP group (z 5 1.99, p 5 .046, d 5 1.10), and we
found a nonsignificant difference for the ATA group.
Moderate to high effect sizes of 0.301.86 were found for
all significant comparisons.
No significant change was found in any of the
measures for the three groups between T1 and T2, the
6-mo follow-up. Most participants in the different groups
maintained their achievements, and some improved in
their performance (see Table 3 for Ms and SDs).
Relative Improvement
EF Measures. Calculating the relative improvement on
the EF measures, the Zoo Map showed that all groups had
improved. The relative improvement of the OGI group
was the highest (M 5 0.62, SD 5 0.23), followed by the
FEP group (M 5 0.44, SD 5 0.45), and that of the ATA
group was the lowest (M 5 0.25, SD 5 0.44; see Figure 1).
Digit Span showed that both study groups had improved.
The FEP groups relative improvement (M 5 0.16, SD 5
0.09) was higher than that of the OGI group (M 5 0.08,
SD 5 0.12). The relative change of the control group
(ATA) was negative (M 5 0.36, SD 5 0.15), suggesting
a decline. All groups improved on the EFPT, but the
control (ATA) groups relative improvement (M 5 0.62,
SD 5 0.22) was higher than for the two study groups, the
OGI group (M 5 0.32, SD 5 0.19) and the FEP group
(M 5 0.32, SD 5 0.13; see Figure 1).
291
 Table 3. Descriptive Statistics of the Three Study Groups: Executive Functioning, Activity, and Participation Measures
OGI Mean (SD) FEP Mean (SD) ATA Mean (SD)
Measures T0 T1 T2 T0 T1 T2 T0 T1 T2
BADS Zoo Map 0.83 (1.16) 2.66 (0.6) 2.66 (0.9) 1.50 (0.8) 2.50 (1.2) 2.83 (0.9) 1.00 (0.9) 2.00 (1.0) 2.40 (1.1)
Digit Span 14.33 (3.14) 15.66 (3.2) 16.20 (3.7) 15.83 (3.40) 8.16 (3.0) 17.5 (2.3) 15.83 (5.20) 15.83 (3.9) 16.00 (4.4)
EFPT 34.08 (5.26) 36.00 (4.6) 38.30 (1.9) 36.08 (2.35) 38.16 (1.0) 36.91 (3.0) 34.75 (6.50) 39.25 (2.5) 39.80 (1.5)
RTIE
IADL 4.55 (0.67) 4.75 (0.7) 4.70 (0.7) 4.48 (0.58) 4.50 (0.5) 4.50 (0.4) 4.48 (0.6) 4.82 (0.8) 4.90 (0.9)
Communication 4.70 (0.78) 4.81 (0.8) 4.69 (0.8) 4.23 (0.37) 4.24 (0.39) 4.36 (0.3) 4.23 (0.37) 4.89 (0.9) 5.07 (0.8)
Work 4.73 (0.43) 4.82 (0.6) 4.89 (0.6) 4.48 (0.58) 4.33 (0.4) 4.47 (0.3) 4.30 (0.43) 4.87 (0.8) 4.86 (6.4)
ACS 50.33 (20.3) 65.38 (18.3) 71.32 (20.6) 56.32 (15.42) 67.00 (24.5) 69.83 (20.1) 56.32 (15.4) 64.75 (21.7) (15.0)
RNL
Client 33.16 (11.2) 42.66 (10.6) 47.60 (4.9) 36.66 (9.83) 41.00 (7.6) 45.66 (5.8) 36.66 (9.8) 37.5 (15.0) 38.0 (16.4)
Caregiver 34.66 (5.95) 44.83 (4.9) 45.00 (6.9) 40.33 (3.01) 44.83 (4.9) 45.8 (5.4) 40.33 (3.0) 46.00 (6.9) 47.20 (7.5)
Note. ACS 5 Activity Card Sort; ATA 5 activity training approach; BADS 5 Behavioral Assessment of the Dysexecutive Syndrome; EFPT 5 Executive Functions
Performance Test; FEP 5 Frontal Executive Program; IADL 5 instrumental activities of daily living; OGI 5 Occupational Goal Intervention; RNL 5 Reintegration to
Normal Living Index; RTIE 5 Routine Task InventoryExpanded; SD 5 standard deviation.

Activity and Participation Outcomes. Results with respect
to the functional measures of activity and community
participation were as follows. For activity in all three com-
ponents of the RTI2E (IADL, communication, and work
readiness), the OGI groups relative improvement ranged
from M 5 0.12 to M 5 0.22; for the ATA group, it ranged
from M 5 0.24 to M 5 0.35. The FEP group showed no
change at all (see Figure 1). For participation, the OGI
group showed higher relative improvement in comparison
with the other groups on both the ACS and the RNL. The
relative improvement of the OGI group on the ACS was
M 5 0.31, a little higher than that of the ATA group (M 5
0.29), and both groups were higher than the FEP group
(M 5 0.22). On the RNL client and caregiver, the OGI
groups relative improvement was the highest (M 5 0.48),
compared with the FEP group (Ms 5 0.230.15), and the
lowest relative improvement was found in the ATA group
(Ms 5 0.11 for both; see Figure 1).
In addition, under each histogram in Figure 1, the
effect sizes (Cohens d ) are shown to provide a comparison
with the measure of relative improvement (see Figure 1).
As can be seen in most cases, higher improvement corre-
sponds with higher effect size.
Discussion
Our purpose in this study was to compare the effectiveness
of two different models of intervention on EFs and activity
and participation outcomes: The OGI (Keren et al., 2008)
focuses on strategy learning while performing activities
and everyday tasks, and the FEP (Delahunty & Morice,
1993, 1996) takes a remedial approach, consisting of pri-
marily paper-and-pencil exercises. Both methods were com-
pared with an ATA, the control group. In general, only one
significant statistical difference was found between the
groups on the change before and after treatment, prob-
ably because of the groups small sample size. How-
ever, we found significant differences within each group
between pre- and posttreatment on different outcome
measures in line with expected trends, even though some
within-groups outcomes showed mixed results. Effec-
tiveness was measured in two ways: by comparison of
pretest and posttest scores with nonparametric statistics
with effect size calculation and by using the relative im-
provement method. Both analyses provide ways to look at
the change occurring after intervention. The results cor-
respond in most cases (see Figure 1), and where they
differ, the groups have either identical means or different
standard deviations.
The results showed significant differences on the EF
measures at T1 in the FEP group on the Digit Span that
requires attention and working memory and in the OGI
group on the Zoo Map that requires planning abilities
within a simulated real-life map. In comparison, the
control group (ATA) showed no significant difference on
these measures. However, we found significant differences
on the EFPT in all three groups and similar results using
the relative improvement method for the rate of change of
EF at T1 (see Figure 1). The improvement in the OGI
and FEP groups was higher, except for the EFPT test, on
which the ATA group showed higher improvement.
When examining the activity and participation out-
comes at the end of the treatment (T1), we found sig-
nificant changes in the OGI group on most measures,
which may suggest that the strength of the OGI approach
is in combining strategy learning with goal management in
everyday tasks, possibly providing a dual effect. Moreover,
the relative improvement analysis in activity (RTI2E) at

292 May/June 2011, Volume 65, Number 3

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 Figure 1. Relative improvement and Cohens d in executive function, activity, and participation measures from Time 0 to Time 1 in each group.
ACS 5 Activity Card Sort; ATA 5 activity training approach; BADS 5 Behavioral Assessment of the Dysexecutive Syndrome; EFPT 5 Executive Functions
Performance Test; FEP 5 Frontal Executive Program; OGI 5 Occupational Goal Intervention; RNL 5 Reintegration to Normal Living Index; RTIE 5 Routine Task
InventoryExpanded.

the end of the treatment (T1) showed that both the OGI
and the ATA groups improved, whereas in the FEP group,
almost no change was demonstrated (see Figure 1). This
result may be explained by the fact that the OGI and ATA
approaches both rely on the use of actual activities in
treatment, even though the OGI works on strategy use and
the ATA works on direct training in activities. By contrast,
the FEP is a remedial treatment that focuses on improving
cognitive abilities with paper-and-pencil exercises that may
not immediately affect activity performance.
On the participation measures, the OGI group
showed greater improvement on the RNL for both client
and caregiver, whereas on the ACS their percentage of
activities increased after all interventions, but less for the
FEP group (see Figure 1). Keren et al. (2008) presented
2 participants, each individually treated with one of the
two experimental methods, whose achievements suggested
a pattern similar to the group results because the partic-
ipant from the OGI group improved on both EFs and
participation, and the participant treated with the FEP
improved mainly on EFs.
The current studys contribution is in measuring out-
comes of participants actual performance of activities and
participation in community daily life. This contribution

The American Journal of Occupational Therapy 293

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 stands in contrast to the studies of Wykes, Newton, et al.
(2007); Wykes, Reeder, et al. (2007); and Medalia and
colleagues (2002), who focused on traditional cognitive
abilities on the one hand and measured treatment effects on
more general, albeit important aspects of social function-
ing, quality of life, and self-esteem on the other hand.
The finding that OGI is effective supports the
proposition that strategy learning with an ecological
emphasis that focuses on improving planning with goals
within daily occupations is beneficial (Levine et al., 2000,
2007). The benefit of this method is its ability to improve
actual activity performance and participation, which are
the major goals sought to enable a return to community
life (World Health Organization, 2001).
Moreover, we found that most of the participants in the
different groups maintained or improved their EF and
activity and participation achievements at 6 mo follow-up
(T2). This finding is similar to those of Wykes, Reeder,
et al. (2007) and Hodge et al. (2010), in which the same
trend of changes also persisted at follow-up (4 or 6 mo
later). This finding is of utmost importance because chan-
ges occurring during treatment appear to have a longer
lasting effect.
In summary, the results show that all participants in the
experimental groups, irrespective of their group member-
ship, gained from the treatment in some way. Thus, a
systematic treatment of EF based on a theoretical model
using either a remedial or a strategy learning approach
improved the performance of clients with schizophrenia on
EF tests. Moreover, the OGI improved performance in
daily functions. The importance of transferring and gen-
eralizing from treatment to real life is strongly acknowl-
edged by researchers and clinicians in rehabilitation and
occupational therapy (Baum & Katz, 2010; Hayes &
McGrath, 2006; Katz & Hartman-Maeir, 2005; Koren,
Seidman, Goldsmith, & Harvey, 2006; Spaulding &
Nolting, 2006). This studys contribution to occupational
therapy intervention in schizophrenia is the inclusion of a
wide range of activity and participation outcomes, whereas
other studies have focused on social skills (Hogarty et al.,
2006), communication skills, motivation and work style
(Hodge et al., 2010; Medalia & Richardson, 2005), func-
tioning at work (Bell et al., 2003), and meal preparation
(Zielinski Grimm et al., 2009). The findings provide
initial support for the OGIs effectiveness for clients with
schizophrenia in improving both EF and daily activity
and participation. The cognitive remedial approach (FEP)
showed effectiveness on formal EF measures. Both treat-
ment approaches showed greater benefits than with the
control group. In general, the achievements gained by all
participants were sustained at 6-mo follow-up.
294
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Limitation of the Study
The preceding initial conclusions have to be regarded
cautiously because the main limitation of the study is each
groups small sample size and the 50% drop-out rate
of those participants who met inclusion criteria and
consented to participate in the study. The power of the
study is therefore low, thus a direct difference between
the treatment approaches was not established. However,
the prepost effects found within each group suggest the
relative differential benefits. Another limitation is the fact
that the person who administered all the assessments was
not completely blinded to the treatment effects. In ad-
dition, it may be that had the number of treatment
sessions (18) and the length of the treatment period
(68 wk) been longer, as seen in the Hadas-Lidor et al.
(2001) study, which had a 6-mo intervention, more
significant improvements may have occurred. These con-
clusions are preliminary and have to be studied further
with larger samples to support and verify these initial
findings. s
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